September 2012

September 2012
Experts debate China’s healthcare reforms
FORUM
NEWS
Weight training lowers
type 2 diabetes risk
in men
Healthcare in China:
Finding the right balance
CONFERENCE
IN PRACTICE
Recreational runners
may strain heart too
Nerves can be a pressing
problem
1,500 Academic Speakers
1,500
Academic Speakers
340 Sessions
340
Sessions
70
Special Topics
70
Special Topics
Date:
Date:
Venue:
Venue:
11-14 October 2012
11-14 October 2012
China National Convention Center (CNCC),
China National
Beijing,
China Convention Center (CNCC),
Beijing, China
Congress Language:
English andLanguage:
Mandarin
Congress
English and Mandarin
Organized by:
Organizing Committee
of Asia Pacific Heart Congress (APHC)
Organized
by:
Organizing
Wall International
Congress
Organizing Committee
Committee of
of Great
Asia Pacific
Heart Congress
(APHC)of Cardiology (GWICC)
Organizing Committee of Great Wall International Congress of Cardiology (GWICC)
Congress Secretariat for Overseas Delegates:
Secretariat
Office of GWICC
& APHC (Shanghai
Office)
Congress Secretariat
for Overseas
Delegates:
Tel:
86-21-6157
ext. 3861/3862/3864/3865
Secretariat
Office3888
of GWICC
& APHC (Shanghai Office)
Fax:
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3899
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Email:
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Fax: 86-21-6157
3899
Email: [email protected]
Please visit www.heartcongress.org for further details
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3
September 2012
Experts debate China’s healthcare reforms
Elvira Manzano
T
he inaugural Healthcare in China summit held in Beijing recently served as a
platform for experts to debate China’s
major health challenges, identify key issues
that could derail implementation of its recent
reforms, and formulate strategies to meet new
targets.
The forum brought together top government officials, policy makers, academics and
experts within the country and from around
the world.
Mr. Lei Haichao, deputy director-general
of the Beijing Health Bureau, said that although China has made significant headway
towards system improvement (eg, the establishment of a nationwide health insurance
system, a primary drug list and a centralized drug procurement system), some issues
remain to be addressed including resource
allocation. He said more than 85 percent of
China’s health budget was spent on diagnosis and treatment, with very little allocated
for disease prevention.
Our services are still treatment-focused
and the burden of healthcare on patients is
still very heavy, especially on rural residents,
he added.
In recent years, the government has approved several health laws and initiated
more projects that are set to benefit public
hospitals. However, more investments have
to be poured into insurance and equipment,
Lei said.
China has implemented major reforms to its healthcare system in recent
years, but resource allocation remains a major issue.
China’s healthcare system funding is
a balance between public and private.
No country has a purely public or purely
private health system, and no country can
provide solely public funding, said Lei. Like
any country, China is trying to find a balance
between the two forms.
At the panel discussions convened during the conference, experts provided suggestions on how best to allocate resources,
progress public hospital reforms, augment
services and raise standards of care. Specific
recommendations included removing physicians’ financial incentives to overprescribe
drugs and tests, controlling investments and
medical costs and refocusing efforts towards
stemming the tide of chronic diseases which
are responsible for a very high proportion
(80 percent) of deaths in China.
4
September 2012
Forum
Healthcare in China: Finding the right
balance
Based on an excerpt from a keynote address by Mr. Lei Haichao, deputy director-general,
Beijing Health Bureau, during the Healthcare in China 2012 Economist Conference held
recently in Beijing, China.
Elvira Manzano
O
ver that past 3 years, China has made
commendable progress with respect
to its healthcare reforms. Since 2009,
the Chinese government has allocated more
than RMB 1.5 trillion to improve the country’s
healthcare system, with significant progress
made in coverage of medical insurance and
the establishment of a primary drug list and
centralized drug procurement system.
There remain deeply entrenched issues,
however, particularly with the way in which
resources are allocated. Our services are still
very much treatment focused, with more
than 85 percent of medical resources spent
on diagnosis and treatment. Relatively little is
spent on the prevention of diseases. Furthermore, the burden of healthcare on patients is
still very heavy, especially on rural residents.
‘‘
With ongoing reforms,
we will see more financial
resources allocated to
hospitals, but personally
I don’t think it is enough yet
Overall however, the Chinese government
has been quite successful in implementing
China is looking to find the right balance between public and private
funding of its healthcare system.
its recent healthcare reforms, playing a leading role in planning and showing high levels
of commitment to building a better system.
The government has already pushed through
more than 10 new laws, as well as initiated
many pilot projects. The results from these
have been good and now they need to roll out
to 10,000 public hospitals.
Further areas that the government can do
to improve Chinas’ healthcare system include
the following:
• Invest more in insurance and equipment.
• Guarantee quality of service in all healthcare centers.
• Provide better service when it comes to
5
September 2012
Forum
public disclosure, so everyone knows the
state of the market.
• Better educate the general public in the
prevention of diseases.
While it is important for the government to
maintain its role as the main provider of primary healthcare services, the private sector
should also be involved in non-primary services. Indeed, the healthcare system needs to
work closely together with the medical insurance system in order to help those with higher
demands and who can afford more expensive
and individualized services.
The situation for hospitals throughout China has been that day-to-day hospital charges
have not been financed by the government. In
fact, hospital staff salaries have usually been
covered by patients’ treatment fees. Hospitals
have therefore faced the ongoing challenges
of how to pay their staff and cover their daily
costs.
With ongoing reforms, we will see more
financial resources allocated to hospitals, but
personally I don’t think it is enough yet.
In the near future we will also see more
government money and training going into
generalist doctors and local facilities, with
GPs and family doctors given more opportunities to train. In addition, in some places,
people who go to local hospitals will be given
more money back as an incentive to go to primary healthcare centers.
We need to find the right balance between
private and public.
No country has a purely public or purely
private system and no country can provide
solely public funding. Like every country,
China is trying to find its balance.
6
September 2012
Indonesia Focus
Local events calendar
1st Current Update On Surgical
Emergencies and Daily Cases
Jakarta, 22-24 September 2012
Hotel Borobudur, Jakarta
Sekr
: Dept. Ilmu Bedah FKUI RSCM Gedung Staff lt. 4 Jl. Diponegoro No. 71, Jakarta
Tel : 021-28711480
Fax : 021-3100050
Email : [email protected]
Current Issue in Pediatric Nutrition
and Metabolic Problem
Jakarta, 22-23 September 2012
Hotel Millenium, Jakarta
Website : http://ciprime2012.
blogspot.com/
Email : ciprime2012@yahoo. com
The 14th International Meeting
on Respiratory Care Indonesia
(Respina) 2012
Jakarta, 5-6 Oktober 2012
Hotel Shangri-la, Jakarta
Sekr : Gedung Asma Lt.2, Jl. Persahabatan Raya No.1, Jakarta 13230
Tel : 021-47864646, 47864321
Fax : 021-47866543
Email : info.respina@yahoo.
com, info.respina.
[email protected]
Website : www.respina.org
2012 ISICM End Year Symposium
Makassar, 10-13 Oktober 2012
Sekr : Indonesian Society of
Intensive Care Medicine
(Perhimpunan Dokter Intensive Care Indonesia; PERDICI)
Gedung Makmal Lt. 2
Komplek FKUI, Jl. Salemba Raya No.6
Tel : 021- 68599155/31909033
Fax : 021-31909033
Email : [email protected]
Website : www.perdici.org
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
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
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,
kopapdixv@pharma-
pro.com
Website : www.kopapdimedanxv.
com
www.MIMS.com
Smart Rx. Every Time.
8
September 2012
Indonesia Focus
Seputar donor ASI dan ibu dengan HIV
Hardini Arivianti
H
asil Survei Sosial Ekonomi Nasional (Susenas) tahun 2005-2010,
cakupan pemberian ASI eksklusif
pada bayi usia 0-6 bulan tidak ada peningkatan yang signifikan, dari 59,7% (2005)
menjadi 61,5% (2010). Sedangkan cakupan
untuk bayi usia 6 bulan meningkat dari
26,3% (2005) menjadi 33,6% (2010). Hal ini
diungkapkan oleh Dr. Minarto, MPS beberapa waktu lalu dalam rangka merayakan
‘World Breastfeeding Week’ (Pekan ASI Sedunia) 2012 yang mengangkat tema global
‘Understanding the Past, Planning for the
Future’.
Banyak faktor yang dapat menyebabkan
rendahnya cakupan ibu yang memberikan
ASI eksklusif, antara lain ibu tidak yakin
manfaat ASI dan ibu tidak mendapat cukup
informasi tentang ASI yang benar, kondisi
lingkungan yang mendukung ibu untuk menyusui, pemasaran susu formula yang belum
tertib dan melibatkan petugas maupun institusi kesehatan serta belum meratanya dan
memadainya keberadaan konselor di setiap
wilayah.
