MEDICAL TRIBUNE OCTOBER 2012

October 2012

Short-term fluoxetine, venlafaxine efficacious for depression

Health policies need to foster right environment

FORUM DEPRESSION

ESC rolls out new practice guidelines

Singapore’s Gardens by the Bay

PPIs safe for long-term use

NEWS AFTER HOURS

Please visit www.isrd.org for further details

Nearly 100 Academic Speakers,15 Sessions and 6 Special Topics

ISRD 2012The very first joint scientific sessionswith the American Thoracic Society

English Sessions Highlights：

• Mechanical Ventilation

• Sleep Apnea

• Update Biomarkers and Therapeutic Strategies in Airway Diseases

• State-of-the-art Ventilation Strategy

• Highlight on COPD Management

• ALI Forum - Mechanism and New Drug Target

• Plenary Session - Message from ATS

• Infection and Immunity

• Translational Respiratory Medicine

Congress Secretariat Office：

UBM Medica ShanghaiE-mail: [email protected]

Chinese Alliance Against Lung Cancer(CAALC)

Shanghai Respiratory Research Institute

American Thoracic Society (ATS)

Prof. Monica Kraft

President of AmericanThoracic Society

Professor of Medicine,Vice Chair of Researchfor Department ofMedicine and Directorof the Duke Asthma,Allergy and AirwayCenter at DukeUniversity MedicalCentre

Prof. Chunxue Bai

President of the 8thISRD & ATS in ChinaForum 2012

Professor of Medicineand Chairman ofDepartment ofPulmonary Medicine,Zhongshan Hospital,Fudan University

Dr. Asrar Malik

Distinguished Professorand Head of theDepartment ofPharmacology,University of IllinoisCollege of Medicine

Schweppe FamillyDistinguished Professorof Pharmacology

Hosted by:

Supported by:

Keynote Speakers:

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ISRD_290x406_V2_PRINT.pdf 1 12/09/2012 6:11 PM

3 October 2012

Elvira Manzano

Five new practice guidelines from the European Society of Cardiology (ESC) recommend new agents, devices and

therapeutic options for managing valvular disease, ST segment elevation myocardial infarction (STEMI), heart failure (HF), atrial fibrillation (AF) and cardiovascular disease (CVD) prevention. A consensus statement was also issued on the latest universal defini-tion of myocardial infarction (MI).

For valvular disease, the importance of a collaborative approach between cardiologists and cardiac surgeons working as a “heart team” has been emphasized. For the first time, transaortic valve implantation (TAVI) is recommended in patients with severe symp-tomatic aortic stenosis (AS) who are unsuit-able for surgery, but only in hospitals with cardiac surgery on site. TAVI should not be performed in patients at intermediate risk for surgery.

Mitral valve repair is the preferred tech-nique in mitral regurgitation, when the repair is considered durable. Mitraclip device may be considered in high-risk or inoperable pa-tients resistant to optimal medical therapy.

In HF, the key changes from the 2008 ESC guidelines include a new indication for miner-alocorticoid antagonist (MRA) eplenerone in patients with systolic HF and mild symptoms, broadening the indication to essentially all HF-REF patients remaining symptomatic despite treatment with a beta-blocker and ACE inhib-itor or ARB. Ivabradine is now recommended to be added to an ACE inhibitor, beta-blocker and MRA for HF-REF patients in sinus rhythm with a persistently high heart rate (>70 bpm).

The use of cardiac resynchronization thera-py (CRT) has been expanded to patients with mild symptoms. Those with a left ventricu-lar ejection fraction (LVEF) of 35 percent or lower, sinus rhythm, and left bundle-branch block QRS morphology, however, benefit the most from the device.

The guidelines also recognize the increas-ing importance of cardiac MRI and include mid-regional proBNP as a ‘rule-out’ blood test in patients with acute HF.

Reperfusion therapy is recommended for all STEMI patients within 12 hours of first symptoms, and beyond the 12-hour window period if there is persistent pain and ECG changes. Clopidogrel and aspirin are recom-mended for fibrinolysis. Dual antiplatelet therapy is indicated for up to 12 months in those having primary PCI, a minimum of 1 month for those receiving a bare metal stent and 6 months for a drug-eluting stent.

For stroke prevention, the use of CHA2DS2-VASc score instead of the CHADS2 score is now recommended for identifying at-risk pa-tients, and new oral anticoagulants such as

ESC rolls out new practice guidelines

The new guidelines include a range of new options for managing heart conditions.

4 October 2012

dabigatran, rivaroxaban or apixaban are now considered preferable to vitamin K antago-nists (Class IIA). Dual antiplatelet therapy with aspirin and clopidogrel, or aspirin only, may be considered in patients who refuse anticoagulation.

Percutaneous closure of the left atrial appendage (LAA) may be considered in those with thromboembolic risk who cannot be managed with oral anticoagulants in the long term. Vernakalant has been introduced as a new antiarrhythmic agent for rapid cardioversion of recent onset AF, with few exceptions. The guidelines also highlight the revised use of dronedarone for paroxysmal or persistent AF. However, it is contraindicated in permanent AF and heart failure.

Catheter ablation is advised for patients with symptomatic paroxysmal AF who have failed antiarrhythmic medications (Class IA).

The guidelines on CVD prevention focus on CVD risk, why prevention is needed, and who should benefit from it. CV risks are classified as very high, high, moderate and low. Strong recommendations are given on diet, smoking, hypolipidemic medications, exercise and other behavioral risk factors.

The ESC also released the latest defini-tion for five types of MI and their clinical implications. The consensus document now recognizes that small amounts of myocar-dial injury or necrosis can be detected by biochemical markers and imaging.

5 October 2012 Forum

Health is intrinsically related to wealth. The Prospective Urban Ru-ral Epidemiological (PURE) study,

a survey of 153,996 adults from 628 urban and rural communities in 17 countries, has highlighted the discrepancies in lifestyle and diet between high-income and low-in-come nations.

The average fruit and vegetable con-sumption per day should be 500 grams or 5 servings, but surprisingly, our analysis of PURE showed that one-third of the coun-tries of the world are not consuming ad-equate amount. The consumption of fruits and vegetables increased among nations with a higher gross domestic product (GDP) and wealth index, but this was offset by an increase in the amount of energy obtained from total and saturated fats, as well as from protein. Energy from total fat, saturated fats and protein increased almost linearly with increasing incomes. Carbohydrate intake, on the other hand, made up approximately 65 percent of energy from diets in poor na-tions – this is because carbohydrates are a cheap source of energy – with the percent-age declining in wealthier nations.

Regarding smoking, the decision to smoke in women depends not only on GDP or wealth but also on cultural factors, includ-ing religion. In men, there is a clear inverse

Health policies need to foster right environmentExcerpted from a presentation by Professor Salim Yusuf, lead researcher of the PURE study and director of the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, during the 2012 European Society of Cardiology Congress held recently in Munich, Germany.

relationship between GDP and wealth and smoking status. Approximately 45 percent of men in the poorest countries smoke com-pared with 20 percent of men in the richest countries. Men started smoking at approxi-mately the same age and frequency in all countries, but the rate of quitting is mark-edly higher in higher-income countries. This is important because the focus of smoking should be on quitting. It’s the people who are alive today and who are smoking today who will die in the next 40 years from to-bacco. If you can get people to quit, then the children will not start. This is what we call ‘epidemiological transition,’ and this is what determines risk factors.

In terms of physical activity, the amount of recreational physical activity increased with increasing GDP and wealth, but

Recreational exercise alone won’t solve the obesity epidemic problem.

6 October 2012 Forumthis increase was offset by a reduction in the amount of obligatory physical activ-ity that is transport-related, job related and household-related activity required for physical labor. Overall, the net result was a reduction of approximately 2,000 [metabolic equivalent task] METS/minute/week, or 2.7 hours of brisk walking every day, among countries with higher incomes.

There is no way – unless you are a mar-athon runner – that we are going to over-come the decrease in activity due to the changing environment. The obesity epi-

demic really requires a change in environ-ment. We can yell at people and say, ‘exer-cise’ 30 minutes a day. But it is not going to be enough. It’s about one-fourth of the difference of lost physical activity which means that in the future, we will all be on treadmills.

While there are creative solutions, the key point is to understand that recreational exercise won’t solve the problem and the entire environment needs to be redesigned. That’s where policy comes in. We really need to create the right environment.

7 Indonesia FocusOctober 2012

Local events calendar

The 9th Congress of Asian Pacific Federation of Societies for Surgery of the Hand in Conjunction with The 5th Congress of the Asian Pasific Federation of the Societies for Hand TherapistBali, 11-13 Oktober 2012 Grand Hyatt BaliSekr : Jl. Pucang Anom Timur III No. 65, Surabaya, Jawa Timur, IndonesiaTel : 021-63869502Fax : 021-63869503Email : apfssh2012@pharma- pro.comWebsite : www.apfssh2012.org

The 35th Annual Scientific Meeting of Indonesian Urological AssociationJakarta, 12-14 Oktober 2012Hotel Gran Melia, JakartaSekr : Departemen Urologi, RSCM, Jl. Diponegoro No.71, Jakarta 10430Tel : 021-3152892, 3923631Fax : 021-3145592

PIT IKA VBandung, 13-17 Oktober 2012Hotel The Trans Luxury, BandungSekr : Ikatan Dokter Anak Indonesia, Cabang Jawa Barat Departemen Ilmu Kesehatan Anak, Fakultas Kedokteran Unpad RS Dr. Hasan Sadikin Jl. Pasteur No.38 Bandung – 40161Tel : 022-2039512Website : www.pitika5.com

Weekend Course on Cardiology (WECOC) 2012Jakarta, 19-21 Oktober 2012Sekr : National Cardiovascular Centre

Harapan Kita, Diklat Bldg 5th Fl, Jl. Letjen S Parman Kav 87, Slipi, JakBar 11420Tel : 021-5684093 ext 1554 & 3505Fax : 021-5608902

Current Concepts In Heads & Neck Surgery and OncologyJakarta, 20-22 Oktober 2012Hotel Shangri-La, JakartaSekr : THT Fakultas Kedokteran Universitas Indonesia, Rumah Sakit Cipto Mangunkusumo, JakartaTel : 021 - 3910701Fax : 021 - 3914154Email : ifnosjakarta2012@ gmail.com

10th Asia and Oceania Thyroid Association CongressBali, 24-27 Oktober 2012Discovery Kartika Plaza Hotel, BaliSekr : Divisi Endokrin, Fakultas Kedokteran Universitas Padjajaran Jl. Pasteur 38, Bandung 40161Tel /Fax : 022-2033274Email : [email protected] : www.aota2012.com

Muktamar Perhimpunan Ahli Bedah Onkologi Indonesia IX 2012Yogyakarta, 1-3 November 2012Hotel The Rich Jogja, YogyakartaSekr : SMF Bedah RSUP Dr. Sardjito, Yogyakarta, Jl. Kesehatan No.1 Sekip, YogyakartaTel : 0274-581333Email : [email protected]

25th Indonesian International Hospital Medical, Pharmaceutical Clinical, Laboratories Equipment & Medicine ExhibitionJakarta, 7-10 November 2012Jakarta Convention CenterSekr : PT. Okta Sejahtera Insani. Perkantoran Aries Niaga Blok A1 No.1P, Jl. Taman Aries, Jakarta Barat 11620Tel : 021- 58907366/68Fax : 021-58906819/20Email : hospital.expo@gmail. comWebsite : www.hospital-expo. com

KOPAPDI XV MedanMedan, 12-15 Desember 2012JW Marriot International, Aryaduta, Grand Aston, MedanSekr : Departemen Penyakit Dalam Fakultas Kedokteran Universitas Sumatera Utara /RS Umum Pusat H. Adam Malik Lt. III , Jl. Bungalau 17, Medan Tel/Fax : 061-4528075Email : papdicabsumut@gmail. comWebsite : www.kopapdimedanxv. com

Smart Rx. Every Time.

www.MIMS.com


Tablet tambah darah bagi ibu hamil anemia

Hardini Arivianti

Jumlah 90 tablet selama masa kehamilan tersebut sesuai dengan program suple-mentasi untuk penanggulangan anemia

pada ibu hamil di Indonesia. Walau kebi-jakan tersebut sudah ada sejak tahun 1970-an, tetapi tetap saja prevalensi anemia pada ibu hamil masih tinggi.

