PDF - Philippine Society of Endocrinology and Metabolism

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A publication
of the Philippine
& Metabolism
Society of Endocrinology
H Staff
ADVOCACY COMMITTEE:
Editor: Gabriel V. Jasul, MD, FPCP, FPSEM
Managing Editor: Patricia B. Gatbonton, MD, FPCP, FPSEM
Art Director: Dondi B. Gerardino, TTB
Printer: Color Production Group
Cover: Vitruvian Man by Leonardo Da Vinci additional graphics
by Dondi Gerardino
Opinions expressed in the articles are those of the authors and do not necessarily reflect
the views of Philippine Society of Endocrinology & Metabolism (PSEM). Acceptance
of the advertising does not imply that these products and services are recommended
by PSEM. Please exercise your own discretion with respect to the products' and services
advertised.
Hormone
Hotspots"
Hormone Hotspots, 2007 All rights reserved. No part of the publication may be reproduced
or transmitted in any form or by any means without the written prior permission of the
PSEM.
September
H Contents
4
5
6
7
11
11
14
16
From the Editor
President's Corner
Diabetes: Kay Tamis Ng
Buhay
Hormone Hirit
Hot Flushes
Eba atAda
Osteoporosis:
Buto-Buto sa Langit
What's up EnDoc
18
10
11
14
16
Secondary Hypertension:
Kakaibang Altapresion
Gizmos and Gadgets
Thyroid: Neck, Neck Mo
Usapang Buntis
For Feet's Sake
2009 Issue
IJ
ID
From the Editor
Dear patients, patrons, and partners,
Time does fly fast! Hormone Hotspots, the only hormone health magazine in the Philippines,
is now two years old and is on its 5th issue. As a patient advocacy project of our society,
the PSEM, this magazine has helped us, your hormone doctors, connect to you, our patients
and readers. Well-informed
choices and complying
patients fare better
in understanding
their disease,
making
with treatment. In the same way, your hormone doctors accomplish
more as health care providers
and as health educators with informational
materials such
as the "H" magazine.
There are therefore
a hundred and one reasons to continue the circulation of the "H" magazine despite the seemingly
insurmountable financial problem amidst the global economic crisis. There will be adjustments and belt-tightening measures
in our publication. But inspired by your support, we will overcome these obstacles and continue to give you the best hormone
health information still FOR FREE.
This issue marks our commitment
to excellent education for the public and our regular columns will keep on providing you
with the latest information on general hormone-related
on pregnancy and on foot care.
members,
is
topics. We welcome in this issue new writers as well as new features
The PSEM Patient Advocacy Committee, with its growing number of young and dynamic
a rich source of talents and ideas for our patient-directed
Committee members are the lifeline of the "H" magazine and all our
programs.
Indeed,
the PSEM Patient Advocacy
successful patient programs in the PSEM.
We give
tribute to their dedication to excellent patient education.
We always value your opinion and we welcome any input on how we can make our work better. Our lines of communication
are always open, electronic
shared responsibility
t.
~.J--V
or otherwise.
Working together
for health and happiness around.
make things better for everyone. Let us spread the spirit of
Enjoy learning from this magazine with your family and friends!
Q..~
G riel V. Jasul, MD, F
Editor, Hormone Hotspots
P, PSEM
Philippine Society of Endocrinology & Metabolism
Our Mission
To lead in the pursuit of excellence in Endocrinology
Our Vision
Quality Endocrine care, education ad research in every region of the Philippines by 2010
Unit 1701, 171F Medical Plaza Ortigas, San Miguel Avenue, Ortigas Center 1600 Pasig City
Tel No. 633-6420· Fax No. 637-3162
E-mail: [email protected]·
Website: www.endo-society.org.ph
11
President's Corner
It is my great pleasure to extend my warmest greetings to our dear patients and readers!
Hormone Hotspots, is what we at PSEM call the 'H'mag,
the first lay magazine devoted
entirely to educating the public on endocrinology, the study of hormones and their disorders.
PSEMs health awareness campaign includes not only education, but also prevention and
promotion
of a healthy lifestyle. Education is a patient's best weapon; understanding
problem is the first step toward accepting personal responsibility
the
for managing the illness
which, we hope, will eventually result in patient empowerment.
I have been managing editor of H mag since its inception, and it is witf.:Jpride that we say
that H mag is now on its 3rd year.
In this issue, the fifth of the series,
we have two new
sections which the editors feel will cover another group of patients we regularly see in our clinics: the pregnant patient with
endocrine disorders and problems of the diabetic foot.
Dr. Laura Acampado tackles "Usapang Buntis. " Or Pete de la Petie gets to finally write about his passion, the diabetic foot
in the section, For Feet's (
a play on Pete's) Sake." Dr. Chi Anonuevo-Cruz ably takes over the slot Pete vacated. We have
also a greater proportion of articles written in the vernacular than when we first started.
PSEM continues to bring H mag to the public for free, and we remain dedicated to fulfilling this part of our mission for as
long as possible.
PSEM is happy and privileged
to be your partner in the journey
towards good health and
the pursuit of happiness.
Cheers all,
~~6.cr~k
Patricia B. Gatb'-J.ton, MD, FPCP, FPSEM
President, PSEM
PSEM OFFICERS
& BOARD OF DIRECTORS 2009-2010
Patricia B. Gatbonton, MD, FPCP, FPSEM
President
Leilani B. Mercado-Asis, MD,PhD, FPCP, FPSEM
Vice-President
GABRIEL V. JASUL, Jr., MD, FPCP, FPSEM
Secretary
Sjoberg A. Kho, MD, FPCP, FPSEM
Treasurer
Directors
Herbert Ho, MD, FPCP, FPSEM
Cecilia A. Jimeno, MD, FPCP, FPSEM
Nemencio A. Nicodemus, Jr.,MD, FPCP, FPSEM
Bien J. Matawaran, MD, FPCP, FPSEM
Laura Trajano-Acampado"MD,
FPCP, FPSEM
Immediate Past President
PSEM ADVOCACY AND PUBLIC RELA nON
COMMITTEE 2008
Chair:
Co-Chair:
Members:
Gabriel V. Jasul, Jr., MD
Bien J. Matawaran, MD
Nemencio A. Nicodemus, Jr., MD
Rosa Allyn G. Sy, MD
Roberto C. Mirasol, MD
Patricia B. Gatbonton, MD
Laura Trajano-Acampado,
MD
Josephine Carlos-Raboca, MD
Sjoberg A. Kho, MD
Herbert Ho, MD
Cecilia A. Jimeno, MD
Aimee Andag-Silva, MD
Mary Jane Gutierrez, MD
Mia C. Fojas, MD
Pepito Dela Pefia, MD
Elaine Cunanan, MD
Cecille Afionuevo-Cruz,
MD
Gia Dimayuga-Wassmer,
MD
Juan Maria Ibarra Co, MD
Marjorie Ramos, MD
Jovie Joy Manuel, MD
Suzette Quiaoit-Alegarbes,
MD
Jean Uy-Ho, MD
Carolyn Narvacan-Montano,
MD
Jimmy A. Aragon, MD
The
Top TEN ....
THINGS YOU
SHOULD DO TO
CONTROL YOUR
BLOOD SUGARS
Roberto C. Mirasol, MD, FPCp, FPSEM
There
are several ways to
control diabetes.
It is believed that
knowledge alone is insufficient. The
knowledge should be translated to
behavior change to be able to achieve
metabolic control. These seven behavior
changes
were developed
by the
American Association
of Diabetes
Educators called AADE7*. They will
serve as guideposts to you and your
healthcare professional in the control
of your diabetes.
1. Healthy eating. You should start
making healthy food choices. Learn to
eat low fat meals. Avoid sources of
hidden fats. Sugars and sources of
sugars
should
be limited.
Eat
vegetables. Understand portion sizes.
You should control the amount of food
you are eating.
It is the amount
eventually which will spell out the
.difference between being in control or
not. You should eat small frequent
feedings. Avoid binge and buffet eating.
If you are overweight or obese, control
your weight. Learn how to read labels
to know and be aware of the food you
are eating.
2. Be active. You should have regular
activity. Do this most days of the week,
30 minutes of moderate intensity.
Exercise alone however is not sufficient.
You should diet as well. Walk, walk,
walk more. Use stairs not elevators or
escalators.
Dance and be active.
Exercise with a partner. Clean your
room. Wash your car. Walk the dog. Do
gardening.
3.
Monitor your blood sugars.
Daily self-monitoring
of your blood
glucose will provide you with feedback
as to the effect of food, physical activity
and medications
on blood glucose
levels. Learn how to use a blood
glucose meter. Ask your doctor or nurse
educator about frequency, target values
and interpretation of results. If you get
very l1!gh readings all the time then your
diabetes is out of control and your doctor
will institute Changes to your regimen.
If you have hypoglycemia or low blood
sugar, take something sweet. Aside
from blood sugar, you should also
monitor your blood pressure, lipids and
weight.
4.Take your medicines. There is no cure
for diabetes and it is a progressive
disease, hence the need for lifelong
treatment.
You should take your
medications on time as prescribed by
your doctor. Understand
how your
medicines work including action, side
effects, efficacy, toxicity, prescribed
dosage,
appropriate
timing
and
frequency of administration, effect of
missed
and delayed
doses and
instructions
for storage, travel and
safety. Effective
drug therapy
in
combination
with healthy lifestyle
choices, can lower blood glucose levels
and reduce the risk for diabetes
complications.
5. Problem solving. You should develop
good problem solving skills. High or low
blood sugar should be addressed
immediately.
