October 2012

October 2012
ESC rolls out new practice guidelines
FORUM
DEPRESSION
Short-term fluoxetine,
venlafaxine efficacious
for depression
Health policies need to
foster right environment
NEWS
AFTER HOURS
PPIs safe for long-term
use
Singapore’s Gardens
by the Bay
Please visit www.isrd.org for further details
Hosted by:
Chinese Alliance Against Lung Cancer
(CAALC)
Shanghai Respiratory Research Institute
Supported by:
ISRD 2012
The 100
very Academic
first joint scientific
sessions
Nearly
Speakers,
with the American
ThoracicTopics
Society
15 Sessions
and 6 Special
American Thoracic Society (ATS)
Keynote Speakers:
English Sessions Highlights：
•
•
•
Prof. Chunxue Bai
President of the 8th
ISRD & ATS in China
Forum 2012
Professor of Medicine
and Chairman of
Department of
Pulmonary Medicine,
Zhongshan Hospital,
Fudan University
Prof. Monica Kraft
President of American
Thoracic Society
Professor of Medicine,
Vice Chair of Research
for Department of
Medicine and Director
of the Duke Asthma,
Allergy and Airway
Center at Duke
University Medical
Centre
Dr. Asrar Malik
Distinguished Professor
and Head of the
Department of
Pharmacology,
University of Illinois
College of Medicine
Schweppe Familly
Distinguished Professor
of Pharmacology
•
•
•
•
•
•
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 Shanghai
E-mail: [email protected]
3
October 2012
ESC rolls out new practice guidelines
Elvira Manzano
F
ive 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 definition 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 symptomatic aortic stenosis (AS) who are unsuitable 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 technique in mitral regurgitation, when the repair
is considered durable. Mitraclip device may
be considered in high-risk or inoperable patients resistant to optimal medical therapy.
In HF, the key changes from the 2008 ESC
guidelines include a new indication for mineralocorticoid antagonist (MRA) eplenerone in
patients with systolic HF and mild symptoms,
broadening the indication to essentially all HFREF patients remaining symptomatic despite
treatment with a beta-blocker and ACE inhibitor 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 new guidelines include a range of new options for managing heart
conditions.
The use of cardiac resynchronization therapy (CRT) has been expanded to patients with
mild symptoms. Those with a left ventricular 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 increasing 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 recommended 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 CHA2DS2VASc score instead of the CHADS2 score is
now recommended for identifying at-risk patients, and new oral anticoagulants such as
4
October 2012
dabigatran, rivaroxaban or apixaban are now
considered preferable to vitamin K antagonists (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 definition for five types of MI and their clinical
implications. The consensus document now
recognizes that small amounts of myocardial injury or necrosis can be detected by
biochemical markers and imaging.
5
October 2012
Forum
Health policies need to foster right
environment
Excerpted 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.
H
ealth is intrinsically related to
wealth. The Prospective Urban Rural 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-income nations.
The average fruit and vegetable consumption per day should be 500 grams or
5 servings, but surprisingly, our analysis of
PURE showed that one-third of the countries of the world are not consuming adequate 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 nations – this is because carbohydrates are a
cheap source of energy – with the percentage declining in wealthier nations.
Regarding smoking, the decision to
smoke in women depends not only on GDP
or wealth but also on cultural factors, including religion. In men, there is a clear inverse
Recreational exercise alone won’t solve the obesity epidemic problem.
relationship between GDP and wealth and
smoking status. Approximately 45 percent
of men in the poorest countries smoke compared with 20 percent of men in the richest
countries. Men started smoking at approximately the same age and frequency in all
countries, but the rate of quitting is markedly 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 tobacco. 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
6
October 2012
Forum
this increase was offset by a reduction in
the amount of obligatory physical activity 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 marathon runner – that we are going to overcome the decrease in activity due to the
changing environment. The obesity epi-
demic really requires a change in environment. We can yell at people and say, ‘exercise’ 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.
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October 2012
Indonesia Focus
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 Therapist
Bali, 11-13 Oktober 2012
Grand Hyatt Bali
Sekr : Jl. Pucang Anom Timur III No. 65, Surabaya, Jawa Timur, Indonesia
Tel : 021-63869502
Fax : 021-63869503
Email : apfssh2012@pharma-
pro.com
Website : www.apfssh2012.org
The 35th Annual Scientific
Meeting of Indonesian
Urological Association
Jakarta, 12-14 Oktober 2012
Hotel Gran Melia, Jakarta
Sekr : Departemen Urologi, RSCM, Jl. Diponegoro No.71, Jakarta 10430
Tel : 021-3152892, 3923631
Fax : 021-3145592
PIT IKA V
Bandung, 13-17 Oktober 2012
Hotel The Trans Luxury, Bandung
Sekr : Ikatan Dokter Anak Indonesia,
Cabang Jawa Barat
Departemen Ilmu Kesehatan Anak,
Fakultas Kedokteran Unpad RS Dr. Hasan Sadikin
Jl. Pasteur No.38 Bandung – 40161
Tel : 022-2039512
Website : www.pitika5.com
Weekend Course on Cardiology
(WECOC) 2012
Jakarta, 19-21 Oktober 2012
Sekr : National Cardiovascular Centre Harapan Kita, Diklat Bldg 5th Fl, Jl. Letjen
S Parman Kav 87, Slipi, JakBar 11420
Tel : 021-5684093 ext 1554 & 3505
Fax : 021-5608902
Current Concepts In Heads & Neck
Surgery and Oncology
Jakarta, 20-22 Oktober 2012
Hotel Shangri-La, Jakarta
Sekr : THT Fakultas Kedokteran Universitas Indonesia, Rumah Sakit Cipto Mangunkusumo, Jakarta
Tel : 021 - 3910701
Fax : 021 - 3914154
Email : ifnosjakarta2012@
gmail.com
10th Asia and Oceania Thyroid
Association Congress
Bali, 24-27 Oktober 2012
Discovery Kartika Plaza Hotel, Bali
Sekr : Divisi Endokrin,
Fakultas Kedokteran Universitas
Padjajaran
Jl. Pasteur 38,
Bandung 40161
Tel /Fax : 022-2033274
Email : [email protected]
Website : www.aota2012.com
Muktamar Perhimpunan Ahli Bedah
Onkologi Indonesia IX 2012
Yogyakarta, 1-3 November 2012
Hotel The Rich Jogja, Yogyakarta
Sekr : SMF Bedah RSUP Dr. Sardjito, Yogyakarta, Jl. Kesehatan No.1 Sekip, Yogyakarta
Tel : 0274-581333
Email : [email protected]
25th Indonesian International
Hospital Medical, Pharmaceutical
Clinical, Laboratories Equipment &
Medicine Exhibition
Jakarta, 7-10 November 2012
Jakarta Convention Center
Sekr : PT. Okta Sejahtera Insani. Perkantoran Aries Niaga Blok A1 No.1P, Jl. Taman Aries, Jakarta Barat 11620
Tel : 021-
58907366/68
Fax : 021-58906819/20
Email : hospital.expo@gmail.