“Prevalensi ibu hamil dengan anemia seki-tar 40-50%, berarti 5 dari 10 ibu hamil men-galami anemia,” ujar dr Elvina Karyadi, MSc, PhD, dalam acara “Paparan Penelitian Dis-eminasi Anemia pada Ibu Hamil dan Tablet Tambah Darah” beberapa waktu lalu. Kondi-si ini tentu saja berdampak bagi janin yang dikandung dan juga ibu hamil itu sendiri.

Jika anemia berat maka risiko pendarahan akan meningkat yang bisa memicu kematian ibu, sedang pada bayi berisiko prematur dan berat badan bayi lahir rendah (BBLR).

“Suplemen TTD tetap diperlukan pada seseorang dengan anemia, karena jika hanya mengandalkan makanan saja maka su-lit untuk mengejarnya,” tukas direktur ‘Mi-cronutrient Initiative Indonesia’ (MI) ini lebih lanjut.

Penelitian di Kabupaten Lebak dan Purwakarta

Sejak Maret 2012 lalu Puslitkes FKM-UI bekerjasama dengan MI melakukan penelitian di 4 kecamatan di Kabupaten Lebak dan Pur-wakarta yang menjadi tempat percontohan. Beberapa poin yang didapat dari penelitian tersebut, dapat dilihat pada tabel.

”Hasil temuan lainnya adalah fokus pro-gram tersebut masih pada distribusi TTD dan bukan pada kepatuhan minum TTD,” jelas Kusbandriyo, SKM selaku Kepala Bidang Ke-sehatan Masyarakat Kabupaten Lebak.

Pada tahun 2011 kematian ibu di Lebak cukup tinggi yakni 42 orang/tahun, 22 dian-taranya disebabkan oleh perdarahan. Pada tahun 2007 sekitar 35% ibu hamil mengalami anemia. Sedangkan kematian bayi pada tahun 2011 mencapai 245 bayi, akibat BBLR/asfiksia (96 kasus) dan prematur (38 kasus).

”Salah satu yang berkontribusi terhadap tingginya angka kematian ibu adalah Banten dan Jawa Barat karena populasinya cukup ban-yak. Lebak dan Purwakarta menjadi daerah pecontohan untuk dijadikan pembelajaran ke depan perbaikan program dan menjadi acuan guna meningkatkan program ini di kabupaten

Temuan (ibu hamil) Purwakarta (%) Lebak (%)

* Minum TTD setiap hari 26,3 55,1 * Anemia ringan 29,3 71,1 Anemia berat 24,8 9,1* Pernah diperiksa kadar Hb 11,0 11,8* Trimester 2 dan 3 yang mendapat program > 60 tablet 23,5 42,9* Yang pernah minum TTD 80,3 90,4* Merasakan mual 65,5 51,5* Berhenti minum TTD 70,9 43,2* Trimester 1 dan mengeluh mual 95,0 70,6


lain,” jelas Tomi Herutomo, MKes, sebagai Ke-pala Seksi Promosi Kesehatan Kabupaten Pur-wakarta.

Ada kendalaLebih lanjut dr. Ridwan Gustiana, MPH se-

laku Ketua IBU Foundation menuturkan be-berapa hal yang menjadi kendala masih renda-hnya asupan suplemen TTD ini yaitu masalah pada distribusi sehingga suplemen yang sudah digratiskan oleh pemerintah ini tidak sampai sepenuhnya ke tangan para ibu hamil dan pen-getahuan masyarakat yang rendah sehingga masih banyak persepsi negatif mengenai suple-men ini, salah satunya ada persepsi bayi akan menjadi hitam atau menjadi besar jika minum suplemen ini, padahal kenyataannya tidak.

Efek samping mual setelah minum suple-men juga menjadi kendala dan membuat banyak ibu berhenti, padahal manfaat yang bisa didapat ibu hamil akan jauh lebih besar jika mengonsumsi suplemen ini.“Kita perlu memperbaiki sistem suplainya agar semua terjangkau dan pelatihan bidan agar dapat memberikan komunikasi yang efektif,” ung-kapnya.

Program Penguatan Suplementasi Zat Besi dan Asam Folat pada ibu hamil tersebut ber-tujuan untuk meningkatkan cakupan dan konsumsi suplementasi TTD pada ibu hamil serta peningkatan pengetahuan dan perilaku ibu hamil mengenai pentingnya suplementasi kedua zat gizi tersebut dan pentingnya asupan gizi sebelum dan selama kehamilan.

Hardini Arivianti

Sekitar akhir September lalu, GE Health-care meluncurkan Vscan 1.3 yakni

perangkat genggam berteknologi ultra-sonografi berukuran mini. Perangkat ini memungkinkan para dokter melakukan pemeriksaan non-invasif guna mendapat-kan visualisasi sehingga dokter mampu menentukan tindakan optimal yang dapat dilakukan dan memberikan perawatan yang cepat, efisien dan tepat sesuai kebu-tuhan pasien.

Berdasarkan riset yang pernah dilaku-kan oleh GE Healthcare di Indonesia tahun 2012, pasien yang memerlukan layanan pemeriksaan dengan ultrasonografi men-capai 25% dari seluruh total jumlah pasien setiap bulan.

Vscan, perangkat mini penunjang diagnosis


Menurut Indra W. Suwardi, selaku direk-tur GE Healthcare Indonesia, alat ini meng-gunakan baterai sehingga cocok untuk dipakai di daerah yang belum ada fasilitas listrik. Ukurannya juga mini dan memiliki berat hanya 390 gram.

Peran penting teknologi USG“Indonesia memerlukan teknologi terki-

ni guna mendukung pelayanan kesehatan primer baik di puskesmas maupun di titik-titik layanan kesehatan lainnya di seluruh nusantara, untuk membantu dokter men-gidentifikasi penyakit sedini mungkin dan merekomendasikan tindakan bagi pasien,” tukas Dr. dr. Tb Rachmat Sentika, SpA, MARS.

Selaku staf ahli Kementerian Koordina-tor Kesejahteraan Rakyat untuk Percepa-tan Pembangunan Milenium ini memapar-kan upaya menurunkan angka kematian ibu (AKI) masih merupakan tantangan karena Indonesia masih menjadi salah satu negara dengan angka tertinggi di kawasan Asia Pasifik. Dengan terobosan baru ini, diharapkan dapat berkontribusi terhadap sistem rujukan kesehatan untuk menyela-matkan lebih banyak ibu dan bayi lahir di Indonesia. “Pemeriksaan USG penting untuk memastikan berbagai kelainan ke-hamilan seperti plasenta previa, yang ti-dak memungkinkan bagi ibu hamil untuk

melahirkan normal.” Saat ini diperlukan sekitar 1.347 alat USG untuk dipasang di Puskesmas.

Selain perlunya penyediaan alat USG, per-baikan sistem rujukan di rumah sakit juga perlu dilakukan dan ditingkatkan. “Kematian pada persalinan biasanya terjadi karena fak-tor 3T yaitu keterlambatan mendeteksi, keter-lambatan mengenali tanda, dan keterlambatan mencari fasilitas kesehatan,” jelas dr.Prijo Sidi-pratomo, SpRad (K) pada acara yang sama.

“Penyebab kematian ibu adalah perdara-han (28%) yang diakibatkan oleh anemia dan kekurangan energi kronis. Prevalensi plasenta previa sebesar 6 dari 1000 persalinan. Penye-bab kedua kematian ibu adalah eklamsia,” pa-par Ketua IDI ini lebih lanjut.

Namun menurut dr. Judi Januadi Endjun, SpOG, alat bantu baru ini tidak bisa disamak-an kemampuannya dengan USG yang ada di rumah sakit. Dengan Vscan bisa diketahui po-sisi bayi, letak plasenta, jumlah air ketuban, tak-siran usia bayi, dan juga melihat detak jantung.

Selain itu, Vscan sangat berguna untuk digunakan di daerah-daerah yang belum terjangkau USG dan dapat digunakan oleh dokter umum di layanan primer serta dapat membantu mengetahui kondisi ibu saat/setelah melahirkan. “Alat ini sangat memban-tu dengan durasi selama 2 jam, padahal sekali periksa pasien hanya memerlukan waktu sekitar 3 menit.”


Waspadai TN penyebab nyeri luar biasa

Hardini Arivianti

Penyebab trigeminal neuralgia (TN) adalah penekanan pada N. trigemina-lis (N V) yang mengatur perasa pada

wajah atau sensorik wajah. Ciri umum pen-derita TN adalah rasa sakit luar biasa pada daerah bagian gusi, gigi, mulut dan wajah. Itu sebabnya selama ini penderita TN men-duga gigi adalah pemicu rasa sakit tersebut. Hal ini dijelaskan oleh dr. M Sofyanto, SpBS beberapa waktu lalu.

Nyeri bisa terjadi secara spontan namun leb-ih sering timbul akibat sentuhan atau aktivitas tertentu, seperti menggosok gigi, mengunyah, mencuci muka, makan, minum, bahkan air liur sendiri pun bisa menjadi pemicu nyeri.

Ciri khas nyeri akibat TN dilukiskan dengan suatu nyeri yang mendadak/spontan, akut, uni-lateral dan ada pemicunya. Nyeri dilukiskan seperti sengatan listrik, menusuk dan biasanya pada salah satu sisi wajah. Pada kebanyakan penderita, kadang nyeri berkurang pada malam hari atau pada saat berbaring. ”Gigi, stres, kele-lahan, kecemasan bukan penyebab TN, justru kondisi tersebut dapat memperberat reaksi bu-kan sebagai pemicu,” tukas pakar bedah saraf dari RS Bedah Surabaya ini lebih lanjut.

Mengenai prevalensi TN, dr. Sofyanto menjelaskan, diperkirakan sekitarr 107,5 pada pria dan 200,2 pada wanita per satu juta popula-si. Sisi kanan wajah lebih sering dibandingkan sisi kiri (3:2) dan seringkali dialami oleh usia di atas 40 tahun (10% kasus), walau ada kasus yang menyerang usia 22 tahun.

TN ini memiliki 2 kategori yaitu klasik dan sekunder. TN klasik disebabkan gesekan pem-buluh darah yang menekan nervus trigeminal

– lapisan myelinnya sudah rusak – sehingga mengganggu transmisi sinyal dan menimbul-kan rasa nyeri. TN dikategorikan sekunder bila ada penyakit yang mendasarinya, seperti sklerosis multipel dan penyakit lain yang dapat menimbulkan kerusakan mielin. TN sekunder lebih jarang terjadi.

Diagnosis TN ditegakkan berdasarkan MRI, dan penanganannya dengan dekompresi mi-krovaskular karena pendekatan, retraksi dan komplikasinya minimal. Saraf dan pembuluh darah yang bersinggungan/menempel dilepas-kan atau dipisahkan lalu diganjal dengan se-rabut berbahan teflon. Tindakan operasi ini hanya butuh waktu satu setengah hingga tiga setengah jam dengan 1-2 hari pemulihan. Sera-but berbahan teflon yang disematkan tersebut, tidak diserap, tidak menimbulkan alergi, tidak berubah dan tidak menyebabkan infeksi.

Namun tindakan key hole ini pada beberapa pasien menimbulkan efek samping tertentu diantaranya tinitus, pusing, perubahan tekan-an intrakranial, rasa baal/kebal di lidah/pipi. Rekurensi nyeri didapat pada 2% pasien pasca operasi. Penentu efek samping pasca operasi adalah usia dan trauma pasca operasi. Status re-covery pada usia muda dan tua berbeda. Untuk perawatan tertentu pasca operasi, dr. Sofyanto memberikan analgesik selama 5 hari.

Bila penderita memiliki kontraindikasi terha-dap operasi misalnya ada kelainan jantung dan paru, dapat diberikan golongan antikonvulsan (karbamazepin) sebagai pengobatan lini perta-ma. Namun obat ini kadang menimbulkan resis-tensi. “Bila sudah resistensi, lini kedua adalah ga-bapentin yang diberikan seumur hidup. Obat ini akan memblokade sinyal nyeri sehingga dapat mengurangi frekuensi dan intensitas nyerinya.”