Know what to do when
eating outside. When you get sick, you
should be able to make decisions
regarding food, activity and medications.
Know what to do when travelling. These
problem solving skills are continuously
put to use because the disease is
progressive and chronic complications
emerge, life situations change and you
are aging.
6. Heducinq your risk. Effective risk
reduction behaviors such as regular
eye, foot and dental examinations
reduce diabetes complications
and
maximize health and quality of life. Foot
inspection and care should be done
almost every day. Eye exam every 6
months or every year. You should see
your dentist on a regular basis. Smoking
should stop. If you can't on your own,
seek professional help. Ask your doctor
about the use of aspirin to reduce risk
of heart disease and stroke .
7. Healthy coping. Your health care
professional can help you cope with the
many challenges your diabetes and its
complications
present to you. You
should be motivated enough to change
your behavior and sustain it. When you
feel anxious, threatened or down, your
health care professional is always there
to help you out. You should set
achievable goals and your health care
professional will guide you through the
attainment of these goals. Don't despair
you can do it even if the odds are great.
WE
ARE
HERE
TO
HELP
.•
tlORm
Trick or
Treat?
Patricia B. Gatbonton, MD, FPCp, FPSEM
MY
colleague on these pages, Dr.
Nemencio Nicodemus, has been writing
on thyroid disorders over the last two
years, but I'd like to take this opportunity
to elaborate about how thyroid hormone
affects our bodies and briefly discuss
thyroid
hormone
replacement
specifically.
The thyroid gland is a butterfly shaped
gland in the front of the neck (not to be
mistaken for the Adam's apple). It is the
biggest, single organlfactory specialized
to
produce
hormones.
The
hypothalamus is a center in the brain
which regulates thyroid function by
secreting the releasing
hormone,
thyrotropin releasing hormone, TRH, to
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sustaining actions include promoting
normal fetal and childhood growth and
development; regulating heart rate and
myocardial
contractility;
affecting
gastrointestinal motility and renal water
clearance; and modulating the body's
energy expenditure, heat generation,
and weight maintenance.
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the anterior pituitary gland in the middle
of the brain, which in turn releases
thyroid stimulating
hormone, TSH.
TSH regulates
thyroid
hormone
synthesis and secretion by attaching to
receptors on the thyroid cell which
stimulates the gland to release the two
thyroid hormones, levothyroxine (T4)
and liothyronine (T3) which then exert
their metabolic effect. Among their life-
Low TSH is due to excess thyroid
hormone production and a goiter. If
there is also protrusion of the eyeballs
(exopthalmos),
it is usually from an
autoimmune Grave's disease causing
palpitations,
weight loss, fatigue,
frequent bowel movements, difficulty
sleeping, emotional lability and fine
finger tremors.
How do hormones work? The simple
analogy is that of a lock and key.
Hormones are the keys that open the
lock (the receptor on the cell wall or
inside its nucleus) that then allows a
complex reaction to take place and
produce something else.
When the level of thyroid hormone in
circulation is sufficient, the message is
sent back to the hypothalamus
and
pituitary to reduce the release of
releasing and secreting hormones-the
negative feedback pathway.
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When evaluating you for a goiter, aside
from the history and the physical exam,
the most important laboratory test your
doctor will ask for is a blood level of
TSH. The most common cause of high
TSH level is a goiter with low thyroid
hormone
production
(primary
hypothyroidism). Weight gain, lethargy,
slow heart rate, cold intolerance,
abnormal menstruation, swollen and
puffy face and legs, difficulty or delay
in moving bowels (constipation) are the
usual symptoms. We like to say the
patient is "Iow batt," compared to the
"energizer bunny," of hyperthyroidism.
CH2
I
NH2CHCOOH
Thyroxine
CH2
I
NH2CHCOOH
Triiodothyronine
When the thyroid is unable to make
enough hormone for the body's use, for
whatever reason, we need to augment
or replace the hormone so that the body
can continue to function normally.
Synthetic T4 is now available in pure
form, in multiple dose formulations, and
is not expensive. There is no need to
give T3 because it comes from T4 in
peripheral tissues, so you get both even
if you take only one tablet. It is preferable
to prescribe T4 because the hormone
can be given once a day, its half-life is
approximately 7 days. Treatment effect
is easy to monitor by following FT4 and
serum TSH levels.
sure the level of thyroid hormone is
sufficient because change in weight,
age, pregnancy can all affect the need
how much thyroid hormone you need
at different times .
Once you are on thyroid hormone and
have
a normal
TSH,
you are
EUTHYROID, and are back to normal
thyroid status, and should be fine as
long as you continue to take the
medicine.
Thyroid hormone metabolism and functions
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The daily dose of levothyroxine is age
and dose related. The dose also
depends on why you are getting the
medication in the first place, whether
for replacement or for suppression of
TSH in patients with thyroid cancer. In
very rare cases, for thyroid nodules for
instance, you will only need to take it
for a short period. Because of rapid
turnover, infants and young children
need a higher dose than adults. Elderly
patients will need a lower dose.
In most patients with hypothyroidism,
your doctor will start you with the full
estimated
dose
requirement
Hypotha lam us
immediately. After 4-6 weeks, your
Circumstances in Which
doctor will adjust the dose further based
Levothyroxine
on the serum TSH level. The goal is to
Requirements
May Be
normalize the serum TSH, which is
Altered*
typically between 0.5 and 4 mUll. If
you are older, or if you
Increased levothyroxine
requirements
have underlying heart
Malabsorption
(31)
disease, the physician
Gastrointestinal
disorders
will start you on a
Mucosal diseases of the small bowel (for example,
lower
dose
and
sprue)
After jejunoileal bypass and small-bowel resection
increase
it slowly
Diabetic diarrhea
while monitoring your
Cirrhosis
clinical symptoms and
Pregnancy (35, .16)
TSH.
Therapy with certain pharmacologic
agents
Drugs that block absorption
Some medications or
Cholestyramine
(37)
conditions can affect
Sucralfate (3H)
the absorption
of
Aluminum hydroxide (39)
thyroid hormone in
Ferrous sulfate (40)
Possibly lovastatin (41)
your stomach. Some
Drugs that increase nondeiodinative
T4 clearance
antacids, aluminum
Rifampin (42)
hydroxide antacids,
Carbamazepine
(43)
Possibly phenytoin (44)
calcium, sucralfate or
Drugs that block T, to T, conversion
iron
compounds
Amiodarone
Pituitary
(45, 46)
decrease
T4
Selenium deficiency
absorption. In these
Decreased levothyroxine
requirements
Aging (65 years and older) (47, 4H)
patients, T4 should be
given
before
• References arc given in parentheses.
breakfast, when the
stomach is empty, and
the other compounds taken 4 hours
IAnnals of Internal Medicine
later, after lunch.
Mandel, S. J. et. al. Ann Intern Med
What patients need to understand is
1993;119:492-502
that you need to take levothyroxine for
life. It is wrong to think that once you
have the medication, you don't have to
see your physician any more. Regular
TSH monitoring is necessary to make
I
I
OBESITY IN THE
ELDERL Y : Should they
be treated?
Rosa Allyn G. Sy, MD, FPCp, FPSEM
The
prevalence
of obesity is
increasing in all age groups, including
older persons defined as thoseqreater
than 65 years old. The number of obese
older persons has increased markedly
because of an increase in both the total
number of older persons and the
percentage of the older population who
are obese. The United States registry
reported that in less than 10 years, from
1991 to 2000, there was a 56 percent
increase in the prevalence of obesity
in the 60 to 69 years of age and 36
percent in the 70 years of age and older.
Data from population surveys in the
United States showed that greater than
15 percent of the older American
population is obese and obesity is more
common in older women than in men.
The relation between energy intake and
expenditure is an important determinant
of body fat mass. Results from majority
of studies suggest that energy intake
does not change or even declines with
advancing age. It is the decrease in the
metabolism
of older people that
contributes to the gradual increase in
body fat with advancing
age. The
reduction in the metabolism is related
to the loss in lean mass.
Aging is associated with considerable
.changes in body composition - decrease
in lean body mass and strength,
increase in fat mass, redistribution of
body fat and lean body mass and a
reduction in bone mineral density. The
gradual loss of bodily functions and the
decline in blood concentrations
of
several hormones i.e., sex hormones,
thyroid hormones and growth hormone
and the gradual decline in sex hormonebinding globulin (SHBG) all contribute
to this body composition alteration. The
progressive
decrease
in physical
function
because
of these body
composition changes affect activities
of daily living and quality of life. When
impairment of daily activities becomes
severe to cause disability, frailty occurs.
Among older persons living in the
community, approximately 20 percent
of those >65 years of age and 46
percent of those> 85 percent of age
are considered frail.
Obesity
has important
functional
implications in the older population. It
exacerbates the age-related decline in
physical function.
Obesity is also
associated with significant impairment
in health-related quality of life in older
subjects. Therefore; it is important to
consider weight-loss therapy to improve
physical
function
in obese older
persons, in addition to possibly prevent
and improve the medical complications
associated with obesity.
Treatment
Options:
Weight-loss
treatment that minimizes muscle and
bone losses is recommended for obese
older persons who have functional
impairments or metabolic complications
that can benefit from weight loss. A
modest reduction in energy intake of
500 to 750 kcal/d with 1.0 g/kg BW of
high-quality
protein
per day
supplemented with 1500 calcium, 1000
IU Vit D, multivitamins and minerals is
recommended. Regular physical activity
that improves physical function helps
preserve muscle and bone mass.