com
Website : www.hospital-expo.
com
KOPAPDI XV Medan
Medan, 12-15 Desember 2012
JW Marriot International, Aryaduta,
Grand Aston, Medan
Sekr : Departemen Penyakit Dalam Fakultas Kedokteran
Universitas Sumatera Utara /RS Umum Pusat H. Adam Malik Lt. III , Jl. Bungalau 17, Medan
Tel/Fax : 061-4528075
Email : papdicabsumut@gmail.
com
Website : www.kopapdimedanxv.
com
www.MIMS.com
Smart Rx. Every Time.
9
October 2012
Indonesia Focus
Tablet tambah darah bagi ibu hamil anemia
Hardini Arivianti
J
umlah 90 tablet selama masa kehamilan
tersebut sesuai dengan program suplementasi untuk penanggulangan anemia
pada ibu hamil di Indonesia. Walau kebijakan tersebut sudah ada sejak tahun 1970an, tetapi tetap saja prevalensi anemia pada
ibu hamil masih tinggi.
“Prevalensi ibu hamil dengan anemia sekitar 40-50%, berarti 5 dari 10 ibu hamil mengalami anemia,” ujar dr Elvina Karyadi, MSc,
PhD, dalam acara “Paparan Penelitian Diseminasi Anemia pada Ibu Hamil dan Tablet
Tambah Darah” beberapa waktu lalu. Kondisi 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 sulit untuk mengejarnya,” tukas direktur ‘Micronutrient 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 Purwakarta yang menjadi tempat percontohan.
Beberapa poin yang didapat dari penelitian
tersebut, dapat dilihat pada tabel.
”Hasil temuan lainnya adalah fokus program tersebut masih pada distribusi TTD dan
bukan pada kepatuhan minum TTD,” jelas
Kusbandriyo, SKM selaku Kepala Bidang Kesehatan Masyarakat Kabupaten Lebak.
Pada tahun 2011 kematian ibu di Lebak
cukup tinggi yakni 42 orang/tahun, 22 diantaranya 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 banyak. 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)
* Minum TTD setiap hari
* Anemia ringan Anemia berat * Pernah diperiksa kadar Hb
* Trimester 2 dan 3 yang mendapat program > 60 tablet
* Yang pernah minum TTD
* Merasakan mual
* Berhenti minum TTD
* Trimester 1 dan mengeluh mual
Purwakarta (%)
26,3
29,3
24,8
11,0
23,5
80,3
65,5
70,9
95,0
Lebak (%)
55,1
71,1
9,1
11,8
42,9
90,4
51,5
43,2
70,6
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October 2012
Indonesia Focus
lain,” jelas Tomi Herutomo, MKes, sebagai Kepala Seksi Promosi Kesehatan Kabupaten Purwakarta.
Ada kendala
Lebih lanjut dr. Ridwan Gustiana, MPH selaku Ketua IBU Foundation menuturkan beberapa hal yang menjadi kendala masih rendahnya 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 pengetahuan masyarakat yang rendah sehingga
masih banyak persepsi negatif mengenai suplemen ini, salah satunya ada persepsi bayi akan
menjadi hitam atau menjadi besar jika minum
suplemen ini, padahal kenyataannya tidak.
Efek samping mual setelah minum suplemen 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,” ungkapnya.
Program Penguatan Suplementasi Zat Besi
dan Asam Folat pada ibu hamil tersebut bertujuan 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.
Vscan, perangkat mini penunjang diagnosis
Hardini Arivianti
S
ekitar akhir September lalu, GE Healthcare meluncurkan Vscan 1.3 yakni
perangkat genggam berteknologi ultrasonografi berukuran mini. Perangkat ini
memungkinkan para dokter melakukan
pemeriksaan non-invasif guna mendapatkan visualisasi sehingga dokter mampu
menentukan tindakan optimal yang dapat
dilakukan dan memberikan perawatan
yang cepat, efisien dan tepat sesuai kebutuhan pasien.
Berdasarkan riset yang pernah dilakukan oleh GE Healthcare di Indonesia tahun
2012, pasien yang memerlukan layanan
pemeriksaan dengan ultrasonografi mencapai 25% dari seluruh total jumlah pasien
setiap bulan.
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October 2012
Indonesia Focus
Menurut Indra W. Suwardi, selaku direktur GE Healthcare Indonesia, alat ini menggunakan 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 terkini guna mendukung pelayanan kesehatan
primer baik di puskesmas maupun di titiktitik layanan kesehatan lainnya di seluruh
nusantara, untuk membantu dokter mengidentifikasi penyakit sedini mungkin dan
merekomendasikan tindakan bagi pasien,”
tukas Dr. dr. Tb Rachmat Sentika, SpA,
MARS.
Selaku staf ahli Kementerian Koordinator Kesejahteraan Rakyat untuk Percepatan Pembangunan Milenium ini memaparkan 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 menyelamatkan lebih banyak ibu dan bayi lahir
di Indonesia. “Pemeriksaan USG penting
untuk memastikan berbagai kelainan kehamilan seperti plasenta previa, yang tidak memungkinkan bagi ibu hamil untuk
melahirkan normal.” Saat ini diperlukan
sekitar 1.347 alat USG untuk dipasang di
Puskesmas.