Selanjutnya, dr. Sofyanto memaparkan kasus lainnya pada wajah. Penekanan tidak hanya dialami oleh N. trigeminalis saja. N. facialis (VII) juga bisa menyebabkan hemifa-cial spasme (HFS) yang pada awalnya ditan-dai dengan kedutan di kelopak mata, me-nyebar ke pipi dan mulut sehingga setengah

wajah akan terasa kaku dan merot. Selain itu, penekanan juga terjadi pada N. glos-sopharyngeus (IX) pasien akan mengalami gejala sakit luar biasa saat menelan. Ge-jala tergantung saraf yang tertekan, walau pembuluh darah yang ’menyerempet’ seki-tar 1-2 mm saja.


Penatalaksanaan penyakit metabolik pada layanan primer

Anna Dewiyana

Saat ini dislipidemia, DM tipe 2, obesi-tas dan hipertensi semakin banyak di-jumpai. Sebagai lini pertama layanan

ke-sehatan masyarakat, dokter umum di-hadapkan pada tantangan untuk mengatasi masalah kesehatan tersebut sehingga pasien terhindar dari risiko sindroma metabolik. Untuk meningkatkan mutu pelayanan dan menambah wawasan dokter umum sepu-tar sindroma metabolik, PDUI bekerjasama dengan MIMS Indonesia telah menyeleng-garakan simposium sehari Penatalaksanaan Penyakit Metabolik pada Layanan Primer, pada tanggal 15 September 2012 lalu bertem-pat di Surabaya.

Dislipidemia merupakan kelainan metabo-lisme berupa kelebihan maupun kekurangan lipoprotein, yang ditandai dengan peningka-tan kadar kolesterol, LDL kolesterol, dan tri-gliserida serum, serta rendahnya kolesterol HDL. Demikian Dr. dr. Sri Adiningsih, MS, MCN mengawali presentasinya. Panduan NCEP (National Cholesterol Education Program) memberikan 2 langkah diet untuk manajemen dislipidemia : diet step 1 dengan asupan asam lemak jenuh 8-10%, kolesterol < 300 mg/hari, dapat menurunkan sampai 3-14%; diet step 2 dengan asupan asam lemak jenuh < 7% dari kalori total, kolesterol < 200 mg/hari, menu-runkan sampai 3-7%. Pada kedua langkah diet tersebut pasien dianjurkan membatasi konsumsi lemak tak jenuh tunggal < 15% dan lemak tak jenuh ganda < 10%. Hindari daging berlemak, iga, buntut, jerohan, daging/ayam/

ikan go-reng, kuning telur (termasuk kue), makanan yang mengandung telur, whole milk, yogurt/keju reguler, es krim/whiping cream reguler, minyak kelapa/kelapa, santan, susu coklat, sayur dioles mentega/digoreng/berta-bur keju, dan buah dengan keju.

Dislipidemia pada pasien diabetes mening-katkan kejadian atau mortalitas kardiovaskul-er. Oleh karena itu, upaya pengendalian dis-lipidemia pada DM sebagai ekivalen penyakit jantung koroner (PJK) harus agresif. Penu-runan LDL yang agresif (<100 mg/dL atau <70


mg/dL) dengan terapi statin tanpa menghi-raukan kadar awal akan memberikan manfaat kardiovaskuler. Penyandang diabetes memi-liki faktor risiko kardiovaskuler yang lebih tinggi karena dislipidemianya, ditandai den-gan peningkatan LDL yang didominasi lemak dengan densitas kecil, peningkatan apoB, ren-dahnya HDL dan hipertrigliseridemia. Lemak yang kecil lebih mudah menembus dinding dan menancap di intima, juga lebih mudah teroksidasi. Demikian disampaikan oleh dr. Panji Mulyono, SpPD-KEMD pada sesi lunch symposium [Astra Zeneca Indonesia] yang merupakan bagian dari Simposium PDUI MIMS ini.

Modifikasi gaya hidup selalu menjadi langkah awal tata laksana dislipidemia pada orang dewasa dengan diabetes, seperti yang dinyatakan oleh American Diabetes Association (ADA). Pasien dianjurkan untuk mengurangi asupan lemak jenuh, lemak trans dan koles-terol, menurunkan berat badan, meningkat-kan aktivitas fisik dan berhenti merokok. Pada individu tanpa penyakit kardiovaskuler yang jelas, terapi statin diberikan untuk menurunk-an LDL sampai 30-40%, dengan target primer LDL < 100 mg/dL. Sedangkan pada individu dengan penyakit kardiovaskuler yang jelas, statin diberikan dalam dosis tinggi untuk mencapai target LDL < 70 mg/dL.

Lalu apakah semua statin memberikan manfaat yang sama? CORALL (Compare the effect of Rosuvastatin with Atorvastatin in ApoB/ApoA-I ratio in patients with type 2 diabetes meL-Litus and dyslipidemia) menunjukkan bahwa rosuvastatin lebih poten dibandingkan atorva-statin dalam mereduksi kolesterol LDL. Den-gan dosis yang sama (80 mg), penurunan LDL pada rosuvastatin lebih tinggi dibandingkan simvastatin maupun atorvastatin (63% vs 48% dan 55%), tetapi peningkatan transaminase

lebih banyak dijumpai pada pemberian simv-astatin dan atorvastatin. Dari studi STELLAR (Statin Therapies for Elevated Lipid Levels com-pared Across doses to Rosuvastatin) diketahui perubahan kolesterol HDL pada rosuvastatin 10, 20 maupun 40 mg lebih tingi dibanding-kan atorvastatin 80 mg.

Pembicara kedua pada sesi lunch sympo-sium [Astra Zeneca Indonesia] yang dimoder-atori oleh dr. J. Nugroho Eko Putranto, SpJP, FIHA adalah Prof. dr. Mohammad Yogiarto, SpJP(K), FIHA, FASCC, yang menyampai-kan presentasi mengenai aplikasi pengobatan pasien dislipidemia pada pasien risiko tinggi. Dari 10 faktor risiko penyebab komplikasi kardiovaskuler, ada 3 yang utama, yaitu hip-erkolesterol, merokok dan hipertensi. Makin tinggi kolesterol akan menyebabkan atero-genesis yang lebih berat berupa penyempitan di otak, mata, jantung, pembuluh perifer, ter-gantung predileksinya. Penelitian meta anali-sis menunjukkan bahwa penurunan kadar kolesterol bisa menurunkan angka kematian umum dan khususnya penyakit jantung ko-roner (PJK).

Yang menjadi pertanyaan adalah, seberapa jauh menurunkan kolesterol? Derajat penu-runan LDL tergantung pada komorbiditas yang ada. Makin tinggi risiko kardiovaskuler,


maka harus makin rendah kadar LDLnya bah-kan sampai 70 mg/dL. Apakah berlaku the low-er the better? Belum tentu, karena bagaimana-pun juga, kolesterol tetap diperlukan tubuh. Lalu bagaimana memilih obat yang bagus dan aman untuk mencapai target?

Dislipidemia merupakan faktor risiko utama terjadinya penyakit kardiovaskuler, sehingga penatalaksanaannya harus diper-hatikan, terutama pada pasien risiko tinggi. Pasien dengan sindroma koroner akut, DM tipe 2, TIA/stroke, aterosklerosis, hiperlipid-emia dengan risiko tromboembolik, wanita dengan penyakit kardiovaskuler, HDL ren-dah, termasuk ke dalam pasien risiko tinggi. Pasien risiko tinggi memerlukan pengobatan intensif, yaitu target kolesterol LDL < 100 mg/dL atau bahkan < 70 mg/dL. Kolesterol HDL bukan target khusus tetapi HDL yang rendah merupakan faktor risiko penyakit kardio-vaskuler independen yang kuat. DM dengan dislipidemia dianggap sebagai ekivalen PJK karena dislipidemianya bersifat aterogenik sehingga penurunan LDL harus lebih agresif.

Studi MERCURY (Measuring Effective Re-ductions in Cholesterol Using Rosuvastatin Ther-apy) menunjukkan, bila dibandingkan dengan atorvastatin 10-20 mg, rosuvastatin 10 mg bisa mencapai target sampai 40-50%. Selain menu-runkan LDL, juga meningkatkan HDL dan menurunkan trigliserida sehingga pemberian rosuvastatin mencapai 3 tujuan. Sedangkan dari studi ANDROMEDA (A raNdomized, Dou-ble-blind study to compare Rosuvastatin [10 & 20 mg] and atOrvastatin [10 & 20 Mg] in patiEnts with type II DiAbetes) diketahui rosuvastatin bisa menurunkan apoB sampai 50%. Peneli-tian juga menunjukkan bahwa rosuvastatin 5, 10 dan 20 mg cukup poten menurunkan trig-liserida.

Rosuvastatin 20 mg berpotensi sama den-

gan atorvastatin 80 mg dalam hal menurunk-an LDL dan rasio apoB/apoA-1. Perbedaan dosis ini akan mempengaruhi efek samping. Rosuvastatin terbukti memiliki efikasi yang besar karena dengan 20 mg bisa menurunkan LDL sampai target, mengurangi apoB dan ra-sio apoB/apoA-1. Bahkan dengan dosis yang lebih kecil, 5 mg, rosuvastatin dibandingkan dengan atorvastatin 10 mg dan simvastatin 20 mg, bisa menurunkan LDL lebih besar. Rosuvastatin 5 mg memiliki potensi yang cu-kup bagus, dengan efek terapeutik yang cu-kup bagus dan efek samping yang minimal. Karena makin tinggi dosis maka efek samp-ing terhadap fungsi hati, otot dan ginjal ma-kin besar. Rosuvastatin dengan dosis rendah memliki efek samping yang sangat minimal dibanding statin lain. Penurunan LDL cukup bagus, fungsi ginjal tidak terganggu, mialgia tidak banyak, efek miositis paling minimal. Rosuvastatin juga memperbaiki laju filtrasi glomerulus. Dari beberapa data yang terse-but diatas dapat disimpulkan bahwa dengan dosis kecil, rosuvastatin sudah dapat men-gontrol kadar lemak darah dan menurunkan risiko kejadian kardiovaskuler, dan efeknya tidak sekedar menurunkan lipid tetapi juga menyebabkan regresi plak dan mengurangi volume ateroma. Demikian Prof. Yogi men-gakhiri presentasinya.

DM dalam kehamilanSimposium PDUI MIMS ini juga diisi den-

gan clinical mentoring mengenai diabetes meli-tus (DM) dalam kehamilan yang disampaikan oleh Prof. dr. I. Oetama Marsis, SpOG. Di bi-dang layanan obstetri, DM merupakan prob-lem yang besar karena angka lahir mati teru-tama pada DM yang tidak terkendali, dapat terjadi 10 kali lipat kehamilan normal. Di klinik yang maju sekalipun, angka kematian dil-


aporkan 3-5% dengan angka morbiditas fetal 4%. Diabetes gestasional merupakan diabetes yang diketahui pada waktu hamil dan meng-hilang setelah melahirkan. Keadaan ini terjadi karena adanya resistensi insulin dan hiper insulinemia pada ibu. Diagnosis dini diabetes gestasional meliputi anamnesis, laboratorium (GDS > 200 mg/dL, GDP 126 mg/dL, urin dip-stik, HbA1c > 6%), dan tes toleransi glukosa oral (penapisan dan diagnosis dilakukan se-cara universal dengan menggunakan one step approach dengan beban glukosa 75 gram).

Pada DM yang terkendali, mo-nitor di-lakukan setiap minggu (gula darah, USG, CTG). Jika janin sehat maka persalinan nor-mal dapat dilakukan sampai usia kehamilan mencapai 40 minggu. Jika terjadi gawat janin, makrosomia atau IUGR, maka dilakukan tin-dakan terminasi. Pada DM yang tidak terk-endali, sejak usia kehamilan 34-36 minggu, ibu dirawat dan dilakukan pemeriksaan rutin gula darah, USG dan CTG, juga amniosente-sis. Jika paru-paru janin telah matang, maka dilakukan terminasi; jika paru-paru janin be-lum matang perlu diberikan steroid terlebih dahulu lalu kemudian dilakukan terminasi. Persalinan per vaginam dapat dilakukan pada usia kehamilan preterm, tinggi/berat janin tidak terlalu besar, dan risiko rendah; sedangkan seksio sesar dilakukan bila mak-rosomia > 4500 gram dan terdapat penyulit seperti kelainan vaskularisasi, nefropati dia-betes, retinopati diabetes.