Aerobic
exercise,
endurance
programmes and progressive resistance
training can all be useful. The program
should be started gradually and must
be individually
determined
with
consideration of diseases and disability.
The goals of regular exercise in obese
older persons are to increase flexibility,
endurance and strength. Hence, a multicomponent
exercise program that
includes stretching, aerobic activity and
strength exercises is recommended.
The use of anti-Obesity drugs in elderly
obese is limited. However, orlistat
appears to be the safest of the currently
available drugs in obesity. Bariatric
surgery should be considered only in
selected older subjects who have
disabling
obesity
that can be
ameliorated with weight loss and who
meet the criteria of surgery.
I
H6°,
/
FLASHES
o
GROWTH HORMONE
DISORDERS
Elaine Cunanan, MD, FPCp, DPSEM
~f
Growth
hormone (GH) is a
chemical produced by the pituitary
gland, a tiny oval-shaped organ at the
bottom of our brain. During childhood,
it is important for linear growth or height
increase. It is also important for muscle
and bone development, and distribution
of body fat throughout the body. In
adulthood, it affects energy, muscle
strength, bone health, and psychological
well being. Having either too much or
too little growth hormone can cause
health problems.
Growth hormone excess
How does it manifest?
Some individuals may have too much
GH. This leads to gigantism,
or
extremely tall stature, if it occurs during
childhood. In adults, excessive GH leads
to acromegaly, which is the overgrowth
.of body tissues with subsequent
coarsening
of facial features
and
increase in hand and feet sizes. Height
doesn't increase anymore since vertical
growth stops when the long bones
cease to lengthen with closure of bone
growth
centers
during
puberty.
GH excess is usually caused by a noncancerous tumor of the pituitary gland.
Gigantism and acromegaly are rare
diseases. Only three to four cases are
diagnosed per million people each year.
The features associated with GH excess
develop very gradually and may not
even be recognized for many years.
Other manifestations
that may be
associated with GH excess include:
• Headaches
• Numbness or burning sensation of
the hands or feet due to carpal tunnel
syndrome
• Diabetes mellitus
• Heart attack, heart failure, or enlarged
heart
• High blood pressure
• Goiter (enlarged
thyroid gland)
• Sleep apnea
• Tiredness
• Menstrual disorders (irregular
bleeding;
absence
of periods)
• Decreased libido (IOW sex drive)
• Vision problems (tunnel vision; vision
loss)
• Psychological problems (depression;
anxiety)
Persons with untreated growth hormone
excess have a mortality rate that is two
to three times higher than the general
population.
This is mainly due to
cardiovascular
and respiratory
complications.
How is it diagnosed?
Growth
hormone
stimulates
the
production of another substance called
insulin-like growth tector-t (IGF-1) by
the liver and other body tissues. Excess
GH therefore leads to excess IGF-1.
Measuring the level of IGF-1 in the
blood is a good test to confirm GH
excess. We can also measure blood
GH level one to two hours after giving
oral glucose. If either IGF-1 or blood
GH is elevated, magnetic resonance
imaging (MRI) scan of the pituitary gland
is requested to determine whether a
tumor is the cause of the excess
hormone secretion.
How is it treated?
Once GH excess is confirmed and a
pituitary tumor is seen on MRI, surgery
to remove the tumor is the treatment of
choice. If surgery does not normalize
the GH level (eg in large tumors), or if
a patient cannot undergo surgery, other
therapies include medications
and
irradiation
of the pituitary
gland .
Radiation is considered a last resort in
children with GH excess, because of
possible effects on the developing brain.
The following drugs may be used for
treatment of GH excess - somatostatin
analogues, GH receptor antagonists
(not available in our country), and
dopamine agonists. These medications
mainly work to reduce levels of GH or
IGF-1.
Treated patients need to be monitored
to make sure that GH excess does not
return.
Patients
should
also be
monitored
for medical
problems
associated with GH excess, which
include heart disease, hypertension,
colon polyps, and diabetes mellitus.
Children with GHD have
persistently below
Loss of other hormones produced by
the pituitary gland can result from tumor
impingement.
It can also be a
complication of surgery or radiation
therapy. Patients, therefore, need to be
watched for signs of hypopituitarism
caused by low levels of pituitary
hormones. If this occurs, the patient will
require
appropriate
hormone
replacement therapy.
average growth rate. They
Growth
hormone
deficiency
How does it manifest?
Growth hormone deficiency (GHD) is
the condition of having too little GH. A
child can be born with GHD due to
problems in the development of the
pituitary gland and hypothalamus. The
condition may also arise because of
damage to the hypothalamus or pituitary
gland as a child or adult because of a
tumor, an infection, or radiation to the
brain. Some may have GHD due to still
undefined
cause
(idiopathic).
test for the diagnosis of GHD. Because
the pituitary gland secretes GH in bursts
throughout
the
day,
random
measurements of GH levels in the blood
are not useful. GH stimulation tests
using agents that stimulate GH secretion
(eg insulin, glucagon or arginine) are
commonly used. Low blood IGF-1 level
may support GHD.
Children with GHD have persistently
below average growth rate. They may
have extra fat in the abdomen and face.
As adolescents, they may show signs
of delayed sexual maturity.
may have extra fat in the
abdomen and face. As
adolescents, they may
Side effects of growth hormone therapy
in childhood are very rare. The most
worrisome are increased intracranial
pressure and a hip disorder called
slipped capital femoral epiphysis.
show signs of delayed
sexual maturity.
How is it treated?
Treatment involves giving GH (usually
comes in pens) as a daily injection
under the skin.
Children should be evaluated every
three to six months to monitor height
Currently, there are differences
in
opinion about when to give growth
hormone to adults with GHD. Experts
generally recommend GH replacement
for adults
with severe
clinical
manifestations and clear evidence of
GHD due to hypothalamic-pituitary
disease.
Adults tend to experience more side
effects than children. Most common
side effects are peripheral edema (leg
swelling), painful joints, carpal tunnel
syndrome, numbness, and "unmasking"
or worsening of diabetes.
GH therapy is not advisable for patients
with active cancer because of theoretical
possibility that GH could stimulate tumor
growth.
GH excess and GHD are best evaluated
and treated by endocrinologists
medical specialists in hormone-related
conditions. Because the diagnosis and
treatment of such disorders require
special expertise, patients suspected
to have GH abnormalities should ideally
be
referred
to
an
endocrinologist.1
Possible symptoms in adults with GHD
include:
• Increased body fat (particularly at the
waist)
• Decreased muscle and bone mass
• Thinning skin with fine wrinkles
• Poor sweating or impaired temperature
regulation
• Reduced strength and endurance
• Low energy level
• Decreased well-being (moodiness,
mild depression)
• Loss of interest in sex
• Poor sleep
• High LDL ("bad")
cholesterol
How is it diagnosed?
There is currently no "gold standard"
and rate of growth. When children with
GHD reach late teenage years, tests
should be done to see if they still need
GH therapy until adulthood.
References:
The
Hormone
Foundation:
http://www.hormone.org/
Uptodate: httpwww.uptodate.coml
Andre Rene Roussimoff
"Anor« the Giant"
wrestler and actor has GH excess
Mary Jane Gutierrez, MD, FPCp, DPSEM
Polycystic
Ovary Syndrome
(PCaS) ay isang kalagayan dulot ng
pagbabagong "hormonal" at tinatayang
pinakamadalas
na sanhi ng hindi
pagkakaroon
ng anak
ng mga
kababaihan na may edad na 15-45
taon. Ito ay unang natuklasan noong
1935 nila Drs. Stein and Leventhal at
nakilala sa tawag na Stein-Leventhal
Syndrome.
Ayon sa pananaliksik,
kinabibilangan ng mga pagbabagong
"hormonal"
na ita ay ang mga
sumusunod: a) ang pagkakaroon ng
"insulin resistance", isang kondisyon
na matatagpuan sa mga may diabetes;
b) pagtaas ng "male horomone" 0
"androgen" buhat sa obaryo 0 "ovary
"at "adrenals";c) pagtaas ng "Luteinizing
Hormone"
0 "LH".
Dulot
ng
pagbabagong "hormonal" ay pagkaipon
sa obaryo ng maliliit na bukol 0 "cysts"
na naglalaman ng mga hindi ganap na
.itlog 0 "ovarian eggs" kung kayat hindi
nagtutuloy
ang "ovulation"
na
nagdudulot ng iregular na regia. Ayon
sa Nurses' Health Study, napagalaman
na ang mga kababaihan na may iregular
na regia ay may karagdagang
posibilidad
na magkaroon
ng
komplikasyon sa puso kahit sa edad
na 20-35 taon.
Walang iisang dahilan ang pagkakaroon
ng pcas.
Ito ay hinihinala nagbubuhat
sa lahi 0 "genetics" at kapaligiran 0
"environmental factors". Ayon sa pagaaral, ang pagbabago sa "genes" na
CYP11 ay karaniwan sa mga pcas at
mahigit 50% ng mga kalahi nito ay
IKAW AT ANG POLYCYSTIC
OVARIAN SYNDROME
magkakaroon
din ng ganitong
kondisyon. Dagdag pa rito, 20 - 50%
sa mga ita ay magtutuloy magkaroon
ng diabetes, kung kaya't lahat ng may
pcas
ay dapat
pagawan
ng
"screening" sa diabetes sa edad na 30
taon.
Madalas
din sa mga
pangagatawan
ng may pcas
ay
matataas ang timbang at malalaking
baywang na maaaring nagbubuhat
sa"environmental
factors" tulad ng
pagkain ng labis.