Selain perlunya penyediaan alat USG, perbaikan sistem rujukan di rumah sakit juga
perlu dilakukan dan ditingkatkan. “Kematian
pada persalinan biasanya terjadi karena faktor 3T yaitu keterlambatan mendeteksi, keterlambatan mengenali tanda, dan keterlambatan
mencari fasilitas kesehatan,” jelas dr.Prijo Sidipratomo, SpRad (K) pada acara yang sama.
“Penyebab kematian ibu adalah perdarahan (28%) yang diakibatkan oleh anemia dan
kekurangan energi kronis. Prevalensi plasenta
previa sebesar 6 dari 1000 persalinan. Penyebab kedua kematian ibu adalah eklamsia,” papar Ketua IDI ini lebih lanjut.
Namun menurut dr. Judi Januadi Endjun,
SpOG, alat bantu baru ini tidak bisa disamakan kemampuannya dengan USG yang ada di
rumah sakit. Dengan Vscan bisa diketahui posisi bayi, letak plasenta, jumlah air ketuban, taksiran 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 membantu dengan durasi selama 2 jam, padahal sekali
periksa pasien hanya memerlukan waktu
sekitar 3 menit.”
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October 2012
Indonesia Focus
Waspadai TN penyebab nyeri luar biasa
Hardini Arivianti
P
enyebab trigeminal neuralgia (TN)
adalah penekanan pada N. trigeminalis (N V) yang mengatur perasa pada
wajah atau sensorik wajah. Ciri umum penderita TN adalah rasa sakit luar biasa pada
daerah bagian gusi, gigi, mulut dan wajah.
Itu sebabnya selama ini penderita TN menduga gigi adalah pemicu rasa sakit tersebut.
Hal ini dijelaskan oleh dr. M Sofyanto, SpBS
beberapa waktu lalu.
Nyeri bisa terjadi secara spontan namun lebih 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, unilateral 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, kelelahan, kecemasan bukan penyebab TN, justru
kondisi tersebut dapat memperberat reaksi bukan 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 populasi. 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 pembuluh darah yang menekan nervus trigeminal
– lapisan myelinnya sudah rusak – sehingga
mengganggu transmisi sinyal dan menimbulkan 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 mikrovaskular karena pendekatan, retraksi dan
komplikasinya minimal. Saraf dan pembuluh
darah yang bersinggungan/menempel dilepaskan atau dipisahkan lalu diganjal dengan serabut berbahan teflon. Tindakan operasi ini
hanya butuh waktu satu setengah hingga tiga
setengah jam dengan 1-2 hari pemulihan. Serabut 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 tekanan 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 recovery pada usia muda dan tua berbeda. Untuk
perawatan tertentu pasca operasi, dr. Sofyanto
memberikan analgesik selama 5 hari.
Bila penderita memiliki kontraindikasi terhadap operasi misalnya ada kelainan jantung dan
paru, dapat diberikan golongan antikonvulsan
(karbamazepin) sebagai pengobatan lini pertama. Namun obat ini kadang menimbulkan resistensi. “Bila sudah resistensi, lini kedua adalah gabapentin yang diberikan seumur hidup. Obat ini
akan memblokade sinyal nyeri sehingga dapat
mengurangi frekuensi dan intensitas nyerinya.”
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October 2012
Indonesia Focus
Selanjutnya, dr. Sofyanto memaparkan
kasus lainnya pada wajah. Penekanan tidak
hanya dialami oleh N. trigeminalis saja. N.
facialis (VII) juga bisa menyebabkan hemifacial spasme (HFS) yang pada awalnya ditandai dengan kedutan di kelopak mata, menyebar ke pipi dan mulut sehingga setengah
wajah akan terasa kaku dan merot. Selain
itu, penekanan juga terjadi pada N. glossopharyngeus (IX) pasien akan mengalami
gejala sakit luar biasa saat menelan. Gejala tergantung saraf yang tertekan, walau
pembuluh darah yang ’menyerempet’ sekitar 1-2 mm saja.
15
October 2012
Indonesia Focus
Penatalaksanaan penyakit metabolik pada
layanan primer
Anna Dewiyana
S
aat ini dislipidemia, DM tipe 2, obesitas dan hipertensi semakin banyak dijumpai. Sebagai lini pertama layanan
ke-sehatan masyarakat, dokter umum dihadapkan pada tantangan untuk mengatasi
masalah kesehatan tersebut sehingga pasien
terhindar dari risiko sindroma metabolik.
Untuk meningkatkan mutu pelayanan dan
menambah wawasan dokter umum seputar sindroma metabolik, PDUI bekerjasama
dengan MIMS Indonesia telah menyelenggarakan simposium sehari Penatalaksanaan
Penyakit Metabolik pada Layanan Primer,
pada tanggal 15 September 2012 lalu bertempat di Surabaya.
Dislipidemia merupakan kelainan metabolisme berupa kelebihan maupun kekurangan
lipoprotein, yang ditandai dengan peningkatan kadar kolesterol, LDL kolesterol, dan trigliserida 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, menurunkan 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/bertabur keju, dan buah dengan keju.
Dislipidemia pada pasien diabetes meningkatkan kejadian atau mortalitas kardiovaskuler. Oleh karena itu, upaya pengendalian dislipidemia pada DM sebagai ekivalen penyakit
jantung koroner (PJK) harus agresif. Penurunan LDL yang agresif (<100 mg/dL atau <70
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Indonesia Focus
mg/dL) dengan terapi statin tanpa menghiraukan kadar awal akan memberikan manfaat
kardiovaskuler. Penyandang diabetes memiliki faktor risiko kardiovaskuler yang lebih
tinggi karena dislipidemianya, ditandai dengan peningkatan LDL yang didominasi lemak
dengan densitas kecil, peningkatan apoB, rendahnya 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 kolesterol, menurunkan berat badan, meningkatkan aktivitas fisik dan berhenti merokok. Pada
individu tanpa penyakit kardiovaskuler yang
jelas, terapi statin diberikan untuk menurunkan 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 meLLitus and dyslipidemia) menunjukkan bahwa
rosuvastatin lebih poten dibandingkan atorvastatin dalam mereduksi kolesterol LDL. Dengan 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 simvastatin dan atorvastatin. Dari studi STELLAR
(Statin Therapies for Elevated Lipid Levels compared Across doses to Rosuvastatin) diketahui
perubahan kolesterol HDL pada rosuvastatin
10, 20 maupun 40 mg lebih tingi dibandingkan atorvastatin 80 mg.