Menyiasati obesitasdr. Achmad Yuniari Heryana, SpA me-

nyatakan bahwa di Indonesia terjadi pening-katan angka kejadian obesitas anak, terutama di daerah perkotaan. Penelitian Multisenter (2004) di 10 ibukota propinsi daerah Jawa, Sumatera dan Sulawesi menunjukkan angka

kejadian obesitas pada anak sebesar 2.5–25 %. Obesitas merupakan gangguan multi-faktorial keseimbangan penggunaan energi yang ditandai dengan ada nya penumpukan jaringan lemak. Faktor-faktor endogen yang dapat menyebabkan terjadinya obesitas an-tara lain faktor genetik, perubah an lingkun-gan intrauterin dan endokrinopati yang dis-ertai obesitas. Bayi yang lahir dengan kondisi Intrauterine Growth Retardation (IUGR) akan tumbuh menjadi individu yang resisten ter-hadap insulin, menderita penyakit kardio-vaskuler dan sindroma metabolik. Meskipun mekanisme pastinya belum diketahui tetapi diduga perubahan lingkungan intrauterin menimbulkan perubahan permanen pada set poin aksis hipotalamus-hipofisis-adrenal, sehingga ada kecenderungan bayi-bayi yang lahir dengan kondisi IUGR menjadi obesitas di kemudian hari.

Kriteria obesitas pada anak ditentukan berdasarkan klinis dan antropometris. Menu-rut dr. Nur Aisiyah Widjaya, SpA Nutrisi, secara fisik wajah terlihat membulat, pipi tembem, leher pendek, perut buncit, din ding perut berlipat, akantosis nig rikans, gerakan panggul terbatas, penis kecil. Untuk mengetahui apakah obesitas atau over-weight, untuk anak usia < 2 tahun digunakan kurva BMI dari WHO, untuk anak usia 2-18 tahun digunakan kurva BMI dari CDC. Tata laksana umum adalah menejemen diet dan aktivitas fisik. Pengaturan makan dimodi-fikasi dengan pemberian kalori yang sesuai dengan umur. Terapi medis dan pembedahan jarang dilakukan pada anak.

Tahap pertama merupakan pencegahan plus, dimana anak dianjurkan mengonsumsi lebih ba nyak serat karena jumlah kalorinya sedikit tetapi anak tetap merasa kenyang, mengurangi minum manis, mengurangi ke-


biasaan nonton televisi/main game (maksi-mal 2 jam/hari), menambah aktivitas fisik main (minimal 30-60 menit/hari). Jika tahap pertama tidak berhasil, maka tahap kedua adalah manajemen berat badan terstruktur, yaitu kalori ditentukan sesuai kebutuhan berdasarkan usia, jadwal makan ditentukan, aktivitas fisik ditingkatkan, batasi nonton maksimal 1 jam/hari. Jika tahap kedua gagal, terapkan tahap ketiga yang melibatkan beber-apa ahli diantaranya psikolog, perawat, tera-pis, ahli THT/pulmo, tergantung komplikasi yang terjadi. Biasanya ada keluhan obstructive sleep apnea syndrome (OSAS), penurunan per-forma belajar, tidak aktif. Tata laksana tahap 4 umumnya diberikan kepada remaja obesitas berat yang gagal pada tahap 3, bisa diberikan obat-obatan (sibutramin jika usia > 16 tahun, orlistat untuk usia > 12 tahun). Efektivitas far-makoterapi tidak sebaik merubah gaya hid-up, tetap harus didukung diet yang teratur. Berikan diet sangat rendah kalori yaitu 400-800 kal/hari.

Dalam presentasinya yang berjudul Man-agement Obesity : Focus on medical treatment, dr. Sony Wibisono M, SpPD-KEMD, FINASIM menyampaikan bahwa pengobatan kelebi-han berat badan atau obesitas mencakup dua proses, yaitu penilaian dan tata laksana. Keti-ka melakukan penilaian, dokter akan menen-tukan tingkat keparahan obesitas (apakah ter-masuk overweight BMI 25,0-29,9, obesitas BMI 30-39,9 atau obesitas ekstrim BMI ≥ 40) dan komorbiditas (penyakit lain). Tata laksana tidak hanya mengenai bagaimana menurun-kan berat badan (BB), tetapi juga bagaimana mempertahankan BB dan mengendalikan faktor risiko lainnya.

Jika BMI > 25 atau lingkar pinggang be-sar (pria > 90 cm, wanita > 80 cm), lakukan pemeriksaan klinis dan laboratorium (tekan-

an darah, denyut jantung, glukosa puasa, profil lemak) untuk menilai komorbiditas, juga penilaian dan penapisan untuk depresi atau kelainan makan/mood. Obati komorbidi-tas dan risiko kesehatan lain yang ditemukan. Target penurunan berat badan adalah 5-10% dari berat badan atau 0,5-1 kg/minggu, sela-ma 6 bulan. Program modifikasi gaya hidup meliputi terapi nutrisi (mengurangi asupan energi sampai 500-1000 kkal/hari), aktivitas fisik (30 menit berjalan kaki setiap hari) dan terapi perilaku-kognitif. Farmakoterapi di-berikan kepada pasien dengan dengan BMI ≥ 27 disertai faktor risiko atau BMI ≥ 30, sedan-gkan jika BMI ≥ 35 disertai faktor risiko atau ≥ 40, pertimbangkan bedah bariatrik.

Standar kompetensi era SJN-BPJSSesi terakhir dari simposium diisi oleh Pre-

sidium Nasional PDUI, dr. Dyah A. Waluyo. Beliau menyampaikan, dengan Standar Jami-nan Sosial Nasional (SJSN) diharapkan lay-anan kesehatan secara keseluruhan akan berubah, berbeda sekali dengan saat ini. Jika pada saat ini sistem pembiayaan terutama dari pribadi, nantinya akan berlaku univer-sal coverage dimana seluruh masyarakat In-donesia akan mendapat layanan kesehatan yang sama dan dijamin oleh layanan berbasis asuransi kesehatan, yaitu SJSN. Saat ini ma sing-masing kelompok sudah mulai, yaitu PNS oleh Askes, ABRI oleh Askes ABRI, pe-kerja sektor formal oleh Jamsostek, golon-gan yang tidak mampu oleh Jamkesmas/Jamkesda; nanti semua akan menjadi satu. Problemnya adalah masing-masing me-miliki aturan, syarat premi dan layanan yang berbeda. Menyatukan diatas kertas sudah terwujud dalam bentuk SJSN, dan telah dibentuk badan pelaksananya yaitu Badan Pelaksana Jaminan Sosial (BPJS).


Tetapi tentu tidak mudah untuk mereali sasikannya sehingga periode sekarang adalah saat untuk bargaining, mana yang akan dipak-ai. Apakah sama dengan Askes, apakah sama dengan Jamsostek atau berbeda sama sekali. Yang pasti, ada atau tidak adanya SJSN/BPJS, sebagai dokter layanan primer harus tetap mengupgrade diri sehingga ketika sistem apa pun yang nantinya dipakai, kita sudah siap.

Tidak semua layanan akan masuk ke dalam SJSN karena akan ada mandat dan kontrak deng-an BPJS, syaratnya adalah standar kompetensi dan standar pela yanan. Kemenkes 2011 menyatakan bah-wa ada 2 layanan yang diakui, yaitu klinik pratama (layanan kesehatan umum) dan klinik utama (spesialis). Praktek mandiri di-harapkan bergabung menjadi satu layanan primer, membentuk suatu sistem jaringan layanan dokter umum. Mulai pikirkan untuk bergabung praktek bersama karena praktek mandiri tidak akan diikutsertakan dalam

SJSN sebab yang diliihat adalah fasilitas lay-anan kesehatan. Mulai pikirkan untuk mem-bentuk klinik yang terstandar, klinik pratama yang mandiri dan kolektif (mengajak keper-awatan dan kebidanan). Konsepnya ada klinik-klinik kecil, minimal dengan 2 dokter dibantu 1 perawat lalu ada klinik yang lebih lengkap sehingga berjejaring antar klinik, jadi rujukan tidak hanya vertikal tetapi hor-isontal. Klinik utama memiliki peralatan yang lebih lengkap, ada USG dan pemerik-saan laboratorium sederhana.

Juga didorong terbentuknya koperasi se-hingga dokter tidak hanya menjadi karyawan klinik yang dapat disepelekan oleh pemilik klinik. Dokter umum hendaknya bekerja di klinik dengan bargaining menjadi bagian dari pemilik, dimana ada sebagian modal yang di-berikan kepada okter yang berpraktek di klinik tersebut. Sehingga profesi ini mampu meng-hidupi anggotanya, dan terwujud dokter yang bermartabat dan masyarakat yang sehat.

21 October 2012 Depress ion

Depression, other mental disorders increase risk of early death

Radha Chitale

Mental disorders such as depression, bipolar disorder and schizophrenia, which may not require hospitaliza-

tion due to severity, can still increase risk of premature death, according to a long-term study of Swedish patients.

“Mental disorders have been associated with increased mortality, but the evidence is primarily based on hospital admissions for psychoses,” said the researchers, who com-piled data from psychiatric interviews with Swedish men of mean age 18.3 years who were conscripted for military service over a mean 22.6 years of follow up through national reg-istries.

When diagnosed at conscription, depres-sion was associated with double the risk of premature death (age-adjusted hazard ratio of 1.81) and the presence of bipolar disorder in-creased the risk of death by more than 5 times (age-adjusted hazard ratio of 5.55). [Arch Gen Psychiatry 2012;69:823-831]

In total, 1.09 million men were conscripted between 1969 and 1994 of which 5.6 percent were diagnosed at conscription with a mental disorder.

Compared with men without mental ill-nesses, men who were diagnosed later upon admission to a hospital had mortality hazard ratios of 5.46 for neurotic and adjustment dis-orders and 11.2 for substance abuse disorders not including alcohol.

Men admitted to hospital for psychiatric rea-sons following conscription numbered 60,333,

10,665 of whom were already diagnosed dur-ing conscription.

The mortality risk associated with other di-agnoses after adjusting for age, socioeconomic status, blood pressure, body mass index, intel-ligence, and education included hazard ratios of 1.53 for depression, 5.19 for bipolar disorder, 2.52 for schizophrenia, 1.88 for personality dis-orders, 1.62 for other non affective psychoses, 1.48 for neurotic and adjustment disorders, 2.38 for alcohol-related disease and 2.68 for other substance abuse.

The associations were partially attenuated by adjusting for smoking, alcohol intake, intel-ligence, education and late-life socioeconomic status but were not affected by early-life so-cioeconomic status, body mass index or blood pressure.

During the follow up period, 15,110 men died. Age stratification of the 4,879 men who were

diagnosed during hospitalization who died subsequently showed that mortality risk was five to 11 times higher for men born between 1951 and 1958 and seven to 29 times higher for men born between 1968 and 1976.

The mortality risk remained significantly elevated even after excluding about 20-32 per-cent of deaths considered suicide.

This might be due to more severe disease, particularly in the group diagnosed early, the researchers noted.

The results of the all-male study population were further limited by potentially unmea-sured factors such as comorbid illness, lifestyle, medications and varying access to healthcare, the researchers said.


Heart attack increases spouse depression, anxiety Elvira Manzano

The death of a spouse from heart attack increases the risk of depression and anx-

iety in the surviving partner, requiring an increased use of psychotropic medications, a large Danish study has found.

“Losing a spouse or having a spouse ex-periencing a non-fatal MI is a major public health issue for which there is very little awareness among physicians and policy makers,” said study author Dr. Emil Fosbøl, a cardiologist and researcher at Denmark’s Gentofte University Hospital, Hellerup, Denmark. “People involved with patient care should be aware of spouses’ mental re-actions after a life-threatening event such as an MI. I would like to see a more formal way of screening spouses for depression in rela-tion to the event, but also subsequently.”

Using data from Danish national regis-tries, Fosbøl and colleagues compared the incidence of hospital system contact (hos-pital admission or ambulatory visit), use of antidepressants and benzodiazepines, and suicide among spouses of patients who had fatal and non-fatal MI (16,506 and 44,566, respectively) for the first time with those whose spouses died or were hospitalized for other causes (49,518 and 131,564, respec-tively).