May mga karagdagang
kondisyong
nakikita sa mga may pcas at kabilang
dito ay pagbabago sa kolesterol at
presyon.
Ang mabuting kolesterol
(HDL) ay bumababa at tumataas naman
ang ibang uri ng kolesterol (triglyceride).
Mas mataas din ang presyon (high
blood) ng mga ito. Ang pagkakaroon
ng mataas na "blood sugar", malaking
pangangatawan, mataas na presyon,
mataas ng kolesterol ay maaari rin
makita sa isang kondisyon kinikilala na
"syndrome X" 0 "metabolic syndrome".
Nagkakaroon din ng pagbabago sa
"hemostatic factors" tulad ng pagtaas
"tissue plasminogen
activator", na
nagiging sanhi ng paglapot ng dugo.
Ang lahat ng ita ay
maaaring
magpaliwanag
kung bakit
may
karagdagang
pagkakaroon
ng
komplikasyon sa puso at "stroke" ang
Normal ovary
Polycystic ovary
Liban sa diabetes, malaking pangangatawan, mataas na presyon at kolesterol, may
mga ulat din ng kanser sa matres 0 "endometrial cancer" ang mga may peas.
may pcas kumpara
kababaihang walang nito.
sa
mga
"adult-onset congenital hyperplasia 0
CAH", "hyperprolactinemia",
"adrenal
o ovarian
androgen-producing
adenomas",
"hyperthecosis",
and
"Cushing's syndrome".
Liban
sa diabetes,
malaking
pangangatawan, mataas na presyon at
kolesterol, may mga ulat din ng kanser
sa matres 0 "endometrial cancer" ang
mga may pcas.
Ang iba-ibang anyo 0 "phenotype" ng
pcas ang dahilan ng samu't saring
mga sintomas
na mahirap ·agad
matukoy. Maliban sa pagkakaroon ng
iregular na regia at hindi pagkakaanak,
kabilang sa mga sintomas at senyales
ay ang pagtubo ng karagdagang buhok
sa ibang lugar sa katawan lalo na sa
mukha at binti, pagnipis ng buhok sa
ulo, pagkakaroon ng tighiyawat
0
"acne" at pangingitim at pagkapal ng
balat sa batok (acanthosis nigricans).
Ang iba naman ay nakakaranas
ng
sobrang kalungkutan dulot ng mga
pagbabagong nabanggit.
Sa lupon ng eksperto na nagtipon ay
naglahad ng basihan ng pcas, at
kinabibilangan
nito ay ang mga
sumusunod: 1) iregular na regia at hindi
pagkakaroon ng "ovulation"; 2) klinikal
at "biochemical"
na senyales
ng
pagtaas ng "androgen hormone"; 3)
hindi kinabibilangan ng sakit tulad ng
May mga epektibong pamamaraan ng
paggagamot
ng- pcas at mga
kondisyong nakapaloob dito at kabilang
dito ang tamang pagkain at ehersisyo
(lifestyle change), pagpapapayat, gamot
na nagpapababa ng kolesterol, presyon
at "insulin resistance", "nonandrogenic
oral contraceptive pills" at "antiandrogen
pills".
Kung
hihihinala
ang ganitong
kondisyon, agad makipag-ugnayan sa
inyong duktor -Endocrinologist at a8GYNE specialist- upang magawa ang
mga nararapat
na pagsusuri
sa
kagalingan ng pcas.
Aimee Andag-Silva,
MD, FPCp, FPSEM
"Kung tila paru-paro and THYROID ni
Kaha ... Ano naman ang PARA THYROID
lumahi hay Tehla?"
Sa
mga lamang loob na bumubuo
ng "endocrine system" ay sikat na ang
pancreas 0 "pale" na apektado sa
diabetes, at ang thyroid na apektado
sa goiter. Malimit ilarawan ang thyroid
na hugis paru-paro sa ibaba ng ating
leeg. Alam ba ninyo na may nakadikit
sa mga sulok nito sa bandang likod na
kakaibang endocrine gland na tinatawag
na "PARATHYROID"?
Ang Parathyroid Gland ay naglalabas
ng hormone
na pinangalanang
'parathyroid hormone 0 PTH. Ito ay
mahalaga sa pag-kontrol sa antas ng
calcium sa ating dugo. Apat na piraso
ang bilang nito sa karamihan sa atin,
ngunit may ilang tao na lima 0 anim
ang tag Iay. Kasing laki ito ng butil ng
mais at mahirap itong makita kahit sa
gitna ng mga operasyon sa thyroid.
Ano ang kinalaman nito sa ating buto?
Ang PTH ay inilalabas ng parathyroid
gland kapag bumababa ang antas ng
calcium sa ating dugo. Ang PTH ay
kumakapit sa buto at tinatanggal ang
calcium na naka-deposito dito papunta
sa dugo upang mapanatili sa normal
Ang Parathyroid Gland ay
naglalabas ng hormone na
pinangalanang
parathyroid hormone 0
PTH. Ito ay mahalaga sa
pag-kontrol sa antas ng
calcium sa ating dugo.
na
ang serum calcium. Pinapalakas din
nito ang pag-likom ng ating bato 0
kidneys sa calcium mula sa ihi papunta
rin sa dugo. Sa bituka ay pinapagana
nito ang vitamin D upang mas marami
tayong makuhang calcium sa ating
kinakain. Mahalaga na mapanatiling
normal ang antas ng calcium sa dugo
upang maging maayos
ang mga
proseso sa ating mga kalamnan mula
ulo hanggang paa.
Kung ang parathyroid
gland ay
magkasakit 0 di kaya'y matanggal sa
operasyon dahil mahirap nga itong
matunton, ay babagsak ang ating PTH
at mawawala ang ating kakayanan na
mapanatiling normal ang calcium sa
ating dugo. Hindi natin makukuha ang
calcium sa ating mga kinakain sa arawaraw dahil hindi ita tatagos sa ating
bituka. Hindi rin mababantayan ng ating
kidneys ang pagtapon ng calcium sa
ating ihi. Sa kakulangan ng pag-likom
nito, ay mababawasan ang calcium na
maaaring i-deposito sa ating buto. Ang
buto ay magiging mahina at marupokmagkakaroon tuloy ng osteoporosis.
Kapag sumobrang baba ang calcium
sa ating dugo at walang PTH na
Pag masyado nang mataas ang calcium sa dugo ay masama ang epekto
nito sa utak, muscles, kidneys, at maging sa puso. Karamihan ng mga
pasyente (80%) na may mataas na calcium sa dugo ay waiang
nararamdaman, 0 di kaya'y di masyadong halata ang manipestasyon.
lumalabas sa ating parathyroid ay maari
ding mag-kombulsyon,
manigas at
kisigin ang mga muscles 0 laman.
Delikado ang sob rang pag-baba ng
calcium sa katawan.
Kung ang parathyroid gland naman ay
tubuan ng bukol 0 maging masyadong
malaki at aktibo sa paglabas ng. PTH
(HYPERparathyroidism),
ay tataas
naman nang sobra ang calcium natin
sa dugo. Ito ay tataas dahil kakainin
ng PTH ang buto upang mad ala ang
calcium papunta sa dugo. Magiging
malakas din ang pag-higop sa calcium
ng ating mga bato habang sinasala nito
ang dugo at ihi. Ang pinaka-malimit
tamaan ng hyperparathyroidism ay mga
babaeng edad 50 (tulad ni Tekla sa
ating pamagat). Pag masyado nang
mataas ang calcium sa dugo ay
masama ang epekto nito sa utak,
muscles, kidneys, at maging sa puso.
Karamihan ng mga pasyente (80%) na
may mataas na calcium sa dugo ay
walang nararamdaman, 0 di kaya'y di
masyadong halata ang manipestasyon.
Ang maaring maramdaman lamang ay
ang panghihina ng laman/ muscles,
sobrang pagod, hirap sa pag-dumi,
pagduduwal 0 pananakit ng sikmura 0
pagka-lito. Sa kina-Iaunan ay maaring
magkaroon ng palpitasyon, madaling
pagka-bali ng buto dulot ng pag-nipis
nito, 0 pagkakaroon ng mga bato sa
kidneys. Kapag sobrang taas na ng
calcium sa dugo ay maari ring magkombulsyon ang pasyente at ito ay isa
nang mapanganib
na emergency,
mabuti na lang at hindi ita karaniwang
nangyayari.
Hindi madali ang pagtunton ng sakit ng
parathyroid. Maraming pagsusuri ang
maaring
gawin
ng
inyong
endocrinologist- mga eksaminasyon sa
dugo, sa ihi, sa buto, at sa paghahanap
sa hugis 0 laki ng mga ito. At tulad din
nang maraming endocrine 0 hormonal
na sakit
ay habam-buhay
ang
pagbabantay sa pasyentenq may sakit
dito. Ngayon ay batid na ninyo kung
para
saan
ba
talaga
ang
PARATHYROID.
ENDOCRINOLOGISTS IN
POP CULTURE
Bien J. Matawaran, MD, DPSEM
This column is the obligatory question and answer portion of Hormone Hotspots.
all of you---patients,
We will entertain any questions about Endocrinology
& Metabolism from
friends, colleagues and even enemies (just don't hold your breath waiting for the answer :. I will try to be simple minded as possible
(as if I can try to be otherwise) so that comprehension of endocrine topics will hopefully be easier. I will be your resident Joe D' Mango/Kuya Cesar cum
Helen Vela--- well known "showbiz advisers", until the editors can find a qualified and saner writer for this column. But for now you don't have a choice
but read on or tear this page ASAP.