“Bila ibu tidak mungkin menyusui karena
satu atau lain hal, pilihannya adalah de-ngan
donor ASI,” tukas Dr. Minarto. Dalam Peraturan Pemerintah (PP) No. 33 tahun 2012
tentang pemberian ASI eksklusif mengatur
tentang pemberian ASI eksklusif, pendonor
ASI, pengaturan penggunaan susu formula
dan produk bayi lainnya, pengaturan bantuan produsen atau distributor susu formula,
sanksi administratif, serta tempat kerja dan
sarana umum dalam mendukung program
ASI ekskslusif. Terkait pendonor ASI, dalam
pasal 11 ayat 1 yang dimaksud dengan pendonor ASI adalah ibu yang menyumbangkan
ASI kepada bayi yang bukan anaknya. Dalam
pasal 6 menyatakan, setiap ibu yang melahirkan harus memberikan ASI eksklusif kepada
bayi yang dilahirkannya. Pada PP tersebut,
pendonor ASI dipertegas dalam pasal 11 ayat
1 dan 2 yaitu: (1) dalam hal ibu kandung tidak
dapat memberikan ASI eksklusif bagi bayinya
sebagaimana pasal 6, pemberian ASI eksklusif dapat dilakukan oleh pendonor ASI, (2)
pemberian ASI eksklusif oleh pendonor ASI
sebagaimana dimaksud pada ayat 1, dilakukan dengan syarat: permintaan ibu kandung
atau keluarga bayi yang bersangkutan; identitas, agama dan alamat pendonor ASI diketahui oleh ibu kandung atau keluarga bayi
penerima ASI; atas persetujuan pendonor
ASI setelah mengetahui indentitas bayi yang
diberi ASI; pendonor ASI dalam kondisi kesehatan yang baik dan tidak memiliki indikasi
medis; dan ASI tidak diperjual belikan. (3)
pemberian ASI sebagaimana dimaksud ayat
1 dan ayat 2 wajib dilaksanakan berdasarkan
aspek sosial budaya, mutu dan keamanan
ASI. (4) ketentuan lebih lanjut mengenai pemberian ASI eksklusif dari pendonor ASI sebagaimana dimaksud ayat 1, ayat 2 dan ayat 3
diatur dengan Peraturan Menteri.
Sebagai tindak lanjut PP No. 33 tahun 2012
tersebut, Kemenkes melalui Dirjen Bina Gizi
dan KIA sedang menyusun PERMENKES
yang mengatur tata cara penyediaan fasilitas
khusus menyusui, penggunaan susu formula
bayi dan produk bayi lainnya atas indikasi
media, pemberian ASI eksklusif dari pendonor ASI dan sanksi terkait pasal dalam PP No.
9
September 2012
Indonesia Focus
33 tahun 2012.
“Dalam rangka mencegah penularan HIV
AIDS antar ibu dan anak, dapat dilakukan
dengan cara: memberikan ASI eksklusif selama pengobatan dengan ARV; ASI bisa didapatkan dari pendonor ASI; dan bila ibu dan
donor ASI tidak memungkinkan, baru dipertimbangkan pemberian susu formula,” lanjut
Direktur Bina Gizi Kementerian Kesehatan RI
ini.
Survei nasional
Pada tahun 2010-2011, Ikatan Dokter Anak
Indonesia melakukan beberapa survei nasional. salah satunya insidensi ASI eksklusif.
Pada usia 0-3 bulan sebesar 43% dan 0-6 bulan mencapai 27%. “Sebagian besar masyarakat telah mendengar adanya terminologi ASI
eksklusif. Di pulau Jawa, Bali, Kalimantan
dan Sumatera cukup tinggi mencapai 78%,”
jelas dr. Elizabeth Yohmi, SpA, IBCLC.
ASI merupakan makanan terbaik bagi bayi
namun sayangnya ASI juga dapat menularkan
berbagai virus. Menurut CDC, beberapa virus
yang terdeteksi dalam ASI antara lain HIV-1,
hepatitis D, CMV (1:1000), West Nile,dan human T-cell lymphotropic tipe I dan II.
Transmisi HIV perlu diperhatikan saat di
kandungan, persalinan dan menyusui. Menurut WHO, transmisi melalui laktasi sebesar
5-20%. Analisis Ghent (2002) menunjukkan
tingkat penularan meningkat semakin lama
bayi itu disusui. Hingga 2 tahun meningkat hingga 16%. Menurut meta-analisis 2004
menunjukkan transmisi kumulatif sebesar
9,3% pada usia 18 bulan. Bila ibu hamil dengan HIV + tidak diobati atau tidak mendapatkan ARV dan menyusui selama 2 tahun maka
dapat melipatgandakan risiko bayi terinfeksi
menjadi 40%.
“Saat hamil, ibu (HIV +) sudah dapat
menularkan sebesar 5-10%. Proses persalinan
karena faktor ketidaktahuan ibu, persalinan
biasa meningkatkan penularan hingga 1015%. Bila tidak menyusui, peluang anak tertular menjadi 15-25%. Kalau diberikan ASI selama 6 bulan, meningkat sedikit 20-35% dan
bila menyusui lebih lama lagi, meningkat 3045%,” tukasnya lebih lanjut.
Mengenai situasi HIV dan AIDS di Indonesia (sesuai laporan triwulan Departemen
Kesehatan hingga Maret 2009) di 33 propinsi
(2000-2009), berdasarkan jenis kelamin, 74,5%
( laki-laki) dan 25% (perempuan). Lebih dari
50% kasus AIDS terjadi pada kisaran usia
produktif, 15-29 tahun.
Rekomendasi pemberian makan bayi
sesuai guideline dari WHO tahun 2010
dinyatakan ibu mengonsumsi ARV dari minggu ke-28 kehamilan hingga 1 minggu setelah
persalinan, atau untuk jumlah waktu yang tidak ditentukan jika ibu memakai ARV untuk
kesehatan mereka sendiri; rejimen panjang
ARV selama masa menyusui baik untuk ibu
dan/atau bayi; ASI eksklusif 6 bulan; menyapih bertahap; makanan tambahan setelah 6
bulan; dan tetap merekomendasikan terus
menyusui dan makan campur (makanan
pendamping) dengan mengonsumsi ARV.
Cara mengurangi infeksi melalui ASI
donor, dr. Rosalina D Roeslani, SpA (K)
menjelaskan, skrining oleh dokter, penyimpanan ASI dalam pendingin (< -20 derajat) yang
dapat mematikan atau me-non aktif-kan CMV
dan HTLV, serta pasteurisasi (mematikan
CMV dan HIV).
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10 September 2012 Indonesia Focus
Jakarta Internal Medicine in Daily Practice PAPDI, 1-2 September 2012, Jakarta
Menilai kandung kemih hiperaktif
Hardini Arivianti
C
urrent Management of Overactive Bladder (OAB) menjadi salah satu topik pada
‘Jakarta Internal Medicine in Daily Practice’
(JIM DACE) PAPDI, 1-2 September 2012 lalu.
“Menurut beberapa literatur, OAB diartikan
sebagai kandung kemih hiperaktif,” jelas dr.
Edy Rizal Wahyudi, SpPD, K-Ger, FINASIM
saat membahas ‘How to Optimize OAB Management: Focus on Elderly Problem’.
Pada keadaan normal, frekuensi berkemih
kurang dari 8 kali/24 jam dan tidak pernah terbangun malam hari karena urgensi berkemih
serta ada fase menahan saat kandung kemih
dalam keadaan penuh. Pada OAB, frekuensi berkemih lebih dari 8 kali/24 jam, disertai
nokturia, dan tidak bisa menahan berkemih.
Dibandingkan dengan penyakit kronik
lainnya, prevalensi OAB ini tidak sedikit. Di
Amerika Serikat, OAB berada di atas diabetes
dan osteoporosis. Namun banyak juga kasus
OAB yang tidak terdeteksi. “Penelitian menyimpulkan, kejadian OAB akan meningkat
seiring dengan pertambahan usia,” tukas dr.
Edy. Di Amerika Serikat insidensi pada usia
di atas 40 tahun mencapai 11-12 %.
Dari sebuah survei pada Klinik Geriatri
RSCM yang menilai frekuensi berkemih pada
169 lansia menunjukkan 14,5% (pria) dan
17,9% (wanita). Sedangkan banyaknya berkemih > 2x di malam hari menunjukkan 30,2%
(pria) dan 31,2% (wanita). Secara terperinci
hasil survei di RSCM dan sentra pelayanan
geriatri di beberapa kota di Indonesia (Jakarta, Padang, Bandung, dan Semarang), dapat
dilihat pada tabel berikut:
Beberapa propinsi di Indonesia, lanjut dr.
Edy, memiliki populasi usia lanjut yang besar dibandingkan dengan balita dan hal ini
berkaitan dengan peningkatan usia harapan
hidup yang nantinya dikaitkan lagi dengan
berbagai masalah kesehatan di usia lanjut
Klinik
Geriatri
RSCM
Beberapa sentra layanan geriatri di beberapa
kota di Indonesia
OAB
23,9%
24,4%;
Inkontinensia stress
37,0%
22,9%
Berkemih > 8x/hari
42,6%
42,6%
Nokturia
79,3%
67,3%
yang dikenal dengan istilah 14 I, diantaranya
inkontinensia.
Karakteristik usia lanjut antara lain adanya penurunan fungsi organ, multipatologis,
dan polifarmasi yang nantinya akan berperan
penting saat dilakukannya pengobatan OAB.