The study found the incidence of depres-sion was significantly higher among spouses of patients who had myocardial infarction (MI), fatal or nonfatal, compared with those whose spouses had non-MI events (pre-post, P<0.0001). Overall, the use of antidepres-

sants was higher in the year after MI deaths (incident rate ratio [IRR] 3.30, 95% CI 2.97–3.68) compared with the year before, peak-ing at 2 months post event (IRR 5.72, 95% CI 4.85-6.74). The use of benzodiazepines also increased a month after MI deaths (IRR 46.4, 95% CI 42.2–50.0). The results also applied to spouses of patients who had non-fatal MI (P<0.001). Moreover, spouses of patients who died from MI were more likely to com-mit suicide than those who lost them to oth-er causes (0.24 vs. 0.17 percent, P=0.07). [Eur Heart J 2012. Epub ahead of print]

A standardized mental screening pro-gram could potentially prevent many spous-es from being depressed or taking their own lives, Fosbøl told Medical Tribune. “It would also be interesting to see in a formal-ized study [to determine] whether screening could reduce depression in spouses after a fatal or non-fatal MI.”

Although previous studies have shown that the death of a spouse can affect an in-dividual’s health and life expectancy, death from MI – which can often occur suddenly and unexpectedly – appears to have a larg-er psychological impact on the spouse than death from other causes.“One does not have time to prepare psychologically for the death compared with, for example, cancer,” Fosbøl said.

The study implies that clinical attention needs to be paid to both the patient, who is suffering from the physical and mental trau-ma, and the spouse, who has to live through the event alongside the patient, the authors concluded.


Rajesh Kumar

The antidepressants fluoxetine and venla-faxine are efficacious as short-term ther-

apy for major depressive disorders in all age groups, according to a large meta-analysis.

The researchers pooled data from more than 9,100 patients of all ages with major depressive disorder who had been included in a total of 41 randomized clinical trials of fluoxetine (N=20 trials) and venlafaxine (N=21 trials). They carried out a reanalysis of all person-level longitudinal data for the first 6 weeks of active treatment. [Arch Gen Psychia-try 2012;69:572-579]

They found that patients in all age groups had significantly greater improvement com-pared with those receiving placebo, although the differential rate of improvement was larg-est for adults receiving fluoxetine (34.6 per-cent greater than those receiving placebo). Youth had the largest difference in response rates (24.1 percent in treated vs. control) and remission rates (30.1 percent), with adult dif-ferences generally in the 15.6 percent (remis-sion) to 21.4 percent (response) range.

Geriatric patients had the smallest drug-placebo differences, an 18.5 percent greater rate of improvement, 9.9 percent for response and 6.5 percent for remission. Also, immedi-ate-release venlafaxine produced larger ef-fects than extended-release venlafaxine, and baseline severity did not affect symptoms.

This is the first research synthesis in this area to use complete longitudinal person-level data from a large set of published and unpublished studies.

Most studies included in the meta-analysis were designed for achieving regulatory ap-proval and do not demonstrate the maximum effect a drug can produce. Some studies were as short as 6 weeks whereas the maximum ef-fect during an acute treatment episode is like-ly 12 weeks or longer, the researchers argued.

“The [current] study highlights many of the limitations of meta-analysis that combine evidence from multiple RCTs,” concluded the researchers.

“It further highlights advantages of more complete personal-level analysis when such data are available and increases the need for caution regarding interpretation of meta-an-alytic results when person-level data are not available.”

Short-term fluoxetine, venlafaxine efficacious for depression

24 October 2012 News

Tai chi can benefit patients with COPD

Elvira Manzano

A modified tai chi program may im-prove the exercise capacity and qual-ity of life of patients with chronic

obstructive pulmonary disease (COPD), new research has shown.

In a randomized controlled trial, patients assigned to tai chi were, on average, able to walk 55 meters (95% CI 31 to 80) farther and 384 seconds (95% CI 186 to 510) longer at 12 weeks compared with a control group. [Eur Respir J 2012; DOI:10.1183/09031936.00036912]

“An important finding from our study was the significant improvement in bal-ance and muscle strength following Sun-style tai chi training, which has the poten-tial to reduce the risk of falls in people with COPD,” said one of the study authors Dr. Jennifer Alison, from the University of Sydney, Australia.

Lower limb muscle weakness and impaired gait and balance are common in people with COPD and are major risk factors for falls.

In the study, patients were randomized to a 12-week tai chi program, consisting of a 2-hour session each week, or standard COPD treatment without exercise. The majority of the patients were males. Average age was 73, with co-morbidities that included osteoar-thritis, hypertension, dyslipidemia and coro-nary heart disease. On days when patients were not on sessions, they practiced tai chi at home for 30 minutes.

Compared with the control group, patients on tai chi exercise performed 75 percent bet-ter in the walking test and had a significantly higher score in the Chronic Respiratory Dis-

ease Questionnaire, which indicates better quality of life.

Additionally, tai chi was associated with moderate intensity exercise as demonstrated by a 53-percent reserve in oxygen consump-tion. Significant improvements in balance, strength and performance were also observed in the tai chi group. The effects of tai chi were comparable to what can be achieved during conventional pulmonary rehabilitation.

“This is good news for people with COPD because it gives them more fitness choices,” said lead study author Ms. Regina Wai Man Leung of Concord Repatriation General Hos-pital and the University of Sydney, Austra-lia. “With increasing numbers of people be-ing diagnosed with COPD, it is important to provide different options for exercise that can be tailored to suit each individual,” added

Tai chi improved muscle strength and balance in study patients.


Saras Ramiya

Selected proton pump inhibitors (PPIs) are safe for long-term use in patients with chronic gastrointestinal (GI) con-

ditions, a study shows.The new landmark international study

looked at the long-term effects of pantopra-zole in patients with chronic GI conditions such as peptic ulcers and reflux esophagitis. [Aliment Pharmacol Ther 2012;36(1):37-47]

Following healing of peptic ulcers or reflux esophagitis during 4 to 12 weeks’ treatment with pantoprazole (40 to 80 mg/day), patients received open-label maintenance treatment with pantoprazole (40 to 160 mg/day) for up to 15 years in a single center combined study. Safety assessments were conducted using en-doscopy, clinical examination and laboratory investigations.

The safety set, which comprised 142 adults who received continued pantoprazole treat-ment for over 15 years, showed healing rates of 95.8 percent after 12 weeks without in-creased risks of specific serious conditions like stomach cancer.

“This study shows that pantoprazole effec-tively controls the production of acid and heals upper gastrointestinal ulcers and wounds in the long term without identifiable side ef-fects,” said principal investigator Professor G.

Brunner, of the Division of Gastroenterology and Hepatology, University Medical School, Hannover, Germany, in a press release based on a regional GI media summit organized by Takeda Pharmaceutical Company Limited in Kuala Lumpur.

“In light of this longest safety data on pan-toprazole, doctors and patients have even more assurance that PPI therapy is safe for long term treatment of severe GERD and gas-trointestinal conditions,” he added.

GI problems on the riseGI disorders in Asia have been increasing in prevalence, as shown in studies. “As a result of dietary changes, rising obesity and stress in many parts of Asia, doctors are now seeing a rising number of cases of severe and chronic GI conditions, such as GERD, peptic ulcers

PPIs safe for long-term use

Expanding waistlines across Asia have contributed to increased incidence of

severe and chronic gastrointestinal conditions.

Leung, a cardiorespiratory physiotherapist.The authors said the study provides com-

pelling evidence that tai chi may be an effec-tive alternative training modality for people with COPD who have limited or no access to

pulmonary rehabilitation. The high degree of adherence with both formal and at-home training and practice suggests that the pro-gram is feasible for COPD patients, even for those with comorbidities, they concluded.

26 October 2012 Newsand heartburn,” said Dr. Denis C. Ngo, of the University of Santo Tomas (UST) Hospital, Manila. [J Gastroenterol Hepatol 2008:23:8-22]

In the Philippines, the prevalence of erosive esophagitis rose from 2.9 percent to 6.3 per-cent over 6 years; in Malaysia, the incidence rose from 2.0 percent to 8.4 percent over a 10-year period; time trend studies showed that esophagitis rates in Taiwan more than doubled from 5.0 percent to 12.6 percent over a 7-year period. [J Gastroenterol Hepatol 2007;22:1650-5, Aliment Pharmacol Ther 2009;29:774-80, J Clin Gastroenterol 2009;43:926-32]

The prevalence of symptom-based GERD in Eastern Asia (China, Japan, Korea and Tai-wan) rose from 5.2 percent in 2005 to 8.5 per-cent in 2010. [BMC Gastroenterol 2010;10:94] In Malaysia, the incidence of reflux esophagitis increased from 2.7 percent to 9.0 percent dur-ing the time period from 1991-1992 to 2000-2001, while Indonesia’s Cipto Mangunkusu-mo Hospital reported the prevalence of GERD increasing from 5.7 percent in 1997 to 25.1 per-cent in 2002. [Gastroenterology 2004;126:A443,

Canc Res Treat 2003;5:83]Currently, 2.5 percent to 4.8 percent of

Asians experience weekly symptoms of heartburn and/or acid regurgitation. [Gut 2005;54:710-7] Besides heartburn, patients with GERD and gastrointestinal disorders suffer difficulty swallowing (dysphagia), re-duced vitality, disturbed sleep and consid-erable lower quality of life greater than that observed in other chronic conditions such as diabetes, arthritis or congestive heart failure. [Dig Dis 2004;22(2):108-14]

There is a high prevalence of GERD in indi-vidual Asian countries, ranging from 12.4 per-cent in Taiwan and up to 17 percent in China, and 29.8 percent in Hong Kong. [J Neurogas-troenterol Motil 2011;17(1):14-27, World J Gas-troenterol 2004;10:1647-51, Aliment Pharmacol Ther 2003;18:595-604]

“These conditions are so severe that pa-tients do not require just quick relief for GI conditions, but more sustained control with proton pump inhibitors (PPIs) over the long term,” said Ngo.


Rajesh Kumar

T reatment with surgery was significantly more effective than local steroid injection in alleviating symptoms of carpal tunnel

syndrome (CTS) over a 2-year follow up period, a Spanish study has found.

In the prospective, randomized clinical trial, researchers studied the effects of surgical de-compression versus local steroid injection by randomly assigning 80 wrists to surgical decom-pression and 83 to local steroid injection follow-ing a clinical diagnosis and neurophysiological confirmation of CTS in 101 patients. [Rheumatol-ogy 2012;51:1447-1454]

The primary end point at 2-year follow-up was the percentage of wrists that reached a >20 percent improvement in the visual ana-logue scale score for nocturnal paresthesia. Both treatment groups had comparable sever-ity of CTS at baseline.

Fifty-five wrists in the surgery group and 48 wrists in the injection group completed the fol-low-up. In the intent-to-treat analysis, 60 percent of the wrists in the injection group and 69 per-cent in the surgery group achieved a 20 percent response for nocturnal paresthesia (P<0.001).

Although the clinical relevance of those dif-ferences remains to be defined, the findings are not entirely unexpected as each of the two pro-cedures has its own benefits and disadvantages, said Dr. Chew Li-Ching, consultant in the de-partment of rheumatology and immunology at Singapore General Hospital (SGH).

“The injection can be easily… delivered at the point of care. However, usually, it provides tem-porary relief only compared with surgery. At

SGH, we are well supported by hand surgeons, [therefore] access to surgery has not proven to be an issue,” said Chew.

“Injection is still an acceptable standard of care for CTS, especially if the patient’s symp-toms and findings on neurophysiological test-ing are mild to moderate. The more severe cases such as those associated with weakness and muscle wasting would usually warrant surgery.”

Although randomization based on wrists rather than patients could be considered the study’s limitation, CTS is often a bilateral con-dition and the approach is consistent with the standard of care in clinical practice which con-sists of treating both wrists in cases of bilateral CTS, said the researchers.

“We also felt that by randomizing only the most symptomatic wrist in the bilateral cases, we could have a biased selection [and] the results of the study would not represent the real severity of CTS in the general population…it would transform CTS into a more severe disease than it really is.”

Surgery superior in patients with carpal tunnel syndrome

Wrist surgery is more effective at treating carpal tunnel syndrome than

local steroid injections.