Pembicara kedua pada sesi lunch symposium [Astra Zeneca Indonesia] yang dimoderatori oleh dr. J. Nugroho Eko Putranto, SpJP,
FIHA adalah Prof. dr. Mohammad Yogiarto,
SpJP(K), FIHA, FASCC, yang menyampaikan presentasi mengenai aplikasi pengobatan
pasien dislipidemia pada pasien risiko tinggi.
Dari 10 faktor risiko penyebab komplikasi
kardiovaskuler, ada 3 yang utama, yaitu hiperkolesterol, merokok dan hipertensi. Makin
tinggi kolesterol akan menyebabkan aterogenesis yang lebih berat berupa penyempitan
di otak, mata, jantung, pembuluh perifer, tergantung predileksinya. Penelitian meta analisis menunjukkan bahwa penurunan kadar
kolesterol bisa menurunkan angka kematian
umum dan khususnya penyakit jantung koroner (PJK).
Yang menjadi pertanyaan adalah, seberapa
jauh menurunkan kolesterol? Derajat penurunan LDL tergantung pada komorbiditas
yang ada. Makin tinggi risiko kardiovaskuler,
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October 2012
Indonesia Focus
maka harus makin rendah kadar LDLnya bahkan sampai 70 mg/dL. Apakah berlaku the lower the better? Belum tentu, karena bagaimanapun 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 diperhatikan, terutama pada pasien risiko tinggi.
Pasien dengan sindroma koroner akut, DM
tipe 2, TIA/stroke, aterosklerosis, hiperlipidemia dengan risiko tromboembolik, wanita
dengan penyakit kardiovaskuler, HDL rendah, 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 kardiovaskuler independen yang kuat. DM dengan
dislipidemia dianggap sebagai ekivalen PJK
karena dislipidemianya bersifat aterogenik
sehingga penurunan LDL harus lebih agresif.
Studi MERCURY (Measuring Effective Reductions in Cholesterol Using Rosuvastatin Therapy) menunjukkan, bila dibandingkan dengan
atorvastatin 10-20 mg, rosuvastatin 10 mg bisa
mencapai target sampai 40-50%. Selain menurunkan LDL, juga meningkatkan HDL dan
menurunkan trigliserida sehingga pemberian
rosuvastatin mencapai 3 tujuan. Sedangkan
dari studi ANDROMEDA (A raNdomized, Double-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%. Penelitian juga menunjukkan bahwa rosuvastatin 5,
10 dan 20 mg cukup poten menurunkan trigliserida.
Rosuvastatin 20 mg berpotensi sama den-
gan atorvastatin 80 mg dalam hal menurunkan 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 rasio 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 cukup bagus, dengan efek terapeutik yang cukup bagus dan efek samping yang minimal.
Karena makin tinggi dosis maka efek samping terhadap fungsi hati, otot dan ginjal makin 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 tersebut diatas dapat disimpulkan bahwa dengan
dosis kecil, rosuvastatin sudah dapat mengontrol 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 mengakhiri presentasinya.
DM dalam kehamilan
Simposium PDUI MIMS ini juga diisi dengan clinical mentoring mengenai diabetes melitus (DM) dalam kehamilan yang disampaikan
oleh Prof. dr. I. Oetama Marsis, SpOG. Di bidang layanan obstetri, DM merupakan problem yang besar karena angka lahir mati terutama pada DM yang tidak terkendali, dapat
terjadi 10 kali lipat kehamilan normal. Di klinik
yang maju sekalipun, angka kematian dil-
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October 2012
Indonesia Focus
aporkan 3-5% dengan angka morbiditas fetal
4%. Diabetes gestasional merupakan diabetes
yang diketahui pada waktu hamil dan menghilang 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 dipstik, HbA1c > 6%), dan tes toleransi glukosa
oral (penapisan dan diagnosis dilakukan secara universal dengan menggunakan one step
approach dengan beban glukosa 75 gram).
Pada DM yang terkendali, mo-nitor dilakukan setiap minggu (gula darah, USG,
CTG). Jika janin sehat maka persalinan normal dapat dilakukan sampai usia kehamilan
mencapai 40 minggu. Jika terjadi gawat janin,
makrosomia atau IUGR, maka dilakukan tindakan terminasi. Pada DM yang tidak terkendali, sejak usia kehamilan 34-36 minggu,
ibu dirawat dan dilakukan pemeriksaan rutin
gula darah, USG dan CTG, juga amniosentesis. Jika paru-paru janin telah matang, maka
dilakukan terminasi; jika paru-paru janin belum 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 makrosomia > 4500 gram dan terdapat penyulit
seperti kelainan vaskularisasi, nefropati diabetes, retinopati diabetes.
Menyiasati obesitas
dr. Achmad Yuniari Heryana, SpA menyatakan bahwa di Indonesia terjadi peningkatan 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 multifaktorial keseimbangan penggunaan energi
yang ditandai dengan ada nya penumpukan
jaringan lemak. Faktor-faktor endogen yang
dapat menyebabkan terjadinya obesitas antara lain faktor genetik, perubah an lingkungan intrauterin dan endokrinopati yang disertai obesitas. Bayi yang lahir dengan kondisi
Intrauterine Growth Retardation (IUGR) akan
tumbuh menjadi individu yang resisten terhadap insulin, menderita penyakit kardiovaskuler 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. Menurut 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 overweight, 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 dimodifikasi 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-
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October 2012
Indonesia Focus
biasaan nonton televisi/main game (maksimal 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 beberapa ahli diantaranya psikolog, perawat, terapis, ahli THT/pulmo, tergantung komplikasi
yang terjadi. Biasanya ada keluhan obstructive
sleep apnea syndrome (OSAS), penurunan performa 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 farmakoterapi tidak sebaik merubah gaya hidup, tetap harus didukung diet yang teratur.