Insidensi OAB yang begitu banyak masih belum mencakup semua kasus karena selalu
ada hambatan saat melaporkan kasus, misalnya inkontinensia dianggap wajar, pasien/
keluarga merasa malu, dan pasien mencoba
mengobati sendiri. ‘Sekitar 2/3 pasien, memerlukan waktu dua tahun sebelum memutuskan ke dokter dan bila sudah ke dokter, tidak semuanya dinilai sebagai OAB,” jelasnya
lebih lanjut.
Diagnosis OAB ditegakkan berdasarkan
beberapa faktor, antara lain riwayat pasien,
gejala, pemeriksaan fisik, dan urinalisa. Pengobatan berupa perubahan perilaku, farma-
11 September 2012 Indonesia Focus
kologi dan kombinasi keduanya. Pengobatan
disesuaikan dengan lingkungan, ekspekstansi, gaya hidup, dan usia. Terapi standar
OAB adalah antimuskarinik yang dapat
menimbulkan efek samping berupa mulut
kering, konstipasi dan penglihatan kabur.
Antimuskarinik
“Ada 5 subtipe reseptor muskarinik yaitu
M1-M5 dan yang memperantarai kontraksi
detrusor adalah M2 dan M3,” tukas Prof. Dr.
dr. Armen Muchtar, DAF, DCP, SpFK (K).
Reseptor terbanyak pada kandung kemih
adalah M2 lalu diikuti M3 dan hambatan
langsung pada M3 merupakan mekanisme
kerja antimuskarinik untuk pengobatan
OAB. Oleh karena itu antimuskarinik selektif yang menghambat M3 (darifenacin, solifenacin, solifenacin) lebih disukai dibandingkan dengan yang non-selektif (propiverine,
tolterodine, trospium).
Akan tetapi hambatan terhadap antimuskarinik pada semua reseptor muskarinik yang tersebar di berbagai organ lain
berpotensi menimbulkan efek sam-ping
diantaranya mulut kering karena M3 merupakan reseptor yang memperantarai sekresi
saliva.
Penelitian bakteri pada pakaian
Hardini Arivianti
P
ola hidup higienis pada rumah tangga dapat mencegah terjadinya infeksi
atau penyakit, hal ini dipromosikan
oleh ‘International Scientific Forum on Home
Hygiene’ (IFH). Penelitian yang dilakukannya di beberapa negara, seperti Kanada, Jepang, Amerika dan lainnya menyimpulkan,
bakteri dapat hidup pada pakaian dan peralatan rumah tangga berbahan kain, seperti
alas tempat tidur, handuk, sarung bantal, dll.
Definisi ‘home hygiene’ menurut IFH
adalah segala aktivitas di rumah yang bertujuan untuk mencegah penyebaran penyebaran penyakit infeksi, yang meliputi kebersihan makanan, pemakaian air, pembuangan
limbah, healthcare at home (misalnya ada orang
sakit di rumah), kebersihan individu (mencuci tangan dan pakaian), dan kebersihan
umum (mencuci pakaian).
Menurut salah satu ahli mikrobiologi lingkungan dari IFH, Ryan Gene Gaia Sinclair,
PhD, MPH, memaparkan bila pakaian dan
peralatan rumah tangga (handuk, seprai, sarung bantal, dan peralatan berbahan kain
lainnya) tidak terjaga kebersihannya ditemukan bakteri S Aureus, E coli, K pseudomonas
dan pseudomonas. “Penyebaran bakteri tersebut bervariasi, misalnya S aureus dapat menempel pada dinding mesin cuci yang terbawa
pakaian kotor dan berpotensi menyebar ke
pakaian lain, terutama yang lembab dan basah,” lanjutnya.
Studi yang dilakukan Ojima dkk (2002)
pada 86 rumah di Jepang mengevaluasi kontaminasi yang berasal dari dapur dan handuk, serta handuk di kamar mandi. Hasil isolasi menunjukkan koliform 0-8% (60% towel
counter), E coli 0-2,5%, P aeruginosa 0% (6,2%
dari towel counter) dan S aureus 2,6-7,4%.
Pada saat yang sama, Dr. dr. Hindra Irawan
12 September 2012 Indonesia Focus
Satari, SpA(K) mengutip studi Cotner S dkk
(2010) yang meneliti perbedaan pertumbuhan
bakteri pada kain natural dan artifisial. Hasilnya menunjukkan serat polyester dan acrylic
‘mengikat’ mikroorganisme gram negatif dan
gram positif hingga 80%, sedangkan serat katun ’mengikat’ kurang dari 10%. Bakteri lebih banyak pada kain berbahan dasar sintetis
dibandingkan dengan kain yang dibuat dari
bahan dasar selulosa.
Pada kain berbahan dasar selulosa menjadi
tempat kolonisasi bakteri-bakteri yang normal ada pada keringat manusia, misalnya kelompok propionibacteria, corynebacteria, staphylococcus dan streptococcus. Pada kain sintetis
menjadi tempat kolonisasi oleh bakteri yang
tidak ditemukan dalam keringat manusia.
Studi lain yang dilakukan Neely (2000)
menilai length of survival beragam bakteri
gram negatif pada kain dan plastik yang
digunakan di rumah sakit. Tujuh bahan
diuji yaitu katun (baju), handuk, kain campuran (katun 60%/40% polyester) pada jas
laboratotium, polyester, dan poliuretan
(penutup keyboard). Pada 102 mikroorganisme/swatch, bakteri itu bertahan lama kurang
dari satu jam hingga 8 hari. pada 10(4)-10(5)
bakteri/swatch, bakteri dapat bertahan dari 2
jam hingga lebih dari 60 hari.
Peran tekstil sebagai rantai penyebab infeksi juga diteliti oleh Dirk Hofer (‘Arab Medical Hygiene’, 2011). Tekstil berperan penting
dalam rantai penularan infeksi akibat mikroorganisme patogen, misalnya bakteri, jamur,
dan virus yang ditemukan pada kain dan peralatan lain berbahan kain. Itu sebabnya terutama institusi pelayanan kesehatan seperti
rumah sakit, memerlukan perhatian ekstra
pada kain-kain dan cara mencucinya sebagai
bagian dari pencegahan infeksi.
Dari studi yang dilakukan oleh IFH, mencuci dengan menggunakan bahan deterjen
saja ternyata tidak cukup untuk menghilangkan kuman atau bakteri yang menempel pada
pakaian dan peralatan rumah tangga lainnya
yang berbahan dasar kain. Proses mencuci
menjadi sangat penting, kebersihan secara estetis bukan lagi menjadi tujuan akhir mencuci, namun mencuci harus menjadi salah satu
cara guna mendapatkan pakaian yang bersih
secara higienis dalam arti bebas bakteri yang
dapat menimbulkan penyakit.
14 September 2012 News
COPD patients benefit from antibiotic
prophylaxis
Alexandra Kirsten
P
atients suffering from chronic obstructive pulmonary disease (COPD) may
benefit from a regular intake of antibiotics to prevent acute exacerbations, according to
new research.
A meta-analysis of two clinical trials involving 1,251 patients with COPD showed that patients taking a daily regimen of azithromycin
for 1 year had a significantly reduced frequency
of COPD exacerbations compared with those
receiving placebo. [N Engl J Med 2012;367:3407]
While there was no significant difference between groups in terms of overall mortality, the
study did show that azithromycin intake also
prolonged time to first acute exacerbation and
significantly improved patients’ quality of life.
‘‘
This approach has
the potential to eliminate
one-third of the severe
exacerbations each year
among patients
with COPD
“This approach has the potential to eliminate
one-third of the severe exacerbations each year
among patients with COPD,” said lead author
Dr. Richard Wenzel, Virginia Commonwealth
University, Richmond, Virginia, US, and colleagues.
“A patient who continues to have frequent
acute exacerbations despite guidelines-based
treatment is a potential candidate for prophy-
A meta-analysis has shown that a daily course of azithromycin for a year
significantly cut rate of COPD exacerbations.
lactic use of azithromycin.”
Nevertheless, they cautioned, a patient
should have had at least two episodes of acute
exacerbation in the previous year to be considered for such therapy, both to provide a baseline against which to assess clinical response
and to limit overuse of azithromycin.
This protocol may not be suitable for every
patient, said Wenzel. Some may suffer adverse
consequences with year-long use of azithromycin, such as hearing loss, antibiotic resistance
and heart rhythm disturbances.
According to the WHO, approximately 64
million people suffer from COPD, the fourth
leading cause of death worldwide.
Acute exacerbations of COPD contribute
markedly to the condition’s morbidity and
mortality. On average, patients experience one
to two exacerbations annually, and the rate
generally increases as the disease progresses.
Every episode is potentially life-threatening and can lead to additional lung function
decline.
15 September 2012 News
Involving patients reduces unnecessary
antibiotic Rx
Rajesh Kumar
A
shared decision-making program for GPs
led to greater patient involvement in the
treatment process and fewer prescriptions for
antibiotics to treat acute respiratory infections,
a Canadian study has shown.
The reduction in antibiotic prescriptions
did not have a negative effect on patient outcomes 2 weeks after the GP consultation, said
the researchers. [CMAJ 2012; DOI:10.1503/
cmaj.120568]
They randomized nine family practice
teaching units in six regions of Quebec, Canada
into two study arms: DECISION+2 and control. GPs in the DECISION+2 practices were
offered a 2-hour online tutorial followed by a
2-hour interactive seminar about shared decision-making, while those in the control group
were asked to provide usual care. The primary
outcome was the proportion of patients who
decided to use antibiotics immediately after the
consultation.