Higher vitamin C intake may help reduce heart disease, strokeRajesh Kumar

The recommended dietary allowance (RDA) of vitamin C should be raised to at least 200 milligrams per day for

adults to prevent heart disease and stroke, experts have suggested.

The current RDA for this vitamin in most countries is less than half of what it should be, because medical experts insist on evalu-ating this natural but critical nutrient the same way they do pharmaceutical drugs and reach faulty conclusions, said lead author Dr. Balz Frei, professor and director of the Linus Pauling Institute at Oregon State University in Corvallis, Oregon, US. [Crit Rev Food Sci Nutr 2012; 52:815-829]

Rather than just prevent the vitamin C de-ficiency disease of scurvy, Frei said it is ap-propriate to seek optimum levels that will saturate cells and tissues, pose no risk, and may have significant effects on public health at almost no expense.

“Significant numbers of people around the world are deficient in vitamin C, and there’s growing evidence that more of this vitamin could help prevent chronic disease,” he said.

Studying micronutrients the same way as testing pharmaceutical drugs, through phase III randomized placebo-controlled trials, al-most ensures that scientists will find no ben-eficial effect, said the researchers. Such tri-als are ill suited to demonstrate the disease prevention capabilities of substances that are already present in the human body and are required for normal metabolism, they added.

Some benefits of micronutrients in lower-

ing chronic disease risk also show up only after many years or even decades of their op-timal consumption – a factor often not cap-tured in shorter-term clinical studies, they pointed out.

The US and European researchers re-viewed metabolic, pharmacokinetic, labora-tory and demographic studies and concluded higher levels of vitamin C could help reduce chronic diseases such as heart disease, stroke, cancer, and the underlying issues that lead to them, such as high blood pressure, chronic inflammation, poor immune response and atherosclerosis.

Even marginal deficiency of vitamin C can lead to malaise, fatigue, and lethargy, the re-searchers noted, while healthier levels can enhance immune function, reduce inflam-matory conditions such as atherosclerosis, and significantly lower blood pressure.

Critics have suggested that some of these differences are simply due to better overall diet, not vitamin C levels, but the research-ers noted that some health benefits corre-late even more strongly to vitamin C plasma levels than fruit and vegetable consumption alone.

Dr. Amber Bastian, dietician at the Centre of Excellence (Nutrition), Health Promotion Board Singapore, said her organization up-dated its RDA for vitamin C earlier this year.

“It is 105mg for men and 85mg for women, which is quite progressive as it is higher than Australia (45mg), US (75mg females, 90mg males), WHO (45mg) and Malaysia (70mg),” said Bastian.

“[This RDA] was developed based on cur-

29 October 2012 Newsrent evidence of the amount needed to pro-vide antioxidant protection, rather than to prevent scurvy which is what was tradition-ally used,” she said, adding that the board regularly reviews its dietary recommenda-tions to provide up-to-date recommenda-tions based on the most recent evidence.

Typically, each serving of fruit has around 35mg of vitamin C, while a serving of vegeta-ble has around 40mg. People would achieve an intake of about 150mg per day if they follow HPB’s current recommendation of two servings each of fruits and vegetables per day, added Bastian.

30 October 2012 Conference CoverageEuropean Society of Cardiology Congress, 25-29 August, Munich, Germany

Aspirin can be dropped in PCI patients on oral anticoagulantsChristina Lau

Patients on oral anticoagulants (OAC) undergoing percutaneous coronary in-tervention (PCI) should be treated with

clopidogrel, but not aspirin, according to the first randomized trial to assess optimal antithrom-botic therapy in this high-risk group of patients.

The trial showed that dual therapy with OAC and clopidogrel causes less bleeding than triple therapy with OAC, aspirin and clopidogrel, and is safe with respect to preventing thrombotic and thromboembolic complications.

“Long-term OAC therapy is obligatory in most patients with atrial fibrillation (AF) and in those with mechanical heart valves. Over 30 percent of these patients have concomitant isch-emic heart disease and, if they need to undergo PCI, aspirin and clopidogrel are indicated,” said lead investigator Professor Willem Dewilde of the TweeSteden Hospital in Tilburg, the Nether-lands.

“Until now, no prospective randomized data were available on the optimal antithrombotic therapy for these patients,” he continued. “Al-though triple therapy seems logical for the pre-vention of stroke and stent thrombosis, it often causes serious bleeding complications and the need to discontinue aspirin and clopidogrel.”

The WOEST* study included 573 patients from the Netherlands and Belgium, who were already on OAC for AF or mechanical valves and were undergoing PCI. The primary endpoint was occurrence of all bleeding events after 1 year, classified according to the TIMI (Thrombosis in Myocardial Infarction) bleeding criteria. Second-

ary endpoints were the combination of stroke, death, MI, stent thrombosis and target vessel re-vascularization, and all individual components of the primary and secondary endpoints.

“At 1 year after PCI, patients in the dual ther-apy group had significantly lower incidence of bleeding (19.5 vss 44.9 percent; HR=0.36; P<0.001] and overall mortality [2.6 vs. 6.4 per-cent; HR=0.39; P=0.027) than those in the triple therapy group,” reported Dewilde. “They had no increase in thrombotic or thromboembolic events compared with those on triple therapy.”

Although the trial was open-label and had a limited number of patients, Dewilde suggested that the findings have important implications for future treatment and guidelines. “We propose that a strategy of OAC plus clopidogrel, without aspirin, could be applied in this group of high-risk patients on OAC when undergoing PCI,” he said.

Commenting on the findings, discussant Dr. Marco Valgimigli from Ferrara, Italy pointed out that one bleeding event could be avoided by omitting aspirin in only four patients. “While the reductions were mostly in minimal [6.5 vs. 16.7 percent] and minor bleeding [11.2 vs. 27.2 per-cent], the difference in major bleeding between the dual and triple therapy groups might have become significant with larger numbers,” he said. “With the important findings from WOEST, the taboo of discontinuing or omitting aspirin in the contemporary environment has been broken.”

*WOEST: What is the Optimal antiplatElet and anticoagulant therapy in

patients with oral anticoagulation and coronary StenTing

31 October 2012 Conference CoverageInvestigational drug shows promise in HFChristina Lau

A novel angiotensin receptor ne-prilysin inhibitor – LCZ696 – has demonstrated beneficial effects in

heart failure (HF) patients with preserved ejection fraction in a phase II trial.

LCZ696 is a first-in-class agent comprising the molecular moieties of a neprilysin inhibitor and the angiotensin receptor inhibitor (ARB) valsartan as a single compound. Its dual mechanism of action is believed to restore the altered neurohormonal balance in HF with preserved ejection fraction.

In the PARAMOUNT* study, the efficacy and safety of LCZ696 was compared with that of valsartan in 308 patients from 13 countries. [Lancet 2012; DOI:10.1016/S0140-6736(12)61227-6]

“HF with preserved ejection fraction accounts for up to half of HF cases, and is associated with substantial morbidity and mortality. However, no therapies have been shown to improve clinical outcomes in this condition,” said lead investigator Professor Scott Solomon of the Harvard Medical School and the Brigham and Women’s Hospital in Boston, Massachusetts, US.

Results showed that after 12 weeks of therapy, LCZ696 significantly reduced levels of NT-probBNP by 23 percent compared with valsartan (P=0.005). “NT-proBNP is a marker of cardiac wall stress, and levels are increased in HF patients,” explained Solomon. “The greater reduc-tion in NT-proBNP achieved with LCZ696 was sustained to 36 weeks, although the

difference vs. valsartan was no longer significant.”

Patients treated with LCZ696 also had reduced left atrial size and improved symptoms (as measured by New York Heart Association [NYHA] Functional Classifica-tion), both of which became significant vs. valsartan by week 36.

“LCZ696 was generally well tolerated, with fewer serious and overall adverse events than valsartan,” said Solomon. “Results from PARAMOUNT are encourag-ing, and LCZ696 is currently being tested in a trial of 8,000 HF patients with reduced ejection fraction.”

In another study, spironolactone was shown to improve cardiac function and structure, and reduce neuroendocrine activation in 422 patients with symptomatic diastolic HF.

“In the international phase IIb Aldo-DHF trial, 12-month treatment with the aldosterone receptor antagonist improved diastolic function, induced structural reverse remodeling, and reduced NT-proBNP levels and blood pressure compared with place-bo,” reported Professor Burkert Pieske of the Medical University of Graz in Austria. “How-ever, the treatment did not improve exercise capacity, NYHA class or quality of life.”

Spironolactone was shown to be safe, with-out severe adverse events. “The drug can be considered in patients with diastolic HF, for improving cardiac function and blood pres-sure control,” suggested Pieske.

*PARAMOUNT = Prospective compArison of ARNI with ARB on

Management Of heart failUre with preserved ejectioN fraction

**Aldo-DHF = Aldosterone Receptor Blockade in Diastolic Heart Failure

32 October 2012 Conference CoverageNiacin/laropiprant well tolerated in HPS2-THRIVE trialAlexandra Kirsten

More than three-quarters of patients taking long-term extended release niacin/laropiprant (ERN/LRPT)

in the HPS2-THRIVE* trial have tolerated treatment, according to preliminary results.

HPS2-THRIVE is the largest study so far to assess whether adding ERN/LRPT to statin therapy can further lower cardiovascular risk.

In the trial, a total of 25,673 patients with occlusive arterial vascular disease from the UK, Scandinavia and China were randomized to receive long-term treatment with either ERN/LRPT 2 mg or placebo, in addition to simvastatin therapy. The primary endpoint included major vascular events after a median follow-up of 4 years.

The preliminary results suggest that about 76 percent of the patients can tolerate long-term ERN/LRPT treatment.

A safety analysis suggested that myopathy occurred in 0.5 percent of patients treated with simvastatin 40 mg and ERN/LRPT, however, the vast majority of these cases were found in patients with Chinese descent.

”These observations have resulted in a label change for simvastatin and ERN/LRPT,” explained lead study author Professor Jane Armitage, consultant in Public Health

Medicine at the University of Oxford, England, adding that patients of Chinese descent should not receive simvastatin 80 mg with cholesterol-modifying doses of niacin-containing products.

Niacin did not show any clear adverse effects on the liver in the trial, but known cutaneous and gastrointestinal side effects were confirmed.

Niacin has been shown to be an effec-tive HDL-raising agent, but randomized trial evidence for beneficial cardiovascular effects is limited. Most previous studies have been performed using fibrates, which raise HDL cholesterol only modestly, and those studies produced mixed results. Moreover, the tolera-bility of niacin has been limited by flushing and cutaneous side-effects, which appear to be mediated largely by prostaglandin D. These side effects can be substantially reduced by laropiprant, a selective prostaglandin D receptor antagonist.

Further results from the HPS2-THRIVE are expected to be released in 2013.

*HPS2-THRIVE: Heart Protection Study 2 -Treatment of HDL to Reduce the

Incidence of Vascular Events

Niacin has been shown to be an effective HDL-raising agent.

The preliminary results

suggest that about 76 percent

of the patients can tolerate long-term ERN/

LRPT treatment

‘‘

33 October 2012 Conference CoverageEuropean Society of Cardiology Congress, 25-29 August, Munich, Germany

Aliskiren use not advised in type 2 diabetics with renal impairmentAlexandra Kirsten

Aliskiren, a direct renin inhibitor, should not be used to lower blood pressure in type 2 diabetics at high

risk of cardiovascular and renal events, ac-cording the findings of the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal End-points (ALTITUDE).

“The treatment may even be harmful in these patients,” said lead study author Profes-sor Hans-Henrik Parving from the University of Copenhagen, Denmark

In the ALTITUDE study, a total of 8,561 pa-tients with type 2 diabetes and renal impair-ment were randomized to double-blind treat-ment with either aliskerin 300 mg or placebo once daily, in addition to an angiotensin co-verting enzyme (ACE) inhibitor or angioten-sin receptor blocker (ARB).

The primary analysis was the time to the first event for the composite endpoint of cardiovascular death, resuscitated death, non-fatal myocardial infarction and stroke, unplanned hospitalization for heart failure, onset of end-stage renal disease or doubling of baseline creatinine.

After the monitoring committee found an increased rate of side effects associated with active treatment, the trial was stopped prema-turely.