Berikan diet sangat rendah kalori yaitu 400800 kal/hari.
Dalam presentasinya yang berjudul Management Obesity : Focus on medical treatment, dr.
Sony Wibisono M, SpPD-KEMD, FINASIM
menyampaikan bahwa pengobatan kelebihan berat badan atau obesitas mencakup dua
proses, yaitu penilaian dan tata laksana. Ketika melakukan penilaian, dokter akan menentukan tingkat keparahan obesitas (apakah termasuk 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 menurunkan berat badan (BB), tetapi juga bagaimana
mempertahankan BB dan mengendalikan
faktor risiko lainnya.
Jika BMI > 25 atau lingkar pinggang besar (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 komorbiditas dan risiko kesehatan lain yang ditemukan.
Target penurunan berat badan adalah 5-10%
dari berat badan atau 0,5-1 kg/minggu, selama 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 diberikan kepada pasien dengan dengan BMI ≥
27 disertai faktor risiko atau BMI ≥ 30, sedangkan jika BMI ≥ 35 disertai faktor risiko atau ≥
40, pertimbangkan bedah bariatrik.
Standar kompetensi era SJN-BPJS
Sesi terakhir dari simposium diisi oleh Presidium Nasional PDUI, dr. Dyah A. Waluyo.
Beliau menyampaikan, dengan Standar Jaminan Sosial Nasional (SJSN) diharapkan layanan kesehatan secara keseluruhan akan
berubah, berbeda sekali dengan saat ini. Jika
pada saat ini sistem pembiayaan terutama
dari pribadi, nantinya akan berlaku universal coverage dimana seluruh masyarakat Indonesia 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, pekerja sektor formal oleh Jamsostek, golongan yang tidak mampu oleh Jamkesmas/
Jamkesda; nanti semua akan menjadi satu.
Problemnya adalah masing-masing memiliki 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).
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October 2012
Indonesia Focus
Tetapi tentu tidak mudah untuk mereali
sasikannya sehingga periode sekarang adalah
saat untuk bargaining, mana yang akan dipakai. 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 bahwa ada 2 layanan yang diakui, yaitu klinik
pratama (layanan kesehatan umum) dan
klinik utama (spesialis). Praktek mandiri diharapkan 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 layanan kesehatan. Mulai pikirkan untuk membentuk klinik yang terstandar, klinik pratama
yang mandiri dan kolektif (mengajak keperawatan 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 horisontal. Klinik utama memiliki peralatan
yang lebih lengkap, ada USG dan pemeriksaan laboratorium sederhana.
Juga didorong terbentuknya koperasi sehingga 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 diberikan kepada okter yang berpraktek di klinik
tersebut. Sehingga profesi ini mampu menghidupi anggotanya, dan terwujud dokter yang
bermartabat dan masyarakat yang sehat.
21
October 2012
Depression
Depression, other mental disorders
increase risk of early death
Radha Chitale
M
ental disorders such as depression,
bipolar disorder and schizophrenia,
which may not require hospitalization 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 compiled 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 registries.
When diagnosed at conscription, depression was associated with double the risk of
premature death (age-adjusted hazard ratio of
1.81) and the presence of bipolar disorder increased 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 illnesses, men who were diagnosed later upon
admission to a hospital had mortality hazard
ratios of 5.46 for neurotic and adjustment disorders and 11.2 for substance abuse disorders
not including alcohol.
Men admitted to hospital for psychiatric reasons following conscription numbered 60,333,
10,665 of whom were already diagnosed during conscription.
The mortality risk associated with other diagnoses after adjusting for age, socioeconomic
status, blood pressure, body mass index, intelligence, and education included hazard ratios
of 1.53 for depression, 5.19 for bipolar disorder,
2.52 for schizophrenia, 1.88 for personality disorders, 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, intelligence, education and late-life socioeconomic
status but were not affected by early-life socioeconomic 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 percent 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 unmeasured factors such as comorbid illness, lifestyle,
medications and varying access to healthcare,
the researchers said. 22
October 2012
Depression
Heart attack increases spouse depression,
anxiety
Elvira Manzano
T
he death of a spouse from heart attack
increases the risk of depression and anxiety in the surviving partner, requiring an
increased use of psychotropic medications,
a large Danish study has found.
“Losing a spouse or having a spouse experiencing 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 reactions after a life-threatening event such as
an MI. I would like to see a more formal way
of screening spouses for depression in relation to the event, but also subsequently.”
Using data from Danish national registries, Fosbøl and colleagues compared the
incidence of hospital system contact (hospital 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, respectively).
The study found the incidence of depression 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, peaking 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 commit suicide than those who lost them to other causes (0.24 vs. 0.17 percent, P=0.07). [Eur
Heart J 2012. Epub ahead of print]
A standardized mental screening program could potentially prevent many spouses from being depressed or taking their
own lives, Fosbøl told Medical Tribune. “It
would also be interesting to see in a formalized 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 individual’s health and life expectancy, death
from MI – which can often occur suddenly
and unexpectedly – appears to have a larger 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 trauma, and the spouse, who has to live through
the event alongside the patient, the authors
concluded. 23
October 2012
Depression
Short-term fluoxetine, venlafaxine
efficacious for depression
Rajesh Kumar
T
he antidepressants fluoxetine and venlafaxine are efficacious as short-term therapy 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 Psychiatry 2012;69:572-579]
They found that patients in all age groups
had significantly greater improvement compared with those receiving placebo, although
the differential rate of improvement was largest for adults receiving fluoxetine (34.6 percent 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 differences generally in the 15.6 percent (remission) to 21.4 percent (response) range.