Outcomes among 181 patients who consulted 77 GPs in five family practice teaching units
in the DECISION+2 group were then compared
with 178 patients who consulted 72 GPs in four
family practice teaching units in the control
Unnecessary antibiotic prescriptions may be reduced when patients are
more involved in the decision-making process.
group. The proportion of patients who decided
to use antibiotics after consultation was 52.2
percent in the control group and 27.2 percent
in the DECISION+2 group (absolute difference
25.0 percent, adjusted relative risk 0.48, 95% CI
0.34–0.68).
DECISION+2 was associated with patients
taking a more active role in decision-making
(P≤0.001) and patient outcomes 2 weeks after
consultation were similar in both groups.
Few interventions have proven effective in
reducing the overuse of antibiotics for acute respiratory infections. But the authors suggested
that physician training in a shared decisionmaking process, with greater patient involvement, can make a huge difference.
16 September 2012 News
Single dose of iron improves quality of life
in iron-deficient women
Malvinderjit Kaur Dhillon
W
omen with iron deficiency but
are not anemic no longer have to
suffer from fatigue and impaired
quality of life as a study shows one dose of
ferric carboxymaltose (FCM) replenishes iron
stores and reduces fatigue symptoms.
“Iron deficiency is very prevalent in up to a
third of young western women. It is well documented that iron deficiency leads to fatigue.
Fatigue leads to impairment of cognitive
function, quality of life and physical performance,” said Dr. Michael Hedenus, of Sundsvall Hospital, Sweden, at the 17th Congress of
the European Hematology Association. [Arch
Intern Med 1993;153:2759-65, J Gen Intern Med
1992;7:276-86, Blood 2011;118:3222-7, Haematologica 2012;97(1):193]
“Almost 300 young women who were fatigued and non-anemic were recruited from
four European countries and were blindly
randomized to receive either 1 g of FCM or
250 mL of saline. The patients had to be fatigued according to the instrumental Piper
Fatigue Scale (PFS) [score ≤5]. Several exclusion criteria included patients were not allowed to suffer from major depression or any
other active diseases,” said Hedenus.
Percentage of patients with improved PFS
total score (≥ 1 point reduction) was measured
at 7, 28 and 56 days after treatment and it was
found that the fatigue score improved significantly more often in FCM-treated patients
compared to the placebo group (65.3 percent
A single dose of iron may also reduce fatigue in iron-deficient women.
versus 52.7 percent, P=0.03). Twice as many
women in the FCM group also achieved a 50
percent reduction in their fatigue (33 percent
versus 18 percent, P≤0.01). [Abstract P0405]
Hedenus also noted that a difference in the
median fatigue score was observed in just 7
days after treatment initiation.
In addition to the total fatigue score, all
sub-scores as well as mental quality of life
and self-rated computerized visual analog
scale (VAS) scores of alertness, contentment
and calmness improved in the FCM-treated
women.
Almost all women in the FCM-treated
group successfully replenished their iron
stores and the entire group had hemoglobin
levels ≥ 12 g/dL on day 56.
“A single dose of FCM rapidly reduces
fatigue within a week and was found in this
study to be well tolerated.
Our message is to assess iron status in
non-anemic women with fatigue and consider them for treatment of iron deficiency,” he
concluded.
17 September 2012 News
Synthetic protein may keep flu at bay
Malvinderjit Kaur Dhillon
A
synthetic protein, EP67, has been
found very effective in kick-starting
the innate immune system and help
fight influenza within just 2 hours of being administered, a recent animal study has shown.
Prior to this study, EP67 had been mainly
used as an adjuvant for vaccines, something
added to the vaccine to help activate the immune response.
“The flu virus is very sneaky and actively
keeps the immune system from detecting it
for a few days until you are getting symptoms,” said Dr. Joy Phillips, lead author of
the study at the University of Nebraska
Medical Center, US. Phillips, alongside with
her colleague Dr. Sam Sanderson, decided to
investigate the potential of EP67 to work on
its own.
“Our research showed that by introducing
EP67 into the body within 24 hours of exposure to the flu virus caused the immune system to react almost immediately to the threat,
well before your body normally would,” she
said. [PLoS ONE 2012 doi:10.1371/journal.
pone.0040303]
According to Phillips, EP67 functions the
same, regardless of the influenza strain, as it
works on the immune system itself and not
on the virus. This is in contrast with the influenza vaccine, which has to perfectly match
the currently circulating strain.
In this study, testing was done primarily in mice by infecting them with influenza
virus. Researchers found that mice given a
dose of EP67 within 24 hours of infection did
not get sick or were not as sick as those that
were not treated with EP67.
In mice, being infected with influenza
translates to weight loss, which is how the
level of illness was measured. Typically,
mice lose approximately 20 percent of their
weight when they are infected with influenza. However, mice treated with EP67 were
found to only lose an average of 6 percent.
More importantly, the mice that were
treated a day after being infected with a lethal dose of influenza did not die, Phillips
said.
“When you find out you’ve been exposed
to the flu, the only treatments available now
target the virus directly but they are not reliable and often the virus develops a resistance
against them,” Phillips said. “EP67 could
potentially be a therapeutic that someone
would take when they know they’ve been
exposed that would help the body fight off
the virus before you get sick.”
Philips added that while the study focused on influenza, EP67 could potentially
work on other respiratory diseases and fungal infections, and could have huge potential
for emergency therapeutics.
She also said it could be used in the event
of a new strain of disease, before the actual
pathogen has been identified, much like the
SARS outbreak or the 2009 H1N1 influenza
pandemic.
Future research plans include examining
the effect EP67 has in the presence of a number of other pathogens, and to investigate
how EP67 functions within different cells in
the body.
18 September 2012 News
Calcium supplements linked to MI, kidney
stones
Yen Yen Yip
T
he safety of calcium supplements
has come under further scrutiny as
recent reports suggest they may be
linked with higher risks of myocardial infarction (MI) and kidney stones.
“Calcium supplements have been widely
embraced by doctors and the public on the
grounds that they are a natural and therefore
safe way of preventing osteoporotic fractures,”
wrote Professor Ian Reid and Dr. Mark Bolland from the Faculty of Medical and Health
Sciences, University of Auckland, Auckland,
New Zealand, in an editorial in a recent issue
of Heart journal. [Heart 2012;98:895-896]
The editorial accompanied a study linking
calcium supplements to an increased risk of
heart attacks. [Heart 2012;98:920-925] The European Prospectiv Investigation into Cancer
and Nutrition (EPIC) study, led by researchers based in Heidelberg, Germany, assessed
calcium intake through the diet and supplements of close to 24,000 subjects for about 11
years.
The results showed that subjects who took
calcium supplements regularly were 86 percent more likely to have a heart attack than
those who did not take any supplements.
“Calcium supplements, which might raise MI
risk, should be taken with caution,” concluded lead author Dr. Kuanrong Li from the Division of Cancer Epidemiology, German Cancer
Research Center, Heidelberg, Germany, and
colleagues.
The study also evaluated subjects whose
Calcium supplementation appears less safe when compared with normal
dietary intake of calcium.
calcium intake came from dietary sources.
Those who took a moderate amount of
calcium through their diet (820 mg per day),
instead of supplementation, were about 30
percent less likely to suffer a heart attack compared with those who took less dietary calcium (513 mg per day). Interestingly, those who
included more than 1,100 mg of calcium in
their daily diet did not observe a lowered risk
of heart attack.
‘‘
Taking [calcium] in one
or two daily [doses] is
not natural
In contrast to past research, the EPIC study
did not show an association between higher
calcium intake and reduced CV and stroke
risk, or overall CV mortality.
The safety of calcium supplements has
come into question, said Reid and Bolland.
“It is now becoming clear that taking this
19 September 2012 News
micronutrient in one or two daily [doses] is
not natural, in that it does not reproduce the
same metabolic effects as calcium in food.
“We should return to seeing calcium as
an important component of a balanced diet,
and not as a low cost panacea to the universal
problem of postmenopausal bone loss.”
In a separate study, high doses of calcium
and vitamin D supplements were shown to
cause higher rates of hypercalciuria and hypercalcemia in 163 postmenopausal women
with vitamin D insufficiency.
The study, presented at the 2012 Annual
Meeting of The Endocrine Society in Houston, US, randomized the women to vitamin
D doses ranging from 400 IU to 4,800 IU per
day, and calcium from 1,200 mg to 1,400 mg
daily, over a year. Blood and urinary calcium
levels were measured at baseline and every
3 months during the year-long study period.
The investigators found that about one
in three subjects (33 percent) experienced
hypercalciuria, defined as urinary calcium
levels greater than 300 mg in a 24-hour urine
calcium test. Hypercalcemia was also identified in about one in 10 subjects (10 percent).
Given that both events are known to contribute to the risk of kidney stones, lead
study investigator Professor Christopher
Gallagher, director of the Bone Metabolism
Unit at Creighton University Medical Center, Nebraska, US, has suggested that clinicians should monitor the blood and urine
calcium levels of patients who take calcium and vitamin D supplements on a longterm basis.