At a median follow-up of 32 months, the primary endpoint had occurred in 767 pa-tients taking aliskiren (17.9 percent) and in 721 assigned to placebo (16.8 percent) [95%

CI 0.98-1.20, P=0.14]. Corresponding rates of stroke in each group were 3.4 percent and 2.7 percent, respectively (95% CI 0.98-1.60, P=0.070).

Laboratory results showed albuminuria levels to be 14 percent lower in aliskiren-treated patients, while increases in serum creatinine appeared similar in the two groups. Patients in the aliskiren group experienced significantly increased serum potassium levels of 6 mmol/L (8.8 percent vs. 5.6 percent for placebo), and higher rates of hypotension (12.1 percent vs. 8.0 percent, respectively).

“These results do not support the admin-istration of aliskiren on top of standard ther-apy in type 2 diabetic patients at high risk for cardiovascular and renal events,” concluded Parving.

Aliskiren is the first in the class of drugs called direct renin inhibitors. It was approved in 2007 in the EU and US under the brand-names Rasilez and Tekturna, respectively, for the treatment of essential (primary) hyperten-sion either as monotherapy or in combination with other medications.

Aliskiren may do more harm than good in type 2 diabetics with renal

problems.

34 October 2012 Conference Coverage

First global standards on assessing lung function

European Respiratory Society Annual Congress, 1-5 September, Vienna, Austria

Rajesh Kumar

The first global standards on assessing lung function in different age groups and ethnicities, established through

international collaboration, promise to revolutionize the way physicians diagnose and manage lung disease.

Spirometry is the standard test for measuring lung function. In the absence of a global benchmark for interpreting its results, someone described as abnormal in one clinic can be labeled as normal in another. Also, an adolescent can see his/her level of lung func-tion decrease dramatically when the care is transferred from pediatric to adult clinic. Sim-ilar errors can occur if the individual patient’s ethnicity and associated difference in body composition or stature are not taken into ac-count.

Multinational researchers part of the Global Lung function Initiative (GLI) 2012, set up by the European Respiratory Soci-ety to establish a consensus on the topic, assessed data from 74,187 healthy non- smokers aged 3 to 95 years to derive reference spirometric prediction equations for Caucasians (N=57,395), African Americans (N=3,545), and North (N=4,992) and South-east Asians (N=8,255), including appropriate age-dependent lower limits of normal. [ERJ 2012: DOI: 10.1183/09031936.00080312]

Forced expiratory volume in 1 second

(FEV1) and forced vital capacity (FVC) between ethnic groups differed proportion-ally from that in Caucasians. For individuals not represented by the above four groups, or of mixed ethnicity, a composite equation tak-en as the average of the above equations was established.

“The first standard lung growth chart developed as a result of these equations will help better identification of children most likely to benefit from treatment, thereby avoiding unnecessary medication for those who don’t need it,” said Dr. Janet Stokes of the Great Ormond St Hospital in London, UK, while describing the clinical implications.

The chart will also improve diagnosis and management of chronic obstructive pulmo-nary disease, thus enhancing independence and quality of life in the elderly, said Stokes.

The GLI-2012 lung growth chart will also allow patients to understand the health of their lungs and more effectively manage their condition, or take steps to prevent develop-ment or progression of lung disease, added Ms. Monica Fletcher, chair of the European Lung Foundation in Sheffield, UK.

Subsequent additional data from the Indian subcontinent, Arab, Polynesian, Latin American countries, and Africa will further improve the equations in the future. How-ever, their widespread use will depend on timely implementation by manufacturers of spirometry devices, said the researchers.


Home factors impact on kids’ asthma medication compliance Elvira Manzano

Family lifestyle and issues at home may negatively affect children’s adherence to asthma medication.

In a study of 93 children with asthma conducted in the Netherlands, 72 percent used >80 percent of prescribed doses for asthma. However, almost 30 percent had poor adherence rates. Barriers to adherence include parental and financial problems, as well as having busy parents. Another common and striking finding was that children (8 to 12 years) were given full responsibility to take their medication with-out parental support or supervision, resulting in poor adherence. [ERJ 2012. E-pub ahead of print]

The findings emphasized how crucial it is for health care professionals treating children with asthma to carefully assess these potential barriers so that appropriate interventions can be put in place to correct the problems, said lead study author Dr. Paul Brand, from the University Medical Centre, Groningen, Netherlands.

“Good adherence is achievable. In fact, median adherence rate in the study was 93 percent at first month and 90 percent at third month. But when we conducted in-depth interviews on 20 parents, 12 with low adherence and 8 with high adherence, as to what might be preventing their children from following their treatment plan, they presented several lifestyle factors,” Brand said.

Some parents, the “delegators” and “ strugglers,” did not succeed in getting their children to take their medication prop-erly. They said a range of things going on in their lives prevented their children from adhering to the treatment plan. Their responses included: “when he was 8, we felt that he got to take [the medication] himself.” One parent even said: “Forcing never works…it becomes a struggle, and we never do that.”

Their answers were compared using an electronic monitoring system. Although parents in the low adherent group expressed intentions to strictly follow the treatment plan at the outset, they failed to do so during the course of the study, Brand said. “Struggling families therefore require tailored support.”

Some parents do not succeed in getting their kids with asthma to take their meds.

European Respiratory Society Annual Congress, 1-5 September, Vienna, Austria

36 October 2012 Conference CoverageHe said comprehensive asthma care may

prevent intentional non-adherence, and addressing parental illness and medication beliefs is important. “Excessive responsibility for medicines to school-aged children drives non-adherence,” he concluded.

The results were supported by Mr. David Supple, a parent of an asthmatic child. Speaking about his own experience, he said:

Inhaled glutathione may help cystic fibrosis patients Radha Chitale

A preliminary trial on inhaled glutathione (GSH) showed that it can improve lung capacity in cystic

fibrosis (CF) patients with moderate to severe airways obstruction.

CF is a chronic genetic disease that causes mucus to build up in the lungs, diges-tive tract, and other areas of the body, and affects about 70,000 people worldwide, many of them children.

Glutathione is an antioxidant therapy used as a first-line defense for the lungs against oxidative stress.

Lead researcher Dr. Cecilia Calabrese of Second University of Naples in Italy report-ed that three previous studies on inhaled GSH in CF patients have shown promising outcomes in terms of forced expiratory vol-ume in 1 second (FEV1) and peak expiratory flow, but these were performed on a limited number of patients and only one study was placebo-controlled.

In the current trial, 94 CF patients from Italy over age 6 were divided into a pedi-

atric group (6-18 years) and an adult group (>18 years) and randomized to inhaled GSH (10 mg/kg) or placebo.

Patients were excluded from the trial if they demonstrated a decrease in FEV1 greater than 15 percent during a GSH inhalation test, where FEV1 is evaluated before inhalation and 10 and 60 minutes after inhalation.

FEV1 was evaluated with spirometry at months 1, 3, 6, 9 and 12. Patients were questioned about their lifestyle, frequency of exacerbations, hospital admissions and antibiotic use at months 1, 6 and 12.

Preliminary results showed that inhaled GSH is well tolerated by both pediatric and adult CF patients.

Pediatric patients on GSH therapy did not demonstrate significant increases in FEV1 at 3 and 6 months after beginning therapy com-pared with the placebo group. Mean FEV1 levels at months 0, 1, 3 and 6 were 95.6 ± 22.6 percent, 96.3 ± 23.1 percent, 96.4 ± 19.5 percent and 97.1 ± 20.8 percent in the GSH group, respectively, and 101.1 ± 17.8 percent, 98.3 ± 15.3 percent, 100.4 ± 18.7 percent and

“It can be chaotic having four children and when we have given our son, Alex, respon-sibility over his medication to control his asthma, we have found his adherence slip away. We are conscious of this now and would encourage other parents to keep a close eye on their child’s level of adherence, and to spot potential barriers before they become a problem.”

37 October 2012 Conference Coverage98.6 ± 19.3 percent in the placebo group, re-spectively.

Adults did show moderate increases in FEV1 with GSH therapy compared with placebo but this trend did not reach significance after 6 months. Mean FEV1 levels at months 0, 1, 3, and 6 were 63.3 ± 15.3 percent, 68.1 ± 17.4 percent, 67.3 ± 16 percent and 67.0 ± 16.5 percent in the GSH group, respectively, and 66.7 ± 21.3 percent, 66.5 ± 18 percent, 64.5 ± 18.9 percent and 64.0 ± 20.2 percent in the placebo group,

respectively. However, pooled data on all patients

with FEV1 ≤80 percent showed that signifi-cant improvement persisted 6 months after beginning therapy. Mean FEV1 increased to 62.6 ± 15/1 percent at 6 months from 58.3 ± 13.2 percent at baseline (P=0.04).

“Preliminary results seem to show that inhaled GSH therapy is able to induce a significant increase of FEV1 in CF patients affected by moderate to severe airway obstruction,” Calabrese said.

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38 October 2012 Conference CoverageEuropean Respiratory Society Annual Congress, 1-5 September, Vienna, Austria

Long-distance running raises pulmonary edema risk

Half of runners tested within 20 minutes of completing a marathon had

some level of pulmonary edema.

Dr. Yves St. James Aquino

A recent study found that marathon running can trigger pulmonary edema, which may be associated with

physical signs of breathlessness, severe cough and heart attack or respiratory failure in se-vere cases.

“Marathon running is worldwide. Half-a-million people ran the marathon in the United States this past year and in 2010. And therefore, this is a big topic,” said lead author Dr. Gerald Zavorsky.

Researchers from the US and Italy aimed to determine if pulmonary edema devel-ops from long-distance running, character-izing its incidence and severity. In addition, researchers wanted to determine if the resulting edema is related to finishing time.

The study involved 26 runners who par-ticipated in the 2011 Steamtown Marathon held in Scranton, Pennsylvannia, US. The marathon started at an elevation of 452 meters above sea level, with a net drop to 291 meters at the finish line. The study noted that all run-ners finished with times between 142 and 289 minutes.

To quantify the presence of edema, pos-teroanterior and lateral chest radiographs of the runners were taken the day before the race, then 19, 56 and 98 minutes after finish-ing the race. Three radiologists were tasked to do the radiograph interpretation. The readers worked independently and were not in con-tact with each other. They were also not told

which radiographs were taken before or after the race.

Four radiographic characteristics were assessed, including peri-bronchial cuffing, loss of definition of vascular markings, pul-monary opacification and blurring of hilar sil-houette. The quantification of edema ranged from 0 or no edema to 8 or severe edema. The scores from each reader were then averaged.

Results showed that 50 percent of run-ners had some level of pulmonary edema 20 minutes after the race, and 20 percent of those runners develop moderate to severe pulmonary edema. In four runners (15 per-cent), mild to moderate pulmonary edema was even retained 1 hour after finishing the

39 October 2012 Conference Coveragemarathon.

Upon further evaluation, the study found that women were at 13 times higher risk com-pared with men in the development of pulmo-nary edema (odds ratio 12.8, r2 0.31, P=0.038). No correlation was established between mara-thon time and the development of pulmonary edema, which suggests the risk of edema may be prevalent across all abilities.

However, none of these athletes with radio-logic finding of pulmonary edema exhibited signs such as difficulty of breathing or cough-ing of blood.

According to Zavorsky, potential causes may include stress failure of pulmonary capillaries, fluid-electrolyte imbalances, and increased permeability pulmonary edema. However, the most likely cause is increased pulmonary wedge pressure, whereby pres-sure within pulmonary artery force out fluid into the interstitium.

“While pulmonary edema can be a negative consequence of marathon running, regular exer-cise can also keep you fit and healthy. We do not yet know the impact of this finding on long-term health of runners,” concluded Zavorsky.

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40 October 2012 Conference CoverageFlight hypoxia assessment inappropriate for pediatricsDr. Yves St. James Aquino

British Thoracic Society (BTS) recommendations on hypoxic flight assessment are not appropriate for

pediatric patients, according to a study by UK researchers.

The study involved 107 children age 0.1 to 19.2 years who were referred for a variety of conditions including muscular dystrophy, cystic fibrosis, severe asthma, long-term ventilation, long-term oxygen therapy and sleep breathing disorders.

The BTS recommendations aim to enhance safety for passengers with lung problems who are travelling by air, reduc-ing the number of in-flight emergencies due to respiratory disease. The BTS established upper and lower thresholds for “no in-flight oxygen required” at percutaneous oxygen saturation (SpO2) >95 percent or “in-flight oxygen needed” at SpO2 <92 per-cent.