Geriatric patients had the smallest drugplacebo differences, an 18.5 percent greater
rate of improvement, 9.9 percent for response
and 6.5 percent for remission. Also, immediate-release venlafaxine produced larger effects than extended-release venlafaxine, and
baseline severity did not affect symptoms.
This is the first research synthesis in this
area to use complete longitudinal personlevel data from a large set of published and
unpublished studies.
Most studies included in the meta-analysis
were designed for achieving regulatory approval and do not demonstrate the maximum
effect a drug can produce. Some studies were
as short as 6 weeks whereas the maximum effect during an acute treatment episode is likely 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-analytic results when person-level data are not
available.” 24
October 2012
News
Tai chi can benefit patients with COPD
Elvira Manzano
A
modified tai chi program may improve the exercise capacity and quality 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 balance and muscle strength following Sunstyle tai chi training, which has the potential 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 osteoarthritis, hypertension, dyslipidemia and coronary 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 better in the walking test and had a significantly
higher score in the Chronic Respiratory Dis-
Tai chi improved muscle strength and balance in study patients.
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 consumption. 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 Hospital and the University of Sydney, Australia. “With increasing numbers of people being diagnosed with COPD, it is important to
provide different options for exercise that can
be tailored to suit each individual,” added
25
October 2012
News
Leung, a cardiorespiratory physiotherapist.
The authors said the study provides compelling evidence that tai chi may be an effective 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 program is feasible for COPD patients, even for
those with comorbidities, they concluded.
PPIs safe for long-term use
Saras Ramiya
S
elected proton pump inhibitors (PPIs)
are safe for long-term use in patients
with chronic gastrointestinal (GI) conditions, a study shows.
The new landmark international study
looked at the long-term effects of pantoprazole 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 endoscopy, clinical examination and laboratory
investigations.
The safety set, which comprised 142 adults
who received continued pantoprazole treatment for over 15 years, showed healing rates
of 95.8 percent after 12 weeks without increased risks of specific serious conditions
like stomach cancer.
“This study shows that pantoprazole effectively controls the production of acid and heals
upper gastrointestinal ulcers and wounds in
the long term without identifiable side effects,” said principal investigator Professor G.
Expanding waistlines across Asia have contributed to increased incidence of
severe and chronic gastrointestinal conditions.
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 pantoprazole, doctors and patients have even
more assurance that PPI therapy is safe for
long term treatment of severe GERD and gastrointestinal conditions,” he added.
GI problems on the rise
GI 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
26
October 2012
News
and 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 percent over 6 years; in Malaysia, the incidence
rose from 2.0 percent to 8.4 percent over a 10year 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 Taiwan) rose from 5.2 percent in 2005 to 8.5 percent in 2010. [BMC Gastroenterol 2010;10:94] In
Malaysia, the incidence of reflux esophagitis
increased from 2.7 percent to 9.0 percent during the time period from 1991-1992 to 20002001, while Indonesia’s Cipto Mangunkusumo Hospital reported the prevalence of GERD
increasing from 5.7 percent in 1997 to 25.1 percent 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), reduced vitality, disturbed sleep and considerable 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 individual Asian countries, ranging from 12.4 percent in Taiwan and up to 17 percent in China,
and 29.8 percent in Hong Kong. [J Neurogastroenterol Motil 2011;17(1):14-27, World J Gastroenterol 2004;10:1647-51, Aliment Pharmacol
Ther 2003;18:595-604]
“These conditions are so severe that patients do not require just quick relief for GI
conditions, but more sustained control with
proton pump inhibitors (PPIs) over the long
term,” said Ngo.
27
October 2012
News
Surgery superior in patients with carpal
tunnel syndrome
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 decompression versus local steroid injection by
randomly assigning 80 wrists to surgical decompression and 83 to local steroid injection following a clinical diagnosis and neurophysiological
confirmation of CTS in 101 patients. [Rheumatology 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 analogue scale score for nocturnal paresthesia.
Both treatment groups had comparable severity of CTS at baseline.
Fifty-five wrists in the surgery group and 48
wrists in the injection group completed the follow-up. In the intent-to-treat analysis, 60 percent
of the wrists in the injection group and 69 percent in the surgery group achieved a 20 percent
response for nocturnal paresthesia (P<0.001).
Although the clinical relevance of those differences remains to be defined, the findings are
not entirely unexpected as each of the two procedures has its own benefits and disadvantages,
said Dr. Chew Li-Ching, consultant in the department of rheumatology and immunology at
Singapore General Hospital (SGH).
“The injection can be easily… delivered at the
point of care. However, usually, it provides temporary relief only compared with surgery. At
Wrist surgery is more effective at treating carpal tunnel syndrome than
local steroid injections.
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 symptoms and findings on neurophysiological testing 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 condition and the approach is consistent with the
standard of care in clinical practice which consists 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.”
28
October 2012
News
Higher vitamin C intake may help reduce
heart disease, stroke
Rajesh Kumar
T
he 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 evaluating 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 deficiency disease of scurvy, Frei said it is appropriate 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, almost ensures that scientists will find no beneficial effect, said the researchers. Such trials 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 optimal consumption – a factor often not captured in shorter-term clinical studies, they
pointed out.
The US and European researchers reviewed metabolic, pharmacokinetic, laboratory 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 researchers noted, while healthier levels can
enhance immune function, reduce inflammatory 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 researchers noted that some health benefits correlate 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 updated 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
News
rent evidence of the amount needed to provide antioxidant protection, rather than to
prevent scurvy which is what was traditionally used,” she said, adding that the board
regularly reviews its dietary recommendations to provide up-to-date recommendations based on the most recent evidence.
Typically, each serving of fruit has around
35mg of vitamin C, while a serving of vegetable 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 Coverage
European Society of Cardiology Congress, 25-29 August, Munich, Germany
Aspirin can be dropped in PCI patients on
oral anticoagulants
Christina Lau
P
atients on oral anticoagulants (OAC)
undergoing percutaneous coronary intervention (PCI) should be treated with
clopidogrel, but not aspirin, according to the first
randomized trial to assess optimal antithrombotic 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 ischemic 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 Netherlands.