1
will
veer away from the usual
question and answer format of my
column and will instead deal on what
is an endocrinologist in popular culture.
By now, you may already know that
Endocrinology is a branch of medicine
that is concerned with the study of the
biosynthesis, storage, chemistry, and
physiological function of hormones and
with the cells of the endocrine glands
and tissues that secrete them. Sounds
simple enough, at least based from
Wikipedia.
So it follows
that we
endocrinologists
are doctors who
specialize in treating diseases of the
endocrine system, such as diabetes,
thyroid disorders and many others. In
the Philippines, this subspecialty is quite
young and is not as well known as
.cardiology and pulmonology. However,
as you may now, we now see a lot of
patients with endocrine disorders so
that more often than not you get to see
only a few of our tribe. One thing more,
not a few of patients know what an
endocrinologist is-since most would say
that we are the doctors who do
endoscopy and deal with diseases
"inside" the body. Part of the challenge
of the
Philippine
Society
of
Endocrinology & Metabolism (PSEM)
is to introduce ourselves to patients and
eo-doctors
that we are Hormone
Specialists. True enough there are little
of us exposed in popular culture--- I
can't think of any high profile TV or
movie character who are as well known
as surgeons,
paediatricians
and
cardiologist,
like MJ's Dr. Conrad
Murray. Endocrinology in mainstream
TV or film come far in between, like
Dr. Lisa Cuddy , a character on the
television show House MD and Naomi
Bennet, an endocrinologist and fertility
expert on the television show Private
Practice. It just shows that it is as hard
to find an endocrinologist in TV or film
as it is to find an endocrinologist in your
locality. 9
However, there are a lot of movies or
film characters that deal with diseases
of the endocrine system and you will
be surprised that majority of the time,
it is the plots turning point or highlight.
THE
GODFATHER
III
(1990)
Corleone has diabetes.
CON AIR (1997)
A prison parolee, played by Nicolas
Cage, and another convict, whom he
befriends, are being transported on a
maximum-security plane with some of
the country's most dangerous criminals.
After the plane is skyjacked, Baby 0,
who has diabetes, doesn't receive a
scheduled insulin shot, and his syringes
are destroyed during in-flight chaos.
S TEE
L
MAGNOLIAS
(1989)
A 1990 American thriller film written by
Mario Puzo and Francis Ford Coppola
and directed by Coppola. It completes
the story of Michael Corleone, a Mafia
kingpin who tries to legitimize
his
criminal empire. Character Michael
M
any
moviegoers
recall
Julia
Roberts in the
movie with beads of sweat on her lip
from Sally Field during a severe
hypoglycemic episode in Truvy's Salon.
It was arguably the most famous scene
depicting a person with diabetes in a
major motion picture.
at a price," she says of Dench's
character, who dies of complications
from diabetes presumably brought on
by hanging out in the chocolate shop
instead of adhering to a healthier diet.
MEMENTO (2000)
PANIC ROOM (2002)
A p3yChoIogical
thriller written
and directedby
Christopher
N 0 I an,
adapted from
his brother
.Jo n ath ans
short
story
"Memento
Mori". It stars
Guy Pearce
as Leonard
Shelby, a former insurance
fraud
investigator searching for the man he
believes raped and killed his wife during
a burglary. The main character's wife
has diabetes and is killed by his giving
her overdose
of insulin
shots.
A suspense-thriller
starring multiple
Oscar best actress winner Jodie Foster.
The
young
character,
Sarah,
has
diabetes
and
experiences an
episode of low
blood glucose
(hypoglycemia)
while trapped
in the panic
room with her
mother. Sarah
seems to have
type 1 diabetes and was on continous
subcutaneous insulin injection (CSII)/
insulin pump. Jodie Foster's character
was struggling
to find her ward's
glucagon pen.
CHOCOLAT (2000)
MAD MONEY (2008)
Judi Dench portrays a grandmother with
diabetes. "At the end, through the
metaphor of chocolate, people are able
to embrace a free lifestyle and sexual
freedom and reject repression of all
kinds. And that wasn't available to the
woman with diabetes. Well, it was, but
When Character Jackie Truman (Katie
Holmes) drops her purse, an insulin
needle is among the items co-workers
Bridget Cardigan (Diane Keaton) and
Nina Brewster (Queen Latifah) help her
to retrieve.
Unaware
of Jackie's
WHAT'S UP AND WHAT'S NOT!
Oprah Winfrey's battle from weight gain and weight
is internationally followed. The Queen of Talk eventually
announced that she suffers from a thyroid disorder,
probably Hashimoto's thyroiditis. So if ever you have
weight problems, might as well have your thyroid
checked.©©©
•
DlANI KEATON
Green
QUEEN LATIFAH
KAlII ~
=
'1Comlnt
The Cure for The Blue.
To
Mcry 131
diabetes, they assume she is a drug
addict. Go-with-the-flow Jackie never
corrects them, feeling that their show
of concern
makes the deception
worthwhile.
As you can see, in film, patients still
outnumber endocrinologists.
If ever
you're in the medical profession,
endocrinology is definitely one good
subspecialty
to consider
....
CUT!
I
KAKAIBANG
ALTAPRESYON
Secondary Hypertension: Unveiling the
silence of the' Silent Killer'
Cecile Anonuevo-Cruz,
The
MD, FPCp, DPSEM
P1!eSSUl1e C((}([lk€:1f
Luiuii: Pt!1ra
S~
MeJlJ Higlh
Hindi maikakaila na ang pagkain ay
bahagi ng kasiyahan ng mga Pilipino.
Lalo pa itong napapasarap kung may
kasalo, 0 sa karaniwang biro, "may
kalaban".
Kung kaya't
mahirap
tanggapin
(kasama ng lunukin at
tunawin pa) ang malimit na mga bilin
ng inyong mga duktor:
B~(fJ(fJd
diastolic pressure kapag nagpahinga
ang puso sa pagitan ng pagtibok.
Mahalaga ang dalawang numero na
tumutukoy sa ating blood pressure. Ang
presyon ay natural na nagbabago sa
magdamag. Kung ito ay nananatiling
rnataas, ita na ang tinatawag
na
hypertension, na karaniwang tawag sa
atin ay high blood. Habang tumataas
ang presyon, bumibigat ang trabaho ng
puso at sa katagalan ay nahihirapan
ito. Ang mataas
na presyon
ay
nakakasira din sa ating mga ugat, kung
kaya't kasama sa naaapektuhan ay ang
mga ugat sa puso, bato, utak at mata.
Ang high blood
ay kalimitang
panghabang-buhay
na sakit. Kung
pababayaan at hindi maaagapan, ita
ay maaaring magdulot ng sakit sa puso,
sakit sa bato, stroke, at pagkabulag.
Ang
Asin
at ang
High
Blood
Ang Sakit na High Blood
Ang sodium ay likas na matatagpuan
sa karamihan ng mga isda, karne at
gulay. Dagdag na pinanggagalingan
nito ang karaniwang pangtimplang asin,
patis, vetsin at bagoong. Karaniwang
pinapayo na ang makatwirang dami ng
sodium na maaring kainin sa isang araw
ay sa pagitan ng 1500 mg hanggang
2300 mg, katumbas ng 5g ng asin.
Ang
sodium
ay isa sa mga
mahahalagang electrolytes na sangkap
ng ating dugo. Isa sa mga gawain nito
ay ang pagpapanatili ng balanse ng
tubig sa ating dugo. Sa pagkain ng
maaalat, nagkakaroon ng sunud-sunod
na pagbabago sa puso at bato natin na
nagdudulot ng pagdami ng naiipong
tubig sa ating dugo at katawan, na
nagiging sanhi ng pagtaas ng presyon.
Ang pinakaloob na balot ng ating mga
ugat ay maari ding mamaga, na
magdudulot ng pagkipot ng daluyan ng
dugo.
Ang ating blood pressure (presyon) ay
ang puwersa ng dugo laban sa loob ng
ating mga ugat. Ang presyon ay may
dalawang numero: ang systolic pressure
kapag tumibok ang puso, at ang
Kung araw at gabi, lingo-linggo
at
buwan-buwan ang pagkain ng maalat,
ang mga pagbabago sa ating mga ugat
ay mauuwi sa pirmihang kumplikasyon.
Gayunman,
may mga paraan para
"0, kailangan ninyo iwasan ang pagkain
na mataba."
di kaya'y:
Bawal na ang maalat na sawsawan at
timpla." Lalo na kung ita ay:
"Bawas-bawasan
ang kain para
pumayat."
°
11
Karaniwan namin naririnig, "Wala po
akong bisyo kundi ang kumain."
Magkalinawan tayo: hindi bisyo ang
pagkain,
bagkus ita pa nga
ay
pangangailangan. At kahit ang taong
maysakit
katulad
ng high blood,
nangangailangan ng sapat na pagkain
at sustansiya sa araw-araw para sa
kanyang ikasisigla. Sa madaling salita,
kung ikaw ay high blood, puwede pa
ring kumain ng ayos at masarap!
maiwasan ang mga pagbabagong ito
sa pamamagitan ng pagkain ng wasto.
Napatunayan sa mga pag-aaral na ang
pagsunod sa planadong pagkain ng
sodium at cholesterol
ay higit na
nakakatulong
sa pagpapababa
ng
presyon sa mga taong high blood, at
nakakaiwas sa pagkakaroon ng high
blood sa mga taong
posibleng
magkaroon nito.