The study was a retrospective audit of patients referred to a pediatric respirato-ry function laboratory. The hypoxic chal-lenge test as described by Gong et al sug-gests the maximum cabin altitude of 2,438 meters (8,000 feet) can be simulated at sea level with a gas mixture containing 15 per-cent oxygen in nitrogen [Am Rev Respir Dis 1984;130:980–6].

According to the researchers, the test protocol used 100 percent nitrogen to dilute the contents of a body plethysmograph to a fraction of inspired oxygen (FiO2) of 15 percent, before assessing the SpO2 profile

for 20 minutes. Based on the BTS criteria, failure in the hypoxic challenge constituted a mean SpO2 of less than 90 percent when breathing FiO2 15 percent. Hypoxic chal-lenge testing is the pre-flight test of choice for patients with hypercapnia, according to BTS [Thorax 2002;57:289–304].

Results showed that out of the 107 chil-dren, of which 58 percent were female, 83 percent (N=89) had a baseline SpO2 of greater than 95 percent in FiO2 21 percent. In addition, 29 percent of the patients were noted to be hypoxic in FiO2 15 percent.

The study noted that if BTS criteria were to be applied in this pediatric sample, 17 percent (N=18) would be referred and only 10 percent (N=11) would be detected with hypoxia at mean SpO2 of <90 percent in FiO2 15 percent. However, if all referrals regardless of the BTS criteria will be as-sessed, 35 percent would be detected to have hypoxia. For mean SpO2 desaturation to <85 percent, use of BTS criteria would result in detection of 6.5 percent of cases versus all referral detection of 15 percent.

Based on the results, the BTS recom-mendations for referral for hypoxic flight assessment are not appropriate for pedi-atrics, according to the study. It added that using sea level SpO2 <95 percent as a cutoff for referring patients will result in detection of fewer patients who desatu-rate in hypoxic conditions. Researchers concluded that children with respiratory disease should be considered for a hypox-ic challenge test irrespective of sea-level SpO2 percent.


Personal Perspectives

‘‘ One of the major activities of the European Respiratory Society is this annual congress and it’s been steadily growing, growing not only in numbers, it’s been growing in importance, it’s growing in global perspective… For lung diseases, there is a huge disparity in health care models, huge disparity in how to care for certain patients. Infectious diseases, HIV/AIDS, lung cancer, COPD are diseases that you know occur everywhere.

Dr. Klaus Rabe, President, European Respiratory Society, Professor, University of Kiel, Germany

It’s been an adventure. It’s good because we could just go anywhere we want to go. For the lectures… it is subdivided into four topics. If you do not want the next topic, you go to the next hall. We try to find topics that are relevant to our subspecialty. We just attended a pulmonary rehab session, because of the updates and we plan to set up our own program.

Dr. Ma. Bernardita Chua, Consultant, Perpetual Succour Hospital of Cebu, Philippines

‘‘

It’s already my fourth ERS, and I’m a PhD fellow. The topics of my PhD which I can also follow here are physical activities and comorbidities in COPD patients. There are a lot of sessions I have checked in my personal agenda. They were very good; the symposia especially are very nice.

Hans van Remoortel, PhD Fellow, University Hospital Gasthuisberg, The Netherlands

‘‘

The topics I attended were not too bad. It depends on the subject. Yesterday, I attended four sessions which were very interesting. The topics I’m interested in are COPD, pulmonary hypertension, interstitial lung disease and infections.

Dr. Masoongo Masoongo, Consultant, Arras Hospital, France

‘‘

42 October 2012 Calendar

October23rd Great Wall International Congress of Cardiology (GW-ICC) – Asia Pacific Heart Congress (APHC) 201211/10/2012 to 14/10/2012Location: Beijing, ChinaInfo: Secretariat Office of GW-ICC & APHC (Shanghai Office)Tel: (86) 21-6157 3888 Extn: 3861/62/64/65Fax: (86) 21-6157 3899Email: [email protected]: www.heartcongress.org

42nd Annual Meeting of the International Continence Society 15/10/2012 to 19/10/2012Location: Beijing, ChinaTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected]: www.kenes.com/ics

8th Asian-Pacific Society of Atherosclerosis and Vascular Diseases Meeting 20/10/2012 to 22/10/2012 Location: Phuket, Thailand Info: Asian-Pacific Society of Atherosclerosis and Vascular DiseasesTel: (66) 2940 2483 Email: [email protected]: www.apsavd2012.com

November

2012 Scientific Sessions of the American Heart Association 3/11/2012 to 7/11/2012 Location: Los Angeles, California, US Info: American Heart Association Tel: (1) 214 570 5935 Email: [email protected] Website: www.scientificsessions.org

8th International Symposium on Respiratory Diseases & ATS in China Forum 20129/11/2012 to 11/11/2012Location: Shanghai, ChinaInfo: UBM Medica Shanghai Ltd.Tel: (86) 21-6157 3888 Extn: 3861/62/64/65Fax: (86) 21-6157 3899Email: [email protected]: www.isrd.org

63rd Annual Meeting of the American Association for the Study of Liver Diseases9/11/2012 to 13/11/2012 Location: Boston, Massachusetts, US Info: American Association for the Study of Liver Diseases Tel: (1) 703 299 9766 Website: www.aasld.org

UpcomingNational Diagnostic Imaging Symposium 2/12/2012 to 6/12/2012Location: Orlando, Florida, USInfo: World Class CME Tel: (980) 819 5095Email: [email protected]: www.cvent.com/events/national-diagnostic- imaging-symposium-2012/event-summaryd-9ca77152935404ebf0404a0898e13e9.aspx

Asian Pacific Digestive Week 20125/12/2012 to 8/12/2012Location: Bangkok, ThailandTel: (66) 2 748 7881 ext. 111Fax: (66) 2 748 7880E-mail: [email protected]: www.apdw2012.org

World Allergy Organization International Scientific Conference (WISC 2012)6/12/2012 to 9/12/2012Location: Hyderabad, IndiaInfo: World Allergy OrganizationTel: (1) 414 276 1791 Fax: (1) 414 276 3349E-mail: [email protected]: www.worldallergy.org

43 October 2012 Calendar

54th American Society of Hematology Annual Meeting8/12/2012 to 11/12/2012Location: Georgia, Atlanta, USInfo: American Society of HematologyTel: (1) 202 776 0544Fax: (1) 202 776 0545Website: www.hematology.org

17th Congress of the Asian Pacific Society of Respirology14/12/2012 to 16/12/2012Location: Hong KongInfo: UBM Medica Pacific LimitedTel: (852) 2155 8557Fax: (852) 2559 6910E-mail: [email protected]: www.apsr2012.org

16th Bangkok International Symposium on HIV Medicine16/1/2013 to 18/1/2013Location: Bangkok, ThailandInfo: Ms. Jeerakan Janhom (Secretariat)Tel: (66) 2 652 3040 Ext. 102Fax: (66) 2 254 7574E-mail: [email protected]: www.hivnat.org/bangkoksymposium

28th Congress of the Asia-Pacific Academy of Ophthalmology17/1/2013 to 20/1/2013Location: Hyderabad, IndiaInfo: APAO SecretariatTel: (852) 3943 5827Fax: (852) 2715 9490 Email: [email protected]: www.apaoindia2013.org

Asian Pacific Society of Cardiology 2013 Congress21/2/2013 to 24/2/2013Location: Pattaya, ThailandInfo: Kenes Asia (Thailand Office)Tel: (66) 2 748-7881Fax: (66) 2 748-7880Email: [email protected]: http://www2.kenes.com/apsc2013/pages/home.aspx

44 October 2012 After Hours

Radha Chitale

When they first went up, the enormous splayed towers encased in geometric scaffolding, what would become “supertrees,” standing bare behind the Marina Bay Sands hotel in Singapore recalled a factory more than a home

for flora and fauna. But my recent visit to the National Parks Board’s ambitious Gardens by the Bay

show the area has transformed from a wasteland of construction into a unique botanical park well on its way to becoming an iconic example of sustainability in urban landscaping.

The over S$1 billion project covers 101 hectares of reclaimed land and includes lakes, sky walks, cultural gardens and two biomes that house 220,000 plant varieties from around the world.

The supertrees are clustered in several spots around the park and are vertical


gardens between 25 and 50 meters high. Their scaffolding holds ferns, flowering climbers and bromeliads that will eventually grow to cover the entire structure.

The towers also function to cool the biomes, are air exhaust receptacles and are fitted with photovoltaic cells that harvest solar energy to light up the supertrees at night.

The horticultural attractions of the Gardens are in the domed glass biomes. Walking into the Cloud Forest biome, one goes from sea level to 1,800 meters

above and the sharp temperature drop is a welcome change from the heat outside. The waterfall at the entryway cascades down a mini mountain top covered in pitcher plants and other flowers and shrubs that thrive in cool, moist conditions.

I may have mistakenly expected a wilderness of scented flowers from the Flower Dome, but the manicured central flower field is colourful enough and made a pretty picture for one couple dressed up for wedding photos, seated on matching forest thrones in a bed of gerber daisies, complete with a small gazebo in the background.

The Flower Dome also features garden plants from a variety of regions such as baobab trees from Africa, wine palms from South America and olive groves from the Mediterranean.

Both biomes end with educational exhibits detailing the carbon cycle, different energy sources, the science of polar ice caps, and threats to plants from urbanization and climate change.

The Gardens manage to incorporate a lot of educational information across the park. Plaques studded among the portion of the Gardens that are free to the public describe the varieties of plants, what their uses are, how sustainable elements have been incorporated into the building and a smorgasbord of trivia.

The plants in the biomes, by contrast, are not obviously labelled, probably to indicate that one should rent the self-guided audio tour.

Beyond well-developed biomes, the Gardens are still a project in progress, with clear spots yet to be filled with plants, evidenced by patches of exposed black soil and empty wiring and trellises for plants to take over.

Although the National Parks Board’s vision of a “City in a Garden” germinated the Gardens by the Bay, the vista of Singapore’s central business district looms over the park creating a sense that this is still a garden – a very large garden – in a city.

But that is a question of semantics. At its most basic, the Gardens by the Bay put more plants in an urban space, and that is a good thing.


Medicinal Plants

Several plants in the Gardens by the Bay have medicinal properties. These plants are located all over the park and are selected because they have strong cultural connections to the garden they are in or they are native to the climate.

Lemon Gum (Corymbia citriodora) Australia Garden, Flower Dome - Relieves arthritic pain, alleviates nasal congestion, antiseptic properties

Tree Aloe (Aloe barberae) South African Garden, Flower Dome - Antimicrobial properties, soothes skin, anti-inflammatory

Monkey Puzzle Tree (Araucaria araucana) South American Garden, Flower Dome - Produces a resin used to treat ulcers and sores

Olive Tree (Olea Europaea) Olive Grove, Mediterranean Garden, Flower Dome - Metabolism inducer, reduced LDL cholesterol, blood pressure,

and blood sugar levels

Lavender (Lavandula dentate) Mediterranean Garden, Flower Dome - Reduces insomnia, alopecia, anxiety, stress-related disorders,

post-operative pain

Tongkat Ali (Eurycoma longifolia) Malay Heritage Garden - Increases testosterone production, anti-malarial and anti-microbial properties

Curry Tree (Murraya koenigii) Indian Heritage Garden - Anti-diabetic, anti-oxidant, anti-inflammatory, hepatoprotective

Camphor (Cinnamomum camphora) Indian Heritage Garden - Anasthetic, anti-microbial

Weeping willow (Salix babylonica) Chinese Heritage Garden - Antirheumatic, astringent, source of salicylic acid

Mulberry (Morus alba) Chinese Heritage Garden - Antimicrobial, antioxidant, hypolipidemic

47 October 2012 Humor

“Do you have to go on and on

about how gross the whole thing is?”

“There’s no cure, because you are perfectly healthy!”

“Don’t try to move or go anywhere. We will be right back!”

“I said I was sorry!”

“If the worst happens, can I keep your lawn mower?”

“What your husband is experiencing, it’s what we call rigor mortis, making it difficult

for him to relax!”

“Sure, some of my patients became very sick after the

operation, and others have died, but none of them seriously!”

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MEDICAL TRIBUNE OCTOBER 2012