“Until now, no prospective randomized data
were available on the optimal antithrombotic
therapy for these patients,” he continued. “Although triple therapy seems logical for the prevention 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 revascularization, and all individual components
of the primary and secondary endpoints.
“At 1 year after PCI, patients in the dual therapy 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 percent; 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 highrisk 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 percent], 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 Coverage
Investigational drug shows promise in HF
Christina Lau
A
novel angiotensin receptor neprilysin 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/S01406736(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). “NTproBNP is a marker of cardiac wall stress,
and levels are increased in HF patients,”
explained Solomon. “The greater reduction 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 Classification), 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 encouraging, 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 AldoDHF 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 placebo,” reported Professor Burkert Pieske of the
Medical University of Graz in Austria. “However, the treatment did not improve exercise
capacity, NYHA class or quality of life.”
Spironolactone was shown to be safe, without severe adverse events. “The drug can be
considered in patients with diastolic HF, for
improving cardiac function and blood pressure 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 Coverage
Niacin/laropiprant well tolerated in
HPS2-THRIVE trial
Alexandra Kirsten
M
ore 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.
‘‘
The preliminary results
suggest that about 76 percent
of the patients can tolerate long-term ERN/
LRPT treatment
”These observations have resulted in a
label change for simvastatin and ERN/LRPT,”
explained lead study author Professor Jane
Armitage, consultant in Public Health
Niacin has been shown to be an effective HDL-raising agent.
Medicine at the University of Oxford, England,
addingthatpatientsofChinesedescentshouldnot
receive simvastatin 80 mg with cholesterolmodifying 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 effective 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 tolerability 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
33
October 2012
Conference Coverage
European Society of Cardiology Congress, 25-29 August, Munich, Germany
Aliskiren use not advised in type 2 diabetics
with renal impairment
Alexandra Kirsten
A
liskiren, a direct renin inhibitor,
should not be used to lower blood
pressure in type 2 diabetics at high
risk of cardiovascular and renal events, according the findings of the Aliskiren Trial in
Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE).
“The treatment may even be harmful in
these patients,” said lead study author Professor Hans-Henrik Parving from the University
of Copenhagen, Denmark
In the ALTITUDE study, a total of 8,561 patients with type 2 diabetes and renal impairment were randomized to double-blind treatment with either aliskerin 300 mg or placebo
once daily, in addition to an angiotensin coverting enzyme (ACE) inhibitor or angiotensin 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 prematurely.
At a median follow-up of 32 months, the
primary endpoint had occurred in 767 patients taking aliskiren (17.9 percent) and in
721 assigned to placebo (16.8 percent) [95%
Aliskiren may do more harm than good in type 2 diabetics with renal
problems.
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 aliskirentreated 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 administration of aliskiren on top of standard therapy 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 brandnames Rasilez and Tekturna, respectively, for
the treatment of essential (primary) hypertension either as monotherapy or in combination
with other medications.
34
October 2012
Conference Coverage
European Respiratory Society Annual Congress, 1-5 September, Vienna, Austria
First global standards on assessing lung
function
Rajesh Kumar
T
he 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 function decrease dramatically when the care is
transferred from pediatric to adult clinic. Similar errors can occur if the individual patient’s
ethnicity and associated difference in body
composition or stature are not taken into account.
Multinational researchers part of the
Global Lung function Initiative (GLI) 2012,
set up by the European Respiratory Society to establish a consensus on the topic,
assessed data from 74,187 healthy nonsmokers 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 Southeast 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 proportionally from that in Caucasians. For individuals
not represented by the above four groups, or
of mixed ethnicity, a composite equation taken 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 pulmonary 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 development 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. However, their widespread use will depend on
timely implementation by manufacturers of
spirometry devices, said the researchers. 35
October 2012
Conference Coverage
European Respiratory Society Annual Congress, 1-5 September, Vienna, Austria
Home factors impact on kids’ asthma
medication compliance
Elvira Manzano
F
amily 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 without 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 do not succeed in getting their kids with asthma to take
their meds.
Some parents, the “delegators” and “
strugglers,” did not succeed in getting their
children to take their medication properly. 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.”
36
October 2012
Conference Coverage
He 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:
“It can be chaotic having four children and
when we have given our son, Alex, responsibility 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.”
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, digestive 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 reported that three previous studies on inhaled
GSH in CF patients have shown promising
outcomes in terms of forced expiratory volume 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 compared 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
37
October 2012
Conference Coverage
98.6 ± 19.3 percent in the placebo group, respectively.
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 significant 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. www.MIMS.com
Smart Rx. Every Time.
38
October 2012
Conference Coverage
European Respiratory Society Annual Congress, 1-5 September, Vienna, Austria
Long-distance running raises pulmonary
edema risk
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 severe cases.
“Marathon running is worldwide. Halfa-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 develops from long-distance running, characterizing 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 participated 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 runners finished with times between 142 and 289
minutes.
To quantify the presence of edema, posteroanterior and lateral chest radiographs
of the runners were taken the day before the
race, then 19, 56 and 98 minutes after finishing the race. Three radiologists were tasked to
do the radiograph interpretation. The readers
worked independently and were not in contact with each other. They were also not told
Half of runners tested within 20 minutes of completing a marathon had
some level of pulmonary edema.
which radiographs were taken before or after
the race.
Four radiographic characteristics were
assessed, including peri-bronchial cuffing,
loss of definition of vascular markings, pulmonary opacification and blurring of hilar silhouette. 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 runners 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 percent), mild to moderate pulmonary edema
was even retained 1 hour after finishing the
39
October 2012
Conference Coverage
marathon.
Upon further evaluation, the study found
that women were at 13 times higher risk compared with men in the development of pulmonary edema (odds ratio 12.8, r2 0.31, P=0.038).
No correlation was established between marathon 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 radiologic finding of pulmonary edema exhibited
signs such as difficulty of breathing or coughing 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 pressure within pulmonary artery force out fluid
into the interstitium.