Ang Kontroladong
Sa pagluluto, bawasan ang paggamit
ng mga seasoning katulad ng toyo,
patis, bagoong, bouillon cubes, meat
tenderizer, Worcestershire
sauce at
steak sauce. Sa halip na dagdag alat,
gamitin ang ibang pampalasa tulad ng
mga fresh herbs, calamansi, suka at
paminta.
Kung nangangailangang
gumamit ng de latang gulay, hugasan
ang lam an nito para mabawasan ang
asin.
Pagkain ng Asin
Ang Food and Nutrition Research
Institute (FNRI) sa Pilipinas at ang
National Institutes of Health (NIH) sa
Amerika ay may mga payak at praktikal
na payo para sa pagkontrol ng alat sa
pagkain. Pangunahin sa listahan ay
ang pagpili ng mga pagkain na natural,
na may kaunti 0 halos walang asin.
Ipinapahayag nito na mas mainam ang
sariwang prutas, gulay, karne at isda,
kaysa sa mga processed 0 de latang
pagkain tulad ng ham, bacon, tinapa,
dilis at sardinas. Makakatulong
ang
pagtanggal ng asin, patis, bagoong,
toyo at catsup sa lamesa,
para
maiwasan ang dagdag na asin na
makukuha sa paggamit ng mga ito.
Sa pamimili, ugaliing magbasa ng mga
nutrition facts at food labels na ngayo'y
karaniwang
kasama sa balot ng
pagkain. Piliin ang pagkaing mas
kakaunti ang sodium na nilalaman.
Simulan ngayon ang pagbawas ng
pabili ng mga sitsirya at processed food
na mataas ang alat.
Patikim Naman ng Pagkaing Van!
Narito ang isang natatanging recipe na
maaring subukan para matuklasan na
maaaring
masarap ang pagkaing
angkop sa may high blood, kahit bawas
alat! Ito ay halaw sa FNRI Menu Guide
Calendar
2009.
Para sa mga
karagdagang
recipe, bisitahin ang
www.fnri.dost.gov.ph.
H
Molo Soup
Molo
% cup
1 tbsp
1,4 cup
1 pc
2 tsp
Dash
% cup
1,4 cup
2 tbsp
Soup
1 tbsp
2 tbsp
2 tbsp
1 tsp
% tsp
6 cups
3 cups
Lean ground pork
Onion, chopped
Carrot, chopped
Egg, beaten
Iodized salt
Black pepper, ground
Singkamas, chopped
Water
Green onion, minced
Malo wrapper
Garlic, minced
Cooking oil
Onion, chopped
Iodized salt
Black pepper, ground
Chicken
stock
or
Native pechay, sliced
water
Malo
1. Combine pork, onion, carrot and
singkamas.
2. Season egg with salt and pepper.
Add to pork mixture.
3. Add green onions. Reserve 1,4 cup
of the mixture
for sauteing.
4. Spoon 1 tsp of pork mixture into
molo wrapper. Secure all sides.
Soup
1. Saute garlic, onion and the reserved
1,4 cup of the pork mixture in oil.
2. Season with salt and pepper.
3. Add chicken
stock or water.
4, When boiling, drop wrapped meat.
Cover and simmer for 20 minutes.
5. Add pechay and green onion. Serve
hot.
Ang makulay na daigdig
ng Diabetes
Mia
c. Fojas,
MD, FPCp, DPSEM
Vein Mapping
For those patients who have had regular
"fasting-blood-chemistry-panel-hellextractions", soon enough your worries
might be over. Introducing to you, the
Accuvein
AV300,
helping
health
professionals find difficult to access
veins.
The AV300 is a non-contact hand held
vein-illuminating device that enables
health professionals see a vein map of
hard-to-find veins.
Hemoglobin is detected and highlighted,
being scanned up to Bmm below the
skin surface to locate for peripheral
veins. This gadget weighs only 10
ounces and uses a point and click
technology, switching from hand held to
handsfree mode so one could perform
the venipuncture.
"In fast-paced environments like the ER
or in ambulances, reducing the time to
access veins and ensuring other tests
are conducted
and medication
is
provided quickly is paramount to
improving
patient
care
outcomes," said Dr. Diane
Sixsmith, Chairman of New
York Hospital
Queens.
Aside from the benefits in
emergency
situations,
multiple venipunctures could
be avoided and thus, reduce
patient discomfort and anxiety. On the
other hand, decreasing the need for
multiple
needlesticks
would
economically
be beneficial
to the
laboratory or hospital.
As for observers, looking into vein maps
could be enjoyable as well, for as long
as you don't get to be the one
punctured.
For more information
onAccuVein
AV300, please visit www.eccuvein.com
Fertility Gadget
No, it won't make
you fertile. But for
couples trying to
have
a baby,
meet
the
DuoFertilityfertility monitoring gadget.
This uses a more advanced method of
monitoring the basal body temperature
(claims
to be 99% accurate)
to
determine when one would most likely
be fertile enough to get pregnant up to
6 days in advance. This way, couples
could plan intercourse ahead of time.
DuoFertility consists of a small sensor
and a hand held reader. The sensor is
actually
a patch
measuring
approximately 3 cm in diameter that
can be placed under a woman's arm
near her bra strap. Roughly 20,000
temperature
measurements
can be
collected by the sensor the entire day.
Data is then sent to the reader which
will show a fertility light scale. The
reader has an included software,
generating temperature graphs for each
menstrual cycle. No need to install
anything into the computer since the
software runs from the reader itself.
This gadget comes with a "Pregnant in
12 months or your money back!"
guarantee. Offer ends 20th September
2009.
The price? £495
shipping and VAT.
- including
For more information,
www.duofertility.com
I
please
free
visit
Thyroid: Neck,
Neck Mo
Nemencio A. Nicodemus
Jr., MD, FPCp, DPSEM
AND
ANG KAUGNAYAN NG
THYROID AT IODINE?
Ang iodine
0 yodo
ay isa sa
pinakamahalagang
sangkap
na
kinakailangan ng thyroid upang maging
tama ang pagkilos nito. Ang iodine ay
ginagamit ng thyroid gland upang
gumawa ng mga thyroid hormones, na
kilala rin sa tawag na T3 at T4.
I
Ang karamihan ng iodine sa ating
katawan ay galing sa pagkaing sagana
sa iodine, gaya ng mga halamang dagat
(seaweeds) tulad ng lato at mga isda
at pagkaing dagat (seafoods), tulad ng
tahong at talaba. Sa loob ng ating
I
ANG RADIOACTIVE
IODINE (RAI) BILANG
GA MOT P A RA SA M GA .
SAKIT NG THYROID
katawan, ang iodine na mula sa mga
pagkaing ita ay sumasama sa dugo at
pumupunta sa thyroid gland kung saan
ita ay pumapasok sa loob ng mga "cells"
ng thyroid gland. Ang mga cells ng
thyroid
gland na may kanser ay
kumukuha rin ng iodine mu la sa dugo
pero hindi kasing-ayos ng mga normal
na cells ng thyroid. Ang kakayahan ng
mga cells ng thyroid gland na kuhanin
ang iodine sa dugo papasok sa loob
nito ay ang ginagamit na basihan ng
medisina upang gamutin ang mga
karamdaman
0 sakit
ng thyroid.
ANO ANG RADIOACTIVE
IODINE
(RAI)?
Ang isang sangkap ay tinatawag na
radioactive kung ito ay naglalabas ng
radiation.
Ang iodine 0 yodo ay
maaaring
mabago upang maging
radioactive iodine (RAI) 01-131. Ito ay
maaaring ipainom sa mga pasyenteng
mayroong karamdaman ng thyroid. Ang
RAI, pagkatapos
ito inumin,
ay
pumupunta sa dugo at tumutuloy sa
thyroid
gland kung saan ito ay
pumapasok sa loob ng mga
cells ng thyroid gaya ng
normal na iodine sa pagkain.
Ang radiation na lumalabas
sa RAI ay maaaring
makasira sa mga cells ng
thyroid. Ang sobrang RAI na
hindi pumasok sa thyroid ay
lumalabas sa katawan sa
pamamagitan ng pawis at
ihi. Ang RAI ay ligtas na
ibigay
sa
mga taong
may allergy
sa
mga
pagkaing
d a gat
(seafoods)
d a h i I
kadalasan
ang allergy
ay dahil sa
pagkain
at
hindi
sa
i 0 din
e
mismo.
ANO ANG
GAMIT NG
RAI PARA
5
Radioactive
is ingested
iodine
A
PAGGAMOT
NG MGA SAKIT NG
THYROID?
Ang 1-131 0 RAI ay ginagamit upang
sirain 0 tunawin ang sobrang aktibong
thyroid (hyperthyroidism) at maging ang
kanser ng thyroid.
Sobrang
Aktibong
Thyroid
0
Hyperthyroidism
Maliliit na dosis ng 1-131 (5 - 30
millicuries) lamang ang pinapainom
upang tunawin 0 sirain ang thyroid na
sobrang aktibo, gaya nang nakikita sa
hyperthyroidism
0 toxic goiter. Dahil
dito ay nawawala ang pagiging aktibo
ng thyroid gland at ito ay maaaring hindi
na kumilos 0 gumawa ng mga thyroid
hormones (nagiging hypothyroid). Maari
din naman gumamit ng 1-131 upang
mapaliit ang sobrang malaking goiter,
lalo na kung ita ay nagdudulot
ng
sagabal tulad ng pananakal, paghirap
sa paghinga 0 paglunok. Ang pasyente
ay maaring umuwi agad pagkatapos
uminom ng 1-131. Subalit may ilang
pag-iingat na dapat sundin, gaya nang
nakasulat sa ibaba. Karaniwan na
nakararanas ng kaunting kirot sa bahagi
ng thyroid pagkatapos ng pag-inom ng
1-131 kung ita at ginagamit upang
gamutin ang hyperthyroidism 0 toxic
goiter.