20 September 2012 News
Vitamin E may help reduce liver cancer risk
Radha Chitale
L
arge amounts of dietary or supplementary vitamin E may help reduce
the risk of liver cancer in women, according to a large prospective, populationbased study of Chinese adults.
“We found a clear, inverse dose-response
relation between... vitamin E intake and liver
cancer risk, an association that was independent of supplement use and that appeared
to be slightly stronger among participants
who reported no liver disease or family history of liver cancer,” said researchers from
Vanderbilt Epidemiology Center in Nashville, Tennessee, US, and the Shanghai Cancer Institute in Shanghai, China.
Previous epidemiological studies have
proved inconclusive about the effects of vitamin E on various cancers but there is evidence that vitamin E improves liver function
in people with viral hepatitis. Case controlled studies of dietary vitamin E are few.
The study included 132,837 people from
the Shanghai Women’s Health Study (19972000) and the Shanghai Men’s Health Study
(2002-2006). [J Natl Cancer Inst 2012 Jul 17
Epub ahead of print]
Participants were interviewed about their
dietary habits and vitamin supplement consumption and evaluated using food frequency questionnaires, plus follow-up interviews.
Not including the first 2 follow-up years,
the analysis showed that 118 women and
149 men developed liver cancer an average
10.9 and 5.5 years, respectively.
People who consumed greater amounts
of dietary vitamin E had a lower risk of de-
Supplemental vitamin E intake was inversely correlated with liver cancer
risk in adult Chinese women.
veloping liver cancer compared with those
who consumed less vitamin E (P Trend =
0.01). Supplemental vitamin E was similarly inversely associated with a lower risk of
liver cancer.
The results were consistent for both men
and women with and without self-reported
liver disease or a family history of liver cancer but were only statistically significant for
women.
Liver cancer is the third most common
cause of cancer deaths worldwide and has
a poor survival rate – about 15 percent over
5 years. The majority of liver cancer cases
occur in developing countries and over half
occur in China.
Other studies have suggested that vitamin E is an antioxidant that prevents DNA
damage, enhances DNA repair, prevents
lipid peroxidation, inhibits carcinogens and
boosts the immune system.
A high concentration of dietary vitamins
21 September 2012 News
and minerals may reduce inflammation and
prevent infection, both of which can contribute to liver cancer, particularly in the
presence of chronic hepatitis B or C virus,
but this is so far unstudied. Hepatitis B is a
known risk factor for liver cancer.
Contrary to vitamin E, the study showed
that vitamin C supplements and multivitamins were associated with a higher risk
of liver cancer in adults with self-reported
liver disease or family history of liver cancer, and highest in male smokers. However,
dietary vitamin C and other vitamins were
unrelated to the risk of liver cancer.
The researchers noted this result may
be due to reverse causation as people with
a history of cancer are more likely to take
vitamin supplements, but that further studies on the effect of vitamin supplements on
liver cancer are warranted. 22 September 2012 News
Vitamin B12 may boost Hep C treatment
response
Elvira Manzano
S
upplementation with vitamin B12 may
help increase the effectiveness of antiviral treatment administered to patients with
chronic hepatitis C virus (HCV) infection.
This was the key finding of an open-label
pilot study conducted in Italy.
Patients treated with vitamin B12 plus standard therapy (pegylated interferon-alfa and
ribavirin) had better sustained viral response
(SVR) rates – undetectable serum HCV RNA
6 months after treatment – than those treated
with standard therapy alone (72 percent vs.
38 percent, P=0.001). SVR rates were also significantly higher in genotype 1 carriers and
patients with high viral loads at baseline (41
percent and 38 percent, respectively). [Gut
2012; Epub ahead of print]
“Overall, adding vitamin B12 to standard
therapy strengthened the rate of SVR by 34
percent,” said study author Professor Gerardo Nardone, from the Department of Clinical
and Experimental Medicine, Gastroenterology Unit, University of Naples, Naples, Italy.
SVR is an indicator of long-term remission and currently the best marker of successful therapy for HCV infection. While there is
some support for detection of viral response
3 months after treatment, the 6-month posttherapy identification time-point remains the
gold standard for treatment success.
Vitamin B12 has been shown to inhibit
HCV replication in vitro. In the study by Nardone and colleagues, adding vitamin B12 to
standard treatment further increased viral
response. A total of 94 patients with chronic,
untreated HCV infection were randomized
to standard therapy with or without vitamin
B12 5,000µg monthly for 6 to 12 months.
After one month, response did not differ
between the two groups. However, patients
on vitamin B12 had significantly greater responses at all other time points, particularly 6
months after completion of treatment.
Six patients receiving standard care and
five receiving vitamin B12 plus standard
therapy discontinued treatment because of
adverse events. Multivariate analysis demonstrated that only vitamin B12 supplementation (overall response [OR]=6.9; P=0.002) and
genotype 2 or 3 (OR=9; P=0.001) were independently associated with SVR.
HCV genotypes 2 and 3 are easier to treat
than genotype 1. Patients with genotypes 2
and 3 may have to be treated for 6 months,
with higher response rates of 70 to 80 percent
in most studies, whereas genotype 1 carriers
have to be treated for up to 12 months, with
only 40 to 50 percent response rates.
The addition of vitamin B12 to current standard therapy offers a safe and inexpensive
option for difficult-to-treat patients and those
with high baseline viral load, Nardone said.
“This strategy would be useful in countries
where, owing to limited economic means, the
new generation antiviral therapies cannot be
given in routine practice.”
Commenting on the study, Associate Prof.
Tan Chee Kiat, senior consultant, Department
of Gastroenterology and Hepatology, Singapore General Hospital said the study, being
small and preliminary, has to be validated by
other studies.
“We will need the result to be validated by
other independent studies as the study is just
a pilot study and was open-label rather than
double-blind.”
23 September 2012 News
No effect of maternal antibodies on Hep A
vaccination in infants
Alexandra Kirsten
V
accination against the hepatitis A virus
(HAV) in children 2 years of age and
younger remains effective for at least 10 years
and is not affected by maternal anti-HAV antibody transfer. These were the results of a
recently published study by epidemiologists
from the Centers for Disease Control and Prevention in Atlanta, Georgia, US.
“Persistence of seropositivity conferred by
hepatitis A vaccine administered to children
under 2 years of age is unknown and passively transferred maternal antibodies to hepatitis A virus may lower the infant’s immune
response to the vaccine”, the researchers explained. The trial is the first to examine the effectiveness of a two-dose inactivated hepatitis
A vaccine in children younger than 2 years of
age over a 10-year period.
Study author Dr. Umid Sharapov and colleagues enrolled 197 infants and young children who were healthy at 6 months of age.
The children were divided into three groups
to receive a two-dose hepatitis A vaccine:
group 1-infants 6 to 12 months; group 2-toddlers between 12 and 18 months; and group
3-toddlers 15 to 21 months of age. Each group
was randomized by maternal anti-HAV status. HAV antibody levels were measured at 1
and 6 months, and additional follow-up took
place at 3, 5, 7 and 10 years after the second
dose of the vaccine.
At 1 month after the second dose of the vaccine, children in all groups showed signs of
seroprotection (>10 mIU/mL) from the Hepatitis A virus.
After 10 years of follow-up, most children
retained anti-HAV protection. In the first
A study in the US showed persistence of seropositivity for at least 10 years
after hep A vaccination of infants less than 2.
group, 7 percent and 11 percent of children
born to anti-HAV–negative and anti-HAV–
positive mothers, did not retain HAV protection from vaccination, respectively. Overall, 4
percent of group 3 children born to anti-HAV
negative mothers lost HAV protection. [Hepatology 2012; DOI: 10.1002/hep.25687]
“Our study demonstrates that seropositivity to hepatitis A persists for at least ten years
after primary vaccination with two-dose inactivated HAV vaccine when administered
to children at ages 12 months and older, regardless of their mothers’ anti-HAV status,”
concluded Sharapov.
Additionally he pointed out that a future
booster dose may be necessary to maintain
protection against HAV. The study group
will continue to follow-up participants into
their teens to monitor benefits of the initial
immunization.
24 September 2012 News
Testosterone therapy linked to weight loss
in men
Rajesh Kumar
L
ong-term testosterone therapy may
reduce weight, waist circumference
and body mass index (BMI) in hypogonadal men who are overweight or obese,
according to research presented at the Endo
2012 conference held recently in Houston,
Texas, US.
The open-label, prospective registry
study included 255 men (mean age 60.6
years) with testosterone levels between 1.7
and 3.5 ng/mL who were given parenteral
testosterone undecanoate 1,000 mg every
12 weeks for up to 5 years.
Their mean body weight significantly decreased from 106.22 kg at baseline to 90.07
kg after 5 years (P≤0.0001). Mean waist circumference also significantly declined from
107.24 cm at baseline to 98.46 cm after 5
years (P≤0.0001), while mean BMI declined
from 33.93 to 29.17 (P≤0.0001).
The benefit was progressive over the follow-up period, said the researchers. Mean
weight loss after 1 year was 4.12 percent,
after 2 years 7.47 percent, after 3 years 9.01
percent, after 4 years, 11.26 percent and after 5 years 13.21 percent. At baseline, 96
percent of men had a waist circumference
of ≥94 cm. This proportion decreased to 71
percent after 5 years.