“While pulmonary edema can be a negative
consequence of marathon running, regular exercise 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 Coverage
Flight hypoxia assessment inappropriate
for pediatrics
Dr. Yves St. James Aquino
B
ritish
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, reducing the number of in-flight emergencies due
to respiratory disease. The BTS established
upper and lower thresholds for “no inflight oxygen required” at percutaneous
oxygen saturation (SpO2) >95 percent or
“in-flight oxygen needed” at SpO2 <92 percent.
The study was a retrospective audit of
patients referred to a pediatric respiratory function laboratory. The hypoxic challenge test as described by Gong et al suggests the maximum cabin altitude of 2,438
meters (8,000 feet) can be simulated at sea
level with a gas mixture containing 15 percent 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 challenge 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 children, 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 assessed, 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 recommendations for referral for hypoxic flight
assessment are not appropriate for pediatrics, 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 desaturate in hypoxic conditions. Researchers
concluded that children with respiratory
disease should be considered for a hypoxic challenge test irrespective of sea-level
SpO2 percent.
41
October 2012
Conference Coverage
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
October
23rd Great Wall International Congress
of Cardiology (GW-ICC)
– Asia Pacific Heart Congress (APHC) 2012
11/10/2012 to 14/10/2012
Location: Beijing, China
Info: Secretariat Office of GW-ICC & APHC (Shanghai
Office)
Tel: (86) 21-6157 3888 Extn: 3861/62/64/65
Fax: (86) 21-6157 3899
Email: [email protected]
Website: www.heartcongress.org
42nd Annual Meeting of the International
Continence Society
15/10/2012 to 19/10/2012
Location: Beijing, China
Tel: (41) 22 908 0488
Fax: (41) 22 906 9140
Email: [email protected]
Website: www.kenes.com/ics
th Asian-Pacific Society of Atherosclerosis
8
and Vascular Diseases Meeting
20/10/2012 to 22/10/2012
Location: Phuket, Thailand
Info: Asian-Pacific Society of Atherosclerosis and Vascular
Diseases
Tel: (66) 2940 2483
Email: [email protected]
Website: www.apsavd2012.com
November
012 Scientific Sessions of the American
2
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 2012
9/11/2012 to 11/11/2012
Location: Shanghai, China
Info: UBM Medica Shanghai Ltd.
Tel: (86) 21-6157 3888 Extn: 3861/62/64/65
Fax: (86) 21-6157 3899
Email: [email protected]
Website: www.isrd.org
3rd Annual Meeting of the American
6
Association for the Study of Liver Diseases
9/11/2012 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
Upcoming
National Diagnostic Imaging Symposium
2/12/2012 to 6/12/2012
Location: Orlando, Florida, US
Info: World Class CME
Tel: (980) 819 5095
Email: [email protected]
Website: www.cvent.com/events/national-diagnosticimaging-symposium-2012/event-summaryd9ca77152935404ebf0404a0898e13e9.aspx
Asian Pacific Digestive Week 2012
5/12/2012 to 8/12/2012
Location: Bangkok, Thailand
Tel: (66) 2 748 7881 ext. 111
Fax: (66) 2 748 7880
E-mail: [email protected]
Website: www.apdw2012.org
World Allergy Organization International
Scientific Conference (WISC 2012)
6/12/2012 to 9/12/2012
Location: Hyderabad, India
Info: World Allergy Organization
Tel: (1) 414 276 1791
Fax: (1) 414 276 3349
E-mail: [email protected]
Website: www.worldallergy.org
43
October 2012
Calendar
54th American Society of Hematology
Annual Meeting
8/12/2012 to 11/12/2012
Location: Georgia, Atlanta, US
Info: American Society of Hematology
Tel: (1) 202 776 0544
Fax: (1) 202 776 0545
Website: www.hematology.org
17th Congress of the Asian Pacific Society
of Respirology
14/12/2012 to 16/12/2012
Location: Hong Kong
Info: UBM Medica Pacific Limited
Tel: (852) 2155 8557
Fax: (852) 2559 6910
E-mail: [email protected]
Website: www.apsr2012.org
16th Bangkok International Symposium
on HIV Medicine
16/1/2013 to 18/1/2013
Location: Bangkok, Thailand
Info: Ms. Jeerakan Janhom (Secretariat)
Tel: (66) 2 652 3040 Ext. 102
Fax: (66) 2 254 7574
E-mail: [email protected]
Website: www.hivnat.org/bangkoksymposium
28th Congress of the Asia-Pacific Academy
of Ophthalmology
17/1/2013 to 20/1/2013
Location: Hyderabad, India
Info: APAO Secretariat
Tel: (852) 3943 5827
Fax: (852) 2715 9490
Email: [email protected]
Website: www.apaoindia2013.org
Asian Pacific Society of Cardiology 2013
Congress
21/2/2013 to 24/2/2013
Location: Pattaya, Thailand
Info: Kenes Asia (Thailand Office)
Tel: (66) 2 748-7881
Fax: (66) 2 748-7880
Email: [email protected]
Website: http://www2.kenes.com/apsc2013/pages/home.
aspx
44
October 2012
After Hours
Radha Chitale
W
hen 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
45
October 2012
After Hours
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. 46
October 2012
After Hours
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
- R
elieves 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
- P
roduces a resin used to treat ulcers and sores
Olive Tree (Olea Europaea)
Olive Grove, Mediterranean Garden, Flower Dome
- M
etabolism inducer, reduced LDL cholesterol, blood pressure,
and blood sugar levels
Lavender (Lavandula dentate)
Mediterranean Garden, Flower Dome
- R
educes 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
“Don’t try to move or go anywhere. We will be right back!”
“There’s no cure, because you are perfectly healthy!”
“If you
the worst
happens,
canon
I
“Do
have to
go on and
keephow
yourgross
lawn mower?”
about
the whole
thing is?”
“What your husband is
experiencing, it’s what we call
rigor mortis, making it difficult
for him to relax!”
“I said I was sorry!”
“Sure, some of my patients
became very sick after the
operation, and others have died,
but none of them seriously!”
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