Maaaring
makatulong
sa
paggamot ng kirot ang pag-inom ng
aspirin, ibuprofen 0 paracetamol. Maaari
din umabot nang maraming buwan
(kadalasan
ay 6 na buwan) bago
tuluyang matunaw ang thyroid gland at
makita ang epekto ng RA!.
Kanser ng Thyroid
Matapos ang operasyon at pagtatanggal
ng thyroid gland na may kanser, ang
pag-inom ng RAI ay isa sa maaaring
susunod na hakbang. Malalaking dosis
ng 1-131 (30 - 200 mCi) ang ginagamit
upang tunawin ang mga cells ng thyroid
Hyperlhyroidism In Graves Disease
ExQphtl1almos
(protnJdino Eyes)
pagkatapos ng operasyon. Sa ganitong
pagkakataon, ang isang pasyente ay
kailangang ipasok sa ospital sa isang
espesyal na kwarto kung saan siya ay
mag-isa lamang. Ang paglalagi sa
ospital ay kadalasang higit sa isang
araw subalit hindi lalagpas nang isang
lingo. Ito ay upang iwasan
ang
makihalobilo ang ibang mga tao, laic
na ang mga maliliit na bata na kasama
sa bahay. Dahil sa ang ating salivary
glands 0 pagawaan ng laway sa bibig
ay nagtitipon din ng iodine, maaaring
makaranas ng kirot at pamamaga ng
mga ito kapag matataas na dosis ng 1131 ang pinainom, gaya ng sa kaso ng
kanser ng thyroid. Ito ay maaaring
mabawasan
sa pamamagitan
ng
pagsipsip
ng dayap 0 kalamansi
pagkatapos ng gamutan.
lIang araw ang kinakailagan
upang
mabawasan
ang panganib na maexpose sa 1-131 ang ibang tao sa
paligid?
Naririto ang kadalasang pinapayong
gawain at kung gaano katagal upang
maging ligtas sa radiation mula sa RAI
ang mga kasama sa bahay at mga tao
sa paligid:
- 5 - 11 araw
Dahil sa ang 1-131 ay naglalabas
ng
radiation, kailangan gawin ng mga
pasyente ang kanilang makakaya
upang maiwasan na ma-expose ang
ibang tao, lalo na ang mga buntis at
maliliit na bata.
ANO ANG PAGMATAGALAN
NA
EPEKTO NG RAI 0 1-131?
Sa pangkalahatan, ang RAI ay ligtas at
epektibong
gamot para sa mga
karamdaman ng thyroid na nabanggit
dito. Kung ang RAI ay ginagamit para
sa paggamot ng hyperthyroidism 0 toxic
goiter, mahirap maiwasan na ito ay
humantong sa hypothyroidism. Kung
gayon,
ang
pagkakaroon
ng
hypothyroidism ay kailangan bantayan
at gamutin agad sa pamamagitan ng
pag-inom ng levothyroxine 0 thyroid
hormone. Maaari din makaranas ng
• Paglibansa pagpasoksa trabaho - 1 araw
• Huwagsumakaysa eroplano0 jeep - 1 araw
• Huwag magbibiyahenang matagal na may
katabisa sasakyan- 2 - 3 araw
• Magpanatili ng 3 talampakan distansya sa
ibangtao - 2 - 3 araw
• Uminomng maramingtubig
- 2 - 3 araw
• Huwagmagluto0 maghanda
ng pagkainpara sa ibang tao
- 2 - 3 araw
• Ihiwalay ang kubiyertos na
ginagamit-2 - 3 araw.
Poroiid ~1•• dif5iffi'~ll
• I-flushangtoiletbowl0 inodoro
2 - 3 besespagkagamit- 2 - 3
araw
• Matulogmag-isa0 malayosa
katabi(-7 talampakananglayo
- 5 - 11araw
Iwasanangmatagalangpagtabi
sa mgabataat buntis
Submandibul.,
gt.nd
'/
pansamantalang paglala ng
hyperthyroidism
sa mga
unang
araw 0 linggo.
Mahalagang
tandaan na
ang isang pasyenteng
napainon ng RAI ay dapat
na
may
regular
na
eksaminasyon at checkup
sa kanyang endocrinologist
habang buhay.
Ang mataas na dosis ng RAI
na ibinibigay upang gamutin
ang kanser ng thyroid ay
maaaring
magdulot
ng
permanenteng problema sa
salivary glands 0 pagawaan
ng laway sa bibig na
magdudulot ng pagkawala
ng panlasa at panunuyo ng
bibig. Subalit may mga pagiingat na dapat gawin upang
maiwasan
ito, gaya ng
pagsipsip sa kalamansi 0
dayap pagkatapos uminom
ng RAI. Ang bilang ng dugo
ay
maaaring
Ang mga JaJakinguminom ng RAJ ay maaaring
magkaroon ng pagbaba ng sperm count 0 bilang
ng semilya at pansamantaJang paghina ng
kakayahang makabuntis sa Joob ng hanggang
daJawang taon.
pansamantalang
maapektuhan
din.
ESPESYAL NA PAN GAN GALAGA SA
MGA KABABAIHAN
Ang RAI ay hindi dapat ibinibigay sa
mga pasyenteng buntis 0 nagpapasuso.
Ang pagbibigay ng RAI habang buntis
ay maaaring makasira sa thyroid gland
ng lumalaking sanggol sa sinapupunan.
Kapag ang RAI naman ay ibinigay sa
nanay na nagpapasuso, ito ay maaaring
humalo sa gatas n'g ina at mainom ng
sanggol. Dapat iwasan ang magbuntis
sa loob ng 6 hanggang 12 buwan
pagkatapos ng pag-inom ng 1-131dahil
sa ang mga obaryo ay na-expose din
sa radiation. Ang mga kababaihang
hindi pa umaabot sa menopause ay
pinapayuhang
makipag-usap
sa
kanilang mga doktor ukol sa mga pagiingat na nabanggit. Walang malakas
na ebidensya na nagsasabing ang RAI
ay maaaring magdulot ng pagkabaog
sa mga kababaihan.
ESPESYALNAPANGANGALAGASA
MGA KALALAKIHAN
Ang mga lalaking uminom ng RAI ay
maaaring magkaroon ng pagbaba ng
sperm count 0 bilang ng semilya at
pansamantalang
paghina
ng
kakayahang makabuntis sa loob ng
hanggang dalawang taon. Maaaring
pag-usapan ng doktor at pasyente ang
posibilidad na maglagak ng semilya sa
sperm bank kung inaasahan ang paginom ng maramihang dosis ng RAI sa
mga pasyenteng may kanser sa thyroid.
Ang radioactive iodine (RAI) 0 1-131 ay
isa sa mga napakahalagang gamot sa
mga karamdaman ng thyroid gland.
Maiiwasan ang labis na takot at pagaalala kung ang isang pasyente ay may
tamang kaalaman ukol sa epekto nito
sa katawan. Kausapin ang inyong
endocrinologist ukol sa mga tanong sa
inyong isipan na hindi pa nasagot sa
artikulong ito.
I
Laura Trajano-Acampado,
MD, FPCp, FPSEM
Gestational
Diabetes Mellitus
Ako ay nagagalak na makasama kayo sa kaunaunahang
pagkakataon
Mag na pinamagatang
sa column na ito sa H
Ito ay para rin sa mga nagpaplano
pa lang
magbuntis at sa may mga mahal sa buhay na
0 nagnanais
Ang ating tatalakayin
risk", dapat agad agad silanq masuri
sa umpisa pa lang ng pagbubuntis.
USAPANG BUNTIS. Ang
column na ito ay hindi lamang para sa mga buntis.
nagbubuntis
Bakit kailingan masuri para sa GDM?
(GDM)
na
magbuntis.
Dahil sa mga kumplikasyon
na
pwedeng maidulot ng GDM sa ina at
sanggol, importanteng masuri ang mga
nagbubuntis.
sa unang isyu ng column
na ito ayang GESTATIONAL
tinaguriang GDM.
DIABETES
0 ang
Paano sinusuri ang mga buntis para sa
GDM (screening
and diagnosis)?
Ano ba talaga ang GDM?
An 9
GDM ay abnormal na pagtaas
ng asukal sa dugo na unang napansin
sa pagbubuntis.
Hindi
tayo
makasisiguro na ang pagtaas ng asukal
sa dugo ay nandoon na bago pa man
magbuntis ang pasyente. Nguni't dahil
ang mataas na asukal sa dugo ay
napansin noong ang pasyente ay buntis
. na, GDM ang itatawag sa kundisyon.
Kalimitan nawawala ang abnormalidad
sa asukal
sa dugo pagkatapos
manganak pero sa iba, nagpapatuloy
ang kundisyon kahit nakapanganak na.
Kaya importanteng
masuri muli
pagkatapos manganak.
Kailangang malaman sa unang bisita
sa doktor ang probabilidad (risk) na
magkaroon ng GDM ang isang babaeng
nagbubuntis.
Kung sila ay "very high
Sino ba ang matuturing na "very high
risk"?
Si la ay ang mga mayroong
mga
ganitong katangian:
1. Sobrang katabaan
2. Nagkaroon na ng GDM 0 nagluwal
ng malaking sanggol
3. May peas 0 POlycystic Ovary
Syndrome
4. Malakas na history sa pamilya ng
Type 2 Diabetes Mellitus
Amnion
(partially
removed)
~~~~
Gaano ba kalimit makita ang GDM sa
pagbubuntis?