“It is clear that long-term testosterone
treatment in hypogonadal men makes them
lose weight,” said study author Professor
Farid Saad of the Gulf Medical University,
Ajman, UAE and head of Global Medical
Affairs (Andrology) at Bayer Pharma.
Adverse events and adverse drug reactions (ADRs) occurred in 12 percent and 6
percent of patients, respectively. The most
common ADRs were increase in hematocrit,
increase in prostate specific antigen (PSA),
and injection site pain (all <1 percent). No
case of prostate cancer was observed.
Another study has confirmed similar
benefits of testosterone therapy. The IPASS*
study spanning 23 countries in Europe,
Asia, Latin America, and Australia, analyzed 1,438 (mean age 49.2 years) hypogonadal men who were overweight and were
given a total of 6,333 injections of long-acting-intramuscular testosterone undecanoate over 9 to 12 months. [J Sex Med 2012;
DOI: 10.1111/j.17436109.2012.02853.x]
While their scores of mental and psychosexual functions (libido, vigor, overall
mood, and ability to concentrate) improved
markedly, mean waist circumference decreased from 100 cm to 96 cm. Blood pressure and lipid parameters were also favorably altered in a significant manner, said
the researchers.
After four injection intervals, the percentage of patients with ‘low’ or ‘very low’
levels of sexual desire/libido decreased
from 64 percent at baseline to 10 percent;
moderate, severe, or extremely severe erectile dysfunction decreased from 67 percent
to 19 percent. At the last observation, 89
percent of patients were ‘satisfied’ or ‘very
satisfied’ with therapy.
“Keeping testosterone levels normal has
clear health benefits for the male, other than
sexual,” concluded Professor Peter Lim,
urologist at the Gleneagles Medical Centre
and head of the Society for Men’s Health
Singapore.
*IPASS: International, multicenter, Post-Authorization Surveillance
Study on long-acting-intramuscular testosterone undecanoate
25 September 2012 News
Shift work increases CV risk
Elvira Manzano
P
eople working overnight shifts or any
odd-shifts outside of regular 9am to
5pm working hours are at increased
risk of heart attack and stroke, a meta-analysis has found.
The analysis showed that shift workers
were 23 percent more likely to experience a
heart attack, 24 percent more likely to have
coronary events, and 5 percent more likely to
have a stroke compared with people working day shifts. The risks remained consistent
despite adjustment for factors such as study
quality, socioeconomic status and unhealthy
behaviors, including smoking. Interestingly, shift work was not associated with increased rates of death from any cause. [BMJ
2012;345:e4800]
“Our findings suggest that people who do
shift work should be vigilant about risk factor modification,” said lead study author Dr.
Daniel G. Hackam, assistant professor at the
Department of Epidemiology and Biostatistics at University of Western Ontario in London, Ontario, Canada. “Shift workers should
be educated about cardiovascular symptoms
to forestall the earliest clinical manifestation
of the disease.”
Hackam and colleagues reviewed 34 previous studies linking shift work to vascular
events or mortality. Shift work was defined as
night shifts, rotating or split shifts, on-call or
casual shifts or any non-daytime schedules.
The analysis involved over 2 million workers. Overall, there were 17,359 incidents of
coronary events, 6,598 heart attacks and 1,854
strokes. One in 14 heart attacks and 1 in 40
strokes were directly related to shift work.
The increased risk for heart attack and
stroke may be related to disruption in the
body’s circadian rhythm and impairment in
sleep quality, said the authors. “Even a single
overnight shift is enough to increase blood
pressure and impair variability of heart rate.”
Those who worked night shifts had the
highest risk for coronary events at 41 percent.
Shift workers were also more likely to smoke,
eat unhealthy foods and have no time to exercise. “They should be aware of the health risks
that go with their work patterns. They should
go to their doctors and have their blood pressure, cholesterol, waist circumference and
blood glucose routinely checked,” Hackam
said. He also recommends that employers institute health screening programs in the work
place, give employees time to sleep and rationalize shift scheduling systems.
“Modification and rationalization of shift
schedules may yield dividends in terms of
healthier and more productive workers.”
The study is the largest synthesis of shift
work and vascular risk reported thus far. Despite several limitations of the study, including heterogeneity in the outcome of coronary
events, “we have identified an epidemiological association between shift work and vascular events… which may have implications
for public policy and occupational medicine,”
the authors concluded.
26 September 2012 News
Weight training lowers type 2 diabetes
risk in men
Alexandra Kirsten
M
en who do regular weight training
may be able to reduce their risk of
type 2 diabetes (T2D), according
to the findings of a new study by researchers
based in the US and Denmark.
“Until now, previous studies have reported
that aerobic exercise is of major importance
for type 2 diabetes prevention,” said lead author Mr. Anders Grøntved, visiting researcher in the department of nutrition at Harvard
School of Public Health, Boston, Massachusetts, US. This is the first trial to examine the
role of weight training in the prevention of
T2D.
In their study, data from a prospective cohort study involving 32,002 men enrolled into
the Health Professionals Follow-up Study
conducted in the US from 1990 to 2008 were
analyzed. Participants recorded how much
time they spent each week on weight training and aerobic exercise (including jogging,
running, cycling and swimming) on questionnaires they filled out every 2 years. During 18 years of follow-up, 2,278 new cases of
T2D were documented. [Arch Intern Med 2012;
DOI:10.1001/archinternmed.2012.3138]
What the researchers found was a doseresponse relationship between an increasing
amount of time spent on weight training and
lower risk of T2D (P=0.001 for the trend).
To examine the association of weight training with the risk of T2D and to assess the influence of combining weight training with
Men who engaged in both aerobic and weight training for more than 150
minutes per week had the greatest reduction in T2D risk.
aerobic exercise, the men were categorized
according to how much weight training they
did per week: up to 59 minutes, between 60
and 149 minutes, and 150 minutes or more.
Depending on the training amount, they
reduced their T2D risk by 12 percent, 25 percent and 34 percent, respectively, compared
with no weight training. Men who engaged
in aerobic exercise and weight training for at
least 150 minutes per week had the greatest
risk reduction of 59 percent.
“This study provides clear evidence that
weight training has beneficial effects on diabetes risk over and above aerobic exercise,
which are likely to be mediated through increased muscle mass and improved insulin
sensitivity,” the researchers stated.
The authors added however that further
research is needed to confirm the results of
the study as well as to analyze whether the
findings can be generalized to women. Furthermore, the effect of duration, type and intensity of weight training on T2D risk should
be examined in greater detail.
27 September 2012 Conference Coverage
ASEAN Federation of Cardiology Congress, 13-15 July, Singapore
Recreational runners may strain heart too
Rajesh Kumar
H
igh levels of endurance exercise in
recreational runners may result in
transient but significant ventricular stunning, release of cardiac biomarkers
and acute kidney injury, according to a Singapore study.
Previous studies involving elite long distance runners have linked high-level endurance exercise with elevated cardiac biomarkers, right ventricular dysfunction as well as a
decrease in glomerular filtration rate. However, it has been suggested that such findings
may not apply to the majority of recreational
runners participating in moderate endurance
events.
In the present pilot study, the researchers
recruited 10 healthy subjects (mean age 36.5
years) to complete a 21km treadmill run.
Before and after the run, echocardiograms
and peripheral blood samples were taken
from the participants to confirm the hypothesis that changes in cardiac biomarkers may
reflect RV dysfunction after moderate endurance activity.
Highly sensitive troponin T (hsTnT), Nterminal pro brain natriuretic peptide (NTProBNP) and the novel renal biomarker
neutrophil gelatinase-associated lipocalin
(NGAL) were analysed prior to, within 1
hour of run completion, and 24 hours after
the run.
The hsTnT in five out of 10 subjects ranged
from 15 to 33 pg/mL within 1 hour post-exercise, which was above the 99th percentile (14
pg/mL) of the upper reference limit. These
A pilot study conducted in Singapore showed that recreational runners
can strain their hearts or damage their kidneys while performing heavy
amounts of endurance exercise.
fell below the cut-off in all but one subject
at 24 hours. NTProBNP levels were below
the established cut-off value for detection of
heart failure. There was no direct correlation
between changes in strain and hsTnT or NTProBNP.
While the findings support the concept of
cardio-renal coupling in endurance exercise,
the researchers acknowledge that the number of subjects in this study is small, and validation with a larger study is required.
“Whether these individuals are more
prone to chronic myocardial and/or kidney
injury is unknown. The findings warrant further investigation in larger populations of recreational runners and the general population
should not be unnecessarily alarmed at this
point,” said study researcher Dr. Yeo Tee Joo
of the cardiac department at National University Heart Centre, Singapore.
Yeo said that physicians should reassure
any of their patients who are recreational
runners that the benefits of regular exercise
far outweigh any potential risks.
28 September 2012 Conference Coverage
In a healthy person with no history of cardiovascular disease, he said some key points
they need to be reminded of, are:
• Always keep well hydrated.
• Slow down or stop if there are any unusual
symptoms including: chest pain/uneasiness,
giddiness and/or palpitations.
• Avoid strenuous activity when unwell (eg,
during fever or flu).
• Engage in exercise in a progressive manner.
“[The latter] is in particular for ‘weekend
warriors’ who lead a sedentary lifestyle and
feel compelled to over-strain once or twice
a week rather than exercise regularly at a
manageable intensity, more frequently,”
said Yeo.
