Diabetes and its hidden toll

March 2012

www.medicaltribune.com

Diabetes and its hidden toll

INDONESIA FOCUS

FORUM Turf wars: Resolving interdisciplinary conflict in cardiovascular imaging

Jenjang subspesialisasi dalam RUU Dikdok

CONFERENCE H. pylori eradication alters appetite hormone levels

IN PRACTICE Advancements in the management of anal fistulas

NEWS Daily milk boosts brain power

AFTER HOURS Mayan ruins – remnants of a lost civilization

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March 2012

Diabetes and its hidden toll

A novel high-sensitivity blood marker test has revealed that chronic hyperglycemia may play a role in myocardial injury independent of its effects on the development of atherosclerosis.

Rajesh Kumar