Mga 7% ng pagbubuntis ( 1 to 14%
depende sa populasyon na sinuri at
test na ginamit) ang nagkakaroon ng
kumplikasyon na GDM
Placenta in cross-section
at umbilical cord
Maternal
surface
---
--
---
-----
Iyong may mga higit sa "Iow risk" ay
sinusuri sa ika-24 hanggang ika-28
linggo ng pagbubuntis.
probabilidad na maging mataba "obese"
at magkaroon
ng GDM 0 Type 2
Diabetes
Mellitus
pagtanda niya.
Sabi nila, ang mga "Iow risk" daw ay
hindi na kailangang suriin para sa GDM.
Sino ba ang mga ito?
Ano naman and epektong ng GDM
saina?
Mas malaki ang probalilidad
na
manganak ng maaga (preterm delivery)
at magkaroon ng mataas na presyon
at mga kumplikasyon
nito ang
nagbubuntis
na may GDM.
Dahil
maaring lumaki masyado ang sanggol
pag hindi kontrolado and asukal sa
dugo, mas malaki rin ang probabilidad
na manganak sa pamamagitan
ng
cesarian section na may mas maraming
kumplikasyon kumpara sa normal na
panganganak.
Tama, ang mga "Iow risk" ay hindi na
kailiangang suriin para sa GDM. Kaya
lang para matawag na "Iow risk"
kailangan LAHAT ng ito ay makita sa
nagbubuntis:
1. Edad na < 25 taon
2. Normal na timbang bago magbuntis
3. Bahagi ng lahi (ethnic group) na may
mababang probabilidad ng diabetes
4. Walang malapit (first-degree) na
kamag-anak
na may diabetes
5. Walang panahon na nagkaroon ng
abnormal
na asukal
sa dugo
6. Walang abnormalidad sa nakaraang
pagbubuntis
Anong pagsusuri ang kailangang
gawin para malaman kung may
GDM?
Mayroon tayong tinantawag na 50 9
Glucose Challenge Test (GCT) na
ginagamit nating "screening test". Ito
ay ginagamit sa mga pasyenteng hindi
masyadong "high risk". Kung ito ay
abnormal, tutuloy naman tayo sa 100
9 Oral Glucose Tolerance Test (OGTT)
na tinatawag nating "diagnostic test".
Kung positibo ito, masasabi natin na
ang pasyente ay may GDM.
pamamagitan ng wastong pagkain at
ehersisyo, kailangang bigyan ng insulin
ang pasyente. Hindi pa kasi aprubado
ang pag-inom ng mga tableta para sa
diabetes sa pagbubuntis.
Nguni't
maraming pagsasaliksik ang ginawa at
ginagawa para san a magamit na rin
ang mga tableta para sa diabetes sa
mga susunod na panahon. San a ay
dumating na ang panahon na ito.
Syempre dahil buntis, kailangang
malimit
magpatingin
sa inyong
Obstetrician at Endocrinologist
para
mabantayan ng husto ang kalusugan
ng ina at sanggol.
Sa mga "high risk", kalimitan
ay
dumideretso
na tayo sa OGTT.
Ano ba ang mga maaring maging
kumplikasyon ng GDM sa sangol
kung ang asukal sa dugo ng ina ay
hindi kontrolado?
Paano inaalagan
mayGDM?
Ang pinakamalimit ay pagiging sobrang
laki or macrosomia.
Ang iba ay:
ang pasyenteng
Tulad sa mga may Diabetes Mellitus
Type1 at Type 2, importante
and
wastong
pagkain,
ehersisyo,
at
pagmonitor ng asukal sa dugo sa bahay.
Kailangang maging normal ang asukal
sa dugo para hindi magkaroon
ng
kumplikasyon sa ina at sangol. Kung
hindi makontrol ang asukal sa dugo sa
Pagkatapos manganak, malaki rin ang
probablilidad na magkaroon ng Type 2
Diabetes
Mellitus
sa malapit na
panahon ang nagkaroon ng GDM.
Kailangan
bang magpasuri muli
pagkatapos manganak kahit normal
na ang asukal sa dugo?
Opo. Kailangang sumilalim sa isang
75 9 OGTT and ina 6 hanggang 12
linggo
matapos
manganak
para
malaman kung talagang normal na ang
auskal sa dugo 0 mayroon ng Type 2
Diabets Mellitus ang ina. Kahit normal
and maging resulta, kailangan pa ring
masuri ng regular ang inang nagkaroon
ng GDM dahil malaki ang probablidad
niyang magkaroon ng Type 2 Diabetes
Mellitus
sa malapit na panahon.
Sana
ay nakatulong
kami
sa
pagpapalawak
ng inyong kaalaman
tungkol
sa Gestational
Diabetes
Mellitus. Hanggang sa susunod nating
issue,
maraming
salamat
po!
guarantee. Offer ends 20th September
2009.
1. Hypoglycemia ( mababang asukal
sa dugo)
2. Hypocalcemia ( mababang calcium)
3. Erythremia
4. Poor feeding (mahinang pagkain)
The price? £495
shipping and VAT.
Pagkapanganak,angsangolnginang
may GDM ay may mas mataas
For more information,
www.duofertility.com
na
- including
H
please
free
visit
The Diabetic Foot
Pete de la Pena, MD
As a contributor to a new section in "Hormone
Hotspots", I am indulged to write about a topic I
fancy most---the
diabetic foot.
Diab et iC
foot describes the
foot of a diabetic patient that has risk
for ulceration,
infection
and/or
destruction of deep tissues associated
with neurologic abnormalities, peripheral
vascular disease and/or metabolic
complications of diabetes in the lower
limb.
More than 120 million people in the
world have diabetes mellitus. This figure
is predicted to reach 333 million by
2025. Many of them have diabetic foot
ulcers, which may eventually lead to an
amputation.
Picture this:
.• Every 30 seconds a lower limb is lost
to diabetes
• 40 -70 % of all extremity amputations
are related to diabetes
• 85% of diabetes -related amputations
are preceded by foot ulcers
Even then, there is hope! It is possible
to reduce amputation rates by up to
85%.
Although the pathways to ulceration
and amputation do not differ throughout
the wOfil<!l,the prevalence of ulcers and
amputations varies markedly between
different countries. The differences
probably reflect variations in population
characteristics and wound management
strategies across different regions.
Prompt action must be taken to address
this menace.
This will require:
• Prevention
• Multidisciplinary
treatment of foot
ulcers
• Appropriate organization
• Close monitoring
• Education of people with diabetes and
health care professional.
The time to act is now - better foot care
through education and prevention! After
all small steps when added together
make one giant leap.
Simple tips to prevent foot ulcers.
You must do the ff:
1. Examine your feet for blisters, cuts,
calor changes, swelling and open sores.
(Use a mirror to see the soles of your
feet.)
2. Always protect your feet. Wear
suitable footwear inside and outside
your home to avoid injuring your feet.
3. Check inside your shoes for stones,
sharp Objects and rough patches before
putting your shoes on.
4. Buy new shoes late in the day. This
is because feet become more swollen
towards the end of the day and you can
be sure that your shoes are not too tight
and fit well.
5. Wearing padded socks can help
prevent injury. Make sure they are
neither too tight nor loose. Make sure
they have no holes.
6. Always wash your feet with soap and
water. Take care to wash between your
toes. Dry your feet carefully, especially
between the toes. Use oil or lotion to
keep your skin soft.
7. Cut toe nails straight across and file
any sharp edges.
8. Have your feet checked periodically
by a healthcare
professional.
9. Keep any wounds covered with clean
dressings.
You must avoid
the following:
1. Avoid pointy -toe shoes, high heels,
stilettos and strapless and backless
shoes.
2. Don't wear tight /Ioose socks.
3. When washing your feet be careful
that the water is not hot, so as not to
burn them.
4. Don't use a heater or hot water bottle
to warm your feet. Temperature of the
water should be less than 37 C.
5. Avoid walking barefoot whenever
possible. If this cannot be avoided
because of cultural or religious reasons,
you must be extremely careful and avoid
the risk of burns from hot surfaces in
hot climates.
6. Never try to treat your own feet with
corn medicines or use razor blades to
remove rough skin or calluses. Always
seek professional
help for this.
7. Avoid
becoming
overweight.
8. Don't smoke - smoking damages the
supply blood to the feet.
9. Don't wear jewellery on your feet.
H
--
--
---
----
P CQ IAO
i a proJl ional Filipino bo er. He is currently tbe
WBC LIGHTWEIGHT CHAMPIO •
For bi achievement, he became the flnt Filipino bo er
to in FOUR WORLD TITLES
in four different eight di i ion
He i current!)- rated b the Ring Magazine a. the
#1 POUND-FOR-POUND
BOXER IN THE WORLD •
•@~p(;
.
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~_p-:(t..;...
References: Data on file.
Full product information available upon request.
2nd floor, Bonaventure Plaza, Ortigas Ave~
Greenhills. San Juan City, Philippines 1502
le!. Nos.: 858-1255. Fax: 858-1256
Trusted Quality Healthcare
I Pioglitazone Hell
Piozone
81
15 mg
30 mg Tablet
•
Trusted Quality Healthcare
2nd floor, Bonaventure Plaza, Ortigas Ave.,Greenhills, San Juan City, Philippines 1502. Tel. Nos.; 858-1255.
Fax: 858-1256