Measure BP on both arms
Rajesh Kumar
P
hysicians are being reminded to take routine
blood pressure (BP) measurements from
both arms of their patients following research
that showed a difference of just 10 mmHg in inter-arm systolic BP is closely linked to peripheral
artery disease, especially in non-obese and nonhypertensive patients.
“We as physicians neglect to evaluate BP from
both arms. It’s a simple procedure which can
reveal so much information on other vascular
diseases and correlation with surrogate marker
such as ankle brachial index (ABI),” said author
Dr. Erwin Mulia of the department of cardiology and vascular medicine, faculty of medicine
at Universitas Indonesia, Jakarta, Indonesia.
The cross-sectional study evaluated 80 patients who followed elective coronary angiography from March to May 2011. The mean difference in inter-arm systolic BP was 34.6 mmHg
and mean ABI was 1.3 (0.7-1.8). A difference of
10 mmHg in systolic BP was found in 85 percent
of subjects.
The correlation between inter-arm BP difference and ABI in coronary artery disease patients was 0.337 (P=0.001). In non-overweight/
obese and non-hypertensive patients, the correlation was 0.450 (P=0.001) and 0.501 (P=0.043),
respectively.
“Some also say that [inter-arm difference
in systolic BP] has correlation with severity
of coronary stenosis, though my previous research didn’t show its correlation with Gensini score,” said Mulia.
In primary care services or in rural areas
where availability of diagnostic tools is limited, Mulia said such a simple procedure could
prevent delays in the diagnosis of vascular
diseases.
He pointed out that the textbook of cardiovascular medicine Braunwald’s Heart Disease
recommends blood pressure measurement on
both arms, while earlier research had linked
a difference of just 15 mm Hg or more in inter-arm SBP to the risk of vascular disease or
death.
An earlier meta-analysis concluded that
“a difference in systolic BP of 10 mm Hg or
more…between arms might help to identify
patients who need further vascular assessment [while] a difference of 15 mmHg or more
could be a useful indicator of risk of vascular
disease and death.” [Lancet 2012; 379:905-914]
Therefore, a patient with an inter-arm
sytstolic BP difference of 10 mmHg would
benefit from further investigation for vascular
disease and ought to be targeted with aggressive management of their cardiovascular risk
factors, said Mulia.
Please visit www.isrd.org for further details
Chinese Alliance Against Lung Cancer (CAALC)
Nearly 100 Academic Speakers,
15 Sessions and 6 Special Topics
English Sessions Highlights：
ISRD 2012
The very first joint scientific sessions
with the American Thoracic Society
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
ALI Forum - Mechanism and New Drug Target
Translational Respiratory Medicine
30 September 2012 Atrial Fibrillation
Anti-arrhythmics offer superior survival
rates for older AF patients
Elvira Manzano
A
nti-arrhythmic agents may improve
survival in older patients with atrial
fibrillation (AF) compared with rate
control drugs, a large population-based study
has found.
In the study, which involved 26,130 patients aged ≥66 years who had a primary or
secondary hospitalization for AF, mortality
rates were steadily lower in those receiving
rhythm control therapy (24 percent) after 5
years (ratio [HR] 0.89; 95% CI 0.81 to 0.96) vs.
rate control drugs. At 8 years, the HR for patients on rhythm control drugs further went
down to 0.77 (95% CI 0.62 to 0.95). [Arch Intern
Med 2012;172:997-1004]
“With increasing follow-up time, mortality among patients treated with rhythm controlled drugs gradually decreased relative to
those treated with rate control drugs, reaching a 23 percent reduction after 8 years,” said
study author Dr. Louise Pilote, from McGill
University and the Royal Victoria Hospital
in Montreal, Quebec, Canada. “Rhythm control therapy seems to be superior in the longterm.”
Patients were followed for a mean of 3.1
years and for a maximum of 9 years. While
there was a small increase in mortality associated with rhythm control therapy in the first
6 months of treatment (HR 1.07), a survival
benefit was seen in the same group of patients
over time.
“The risk reduction associated with rhythm
control was more pronounced in patients who
maintained initial treatment over longer periods of time, suggesting that the use of rhythm
control therapy may be beneficial for AF patients in whom antiarrhythmic drugs are ef-
fective and well-tolerated,” Pilote said.
“Before we decide on giving rate control
therapy to a patient, we should see if [the patient] can be on the current rhythm control
therapies and if he can tolerate it. [We should]
make an added effort in those who are good
candidates for rhythm control.”
However, experts cautioned that given the
limitations of such population-based studies,
the findings should not change the current
approach to managing AF.
In an accompanying editorial, Dr. Thomas A. Dewland and Dr. Gregory M. Marcus,
from the University of California, San Francisco, US, said the choice of a rhythm control
vs. a rate control strategy for AF is particularly prone to confounding by indication, as
rhythm control is preferentially offered to
younger patients with fewer medical co-morbidities.
“Although the findings are provocative,
they are insufficient to recommend a universal rhythm control strategy for all patients
with AF,” they said.
However, they also noted that “no clinical
trial has definitively shown that maintenance
of sinus rhythm is inferior to rate control, and
expert consensus recommends a rhythm control strategy for individuals with arrhythmiaattributable symptoms.”
Shorter duration studies previously conducted such as the RACE (Rate Control Versus Electrical Cardioversion) and the AFFIRM
(Atrial Fibrillation Follow-up Investigation of
Rhythm Management) trials provided evidence that the rate control strategy was preferred for older patients without AF-related
symptoms. Dewland and Marcus said the
current study challenges the wisdom of this
approach. 31 September 2012 Atrial Fibrillation
Targeted cardiac ablation highly effective in
treating AF
Radha Chitale
T
argeted cardiac ablation was twice as successful at treating atrial fibrillation (AF)
as standard catheter ablation, according to the
results of the CONFIRM* trial.
The trial is the first to demonstrate that AF
is sustained by small areas of abnormal electrical activity – electrical rotors and focal impulses – that can be targeted for ablation to
achieve long-lasting AF improvement.
“Human AF rotors and focal impulses
were fewer in number, longer lived, and more
conserved in this study than suggested,” said
researchers from the University of California
at Los Angeles, University of California at San
Diego and Indiana University in the US.
The prevalent hypothesis is that AF persists due to “meandering electrical waves,”
which cardiologists treat by catheter ablation
around the pulmonary veins. However, AF
can return in a third or more treated patients,
even after multiple procedures.
“That alters our conceptual framework for
human AF, and enabled FIRM [focal impulse
and rotor modulation] ablation to be practical
and effective.”
The trial included 107 patients with AF who
received standard catheter ablation (N=71) or
FIRM-guided ablation followed by standard
ablation (N=36). [J Am Coll Cardiol 2012 Jul 13.
Epub ahead of print]
FIRM-guided patients were ablated based
on a personalized computational map that
showed precisely where to destroy the source
tissue. Each of the FIRM intervention patients
had about two sources of localized rotors or
focal impulses.
AF terminated or slowed in 86 percent of
FIRM-guided patients compared with 20 percent of FIRM-blinded patients (P<0.001).
FIRM ablation at the source stopped AF in
a median 2.5 minutes.
After 2 years (median 273 days) after one
procedure, 82.4 percent of FIRM-guided patients were AF-free compared to 44.9 percent
of FIRM-blinded patients (P<0.001) based on
implanted electrocardiograph monitoring.
Both FIRM-guided and standard catheter
ablation procedures took similar amounts
of time and adverse events were similar between groups.
The researchers reported that FIRM ablation at target points stopped AF in a median
time of 2.5 minutes, indicating the mechanistic role of rotors and focal sources in sustaining AF.
“Patients in whom FIRM ablation slowed
rather than terminated AF had sources that
could not be eliminated, for safety considerations or protocol imposed time limits… and
may have had residual sources in unmapped
regions,” the researchers said.
AF is the most common form of arrhythmia in the world and significantly increases
the risk of stroke as well as being associated
with cardiac issues. One-year success for ablation therapy without pharmacotherapy is
up to 60 percent with one procedure and up
to 70 percent for three or more.
“FIRM-guided therapy presents an opportunity to improve ablation outcomes while
avoiding more extensive strategies that may
result in serious sequelae,” the researchers
said. *CONFIRM: Conventional Ablation for Atrial Fibrillation With or
Without Focal Impulse and Rotor Modulation
32 September 2012 Atrial Fibrillation
Anticoagulant safety protocols working well
in Europe
Rajesh Kumar
P
hysicians should be reassured that safety indicators in place for anticoagulation
therapy in patients with atrial fibrillation
(AF) are working well, a large European
study suggests.
For patients on warfarin, the International Normalized Ratio (INR) should typically
be between 2.0 and 3.0 (in healthy people, it
is about 1.0). However there have been no
large scale studies to establish the danger
INR level in patients with AF.
The prospective European Action on Anticoagulation (EAA) study has now confirmed
INR >5.0 as the safety indicator, which is
consistent to that currently outlined by the
UK National Health Service improvement
document. [J Clin Pathol 2012;65:452-456]
The EAA study researchers monitored the
INR of 5,839 patients using their blood tests,
which were independently assessed. Any
clinical events, such as bleeding or thrombosis, were also monitored and matched to the
patient’s INR reading.
At least 13 percent who had at least one
INR >5.0 had a bleeding or thrombotic event.
The incidence was significantly higher than
for the 6.2 percent of patients who had a
clinical event but did not develop an INR
>5.0 (95% CI 1.41 to 2.04; P≤0.001).
Of patients starting oral anticoagulation
who had a bleeding episode (minor, major
or fatal), 9.5 percent had at least one INR
>5.0. This was significantly higher than the
4.6 percent in patients who did not develop
INR >5.0 (95% CI 1.32 to 2.04; P≤0.001). In
the first 2 months of treatment, bleeding occurred in 11.0 percent of patients who had
Safety indicators used in the UK for anticoagulant therapy with warfarin
have been correct, according to a study.
at least one INR >5.0. This was significantly
higher than the bleeding rate of 5.0 percent
in patients who did not develop an INR >5.0
(P≤0.001).
“This study demonstrates through significant patient results that the ‘safety indicators’ (as listed in the UK document) are
correct. This is a really important finding for
the hundreds of thousands of patients who
suffer from AF and for the medical staff who
treat them,” said EAA project leader Professor Leon Poller of the EAA central facility
at the faculty of life sciences, University of
Manchester, Manchester, UK
Warfarin is a commonly used anticoagulant all over the world and all countries have
their own safety protocols around its use.
But the findings on the UK protocols should
influence practice. Medical professionals everywhere, including Asia, should be aware of
them and apply them to make the treatment
of AF safer, said Poller.
HIMSS AsiaPac12 will link people and information in new ways that increase
patient care and safety, reduce healthcare costs and improve quality of care
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Opening address by
Guest-of-Honour
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Minister for Health,
Republic of Singapore
Opening Keynote by
Dr Blackford MIDDletON
Corporate Director,
Clinical Informatics Research
& Development, Partners
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closing Keynote by
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MD, FACP
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transforming healthcare through IT ™
34 September 2012 Calendar
September
Medical Fair Asia —
9th International Exhibition on Hospital,
Diagnostic, Pharmaceutical, Medical and
Rehabilitation Equipment Supplies
12/9/2012 to 14/9/2012
Location: Singapore
Info: Messe Düsseldorf Asia
Tel: (65) 6332 9626
Email: [email protected]
Website: www.medicalfair-asia.com
Hospital Management Asia 2012
13/9/2012 to 14/9/2012
Location: Hanoi, Vietnam
Info: Ms. Sheila Pepito
Tel: (632) 846 8339
Email: [email protected]
Website: hospitalmanagementasia.com
London College of Clinical Hypnosis (LCCH-Asia)
Certificate in Clinical Hypnosis
22/9/2012 to 23/9/2012
Location: University of Malaya, Kuala Lumpur, Malaysia
Info: LCCH Secretariat
Tel: (60) 3-7960 6439 / 7960 6449
Email: [email protected]
Website: www.hypnosis-malaysia.com
October
48th Annual Meeting of the European Association
for the Study of Diabetes
1/10/2012 to 5/10/2012
Location: Berlin, Germany
Info: EASD Secretariat
Email: [email protected]
Website: www.easd2012.com
15th Biennial Meeting of the European Society for
Immunodeficiencies (ESID 2012)
3/10/2012 to 6/10/2012
Location: Florence, Italy
Tel: (41) 22 908 0488
Fax: (41) 22 732 2850
Email: [email protected]
Website: www.kenes.com/esid
8th World Stroke Congress
10/10/2012 to 13/10/2012
Location: Brasilia, Brazil
Info: World Stroke Organization
Tel: (41) 22 908 0488
Email: [email protected]
Website: www1.kenes.com/wsc
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 and
8
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
Upcoming
012 Scientific Sessions of the American Heart
2
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
35 September 2012 Calendar
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 Association
6
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
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-diagnostic-imaging-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
36 September 2012 In Practice
Nerves can be a pressing problem
Adjunct Associate Professor
Hee Hwan Tak
M.B.B.S. (Singapore), F.R.C.S. (Glasgow)
A
Singaporean patient who had undergone a kidney transplant complained of unsteadiness in 2009 and
developed a tendency to fall.
The kidney specialist was concerned
enough to admit him for an MRI scan of
the spine to see if there was anything compressing the nerves of his spinal column,
which could cause such symptoms.
The scan revealed significant compression of the nerves in the neck. We all know
that the spinal column houses, protects and
nourishes our nerves. Control of all our
major body systems and organs is via our
nervous systems, which are akin to electrical wires branching out from a central grid.
The nerves in the neck belong to the upper motor nerves, which are more critical.
Injury or damage to these nerves will result
in greater damage and consequences than
lower motor nerves.
There was little chance that this patient’s
compressed nerves would get better by
themselves. I advised him to undergo spinal surgery to free the compressed nerves
and, at the same time, undergo a fusion of
the affected level of the spine.
Fusion as the first surgical option
Fusion involves linking the affected segments, or vertebrae, of the spine, by stimulating bone growth between the segments
and by attaching them with rods, screws
and plates. This stops further movement
between the segments and prevents them
from compressing the nerves.
The patient was not keen and said that
some form of transplant surgery might be
made available to him should his nerves
deteriorate further. I told him that nerve
and stem-cell transplant was still in the animal experiment stage and the only option
at the time was to release the nerves from
further compression before his condition
worsened.
By making more room for the nerves in
such cases, we hope that there will be more
blood supply bringing nutrients to the
nerves. The eventual result may be gradual
recovery of the function of the nerves.
When patients see a spine specialist regarding a spine problem, their main concerns usually are: whether their condition
is serious, whether they will be paralysed
and whether surgery is needed now or in
the future.
Ruling out the “red flags”
Our medical undergraduates have been
taught to rule out “red-flags” or serious spinal conditions, which may be life- or limbthreatening. Examples of such red-flag conditions include cancer, infections, unstable
fractures of the spine and compression of
the upper motor nerves.
These symptoms include weakness of the
arms or legs, fever, urinary incontinence
and loss of appetite or weight. Fortunately,
most complaints of neck and back pain are
due to muscular strain, poor posture and
wear and tear of the spine.
The vertebrae in the spine are cushioned
and separated by spongy intervertebral
discs, which are each made of a fibrous out-
37 September 2012 In Practice
er shell containing a gel-like material. When
the spine degenerates, the shells of the intervertebral discs can weaken and tear.
When this happens, the inner material
bulges out and compresses the spinal nerves.
Chemicals called prostaglandins are also released from the discs. These can result in intermittent attacks of pain, punctuated with
good symptom-free days.
When the nerves within the spinal column
are pinched, the pain may radiate or spread
to the extremities. The patient may complain
of numbness, tingling or weakness of the affected extremities.
The good thing is that most of these symptoms are resolved in most patients, usually
after two to three months of simple treatment
measures such as anti-inflammatory medication, back or neck exercises and lifestyle modification.
As they feel better, patients often ask if the
extent of their nerve compression has been reduced.
A patient gets better not because the degree of nerve compression has lessened but
because the chemical irritation of the nerves
has become less acute.
Anti-inflammatory medication inhibits
the effects of the chemicals that leak from the
damaged intervertebral discs.
However, about 10 to 15 per cent of patients do not feel significantly better after two
to three months. It usually means that their
nerves are unable to cope with the compression around them. This is when the possibility of surgery is discussed.
In general, the aim of all types of spinal
surgery is the same, regardless of the condition of the spine – decompression or freeing
of the nerves. Sometimes, the segment of the
spine may be potentially unstable or painful and may need to be stabilized to some
degree.
Treatment options abound
About 10 to 20 years ago, fusion of the segment was the only option. Nowadays, we
have the luxury of more treatment methods
at our disposal.
These include disc replacement, which
means replacing the damaged intervertebral
disc with an artificial one made of metal and
plastic; and dynamic stabilization, which involves implanting a metal device to reinforce
the damaged part of the spine.
Determining whether to stabilize or not
and the type of stabilization to be used is often a joint decision by the spine specialist and
the patient. We take into account the age, lifestyle, job demands and expectations of the patient in the decision-making process.
Progress has been made in the treatment
that he wanted, although it remains experimental. In October 2010, the world’s first clinical trial using human embryonic stem cells
to treat spinal cord injuries began. The aim is
to convert stem cells into cells similar to our
nerve cells.
Only time will tell if this method will
improve the outcome for patients. Scientific
research may not always produce the results
that we want. But there is no going back in
our quest for improvement in the treatment of
spinal conditions.
About the Author:
Adjunct Associate Professor Hee Hwan Tak, a specialist in spinal disorders and deformities, is the medical director of the Centre for Spine and Scoliosis
Surgery, Singapore Medical Group, and a lecturer at Singapore’s National University of Singapore Yong Loo Lin School of Medicine.
38 September 2012 Humor
“I’ve been Dr. Lamont’s patient for over 12 years
and I’ve never seen his face!”
“Lucy, I think we should
“Go ahead and take those­, I’m curious
get a divorce!”
to see what they will do to you!”
“What’s halitosis?”
“Do you know what gets me?
You put on a white coat and
right away everyone thinks
you are a doctor!”
“Do you have to go on and on
about how gross the whole
thing is?”
“It was just a joke!”
“Glad you could make it!”
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ISSN 1608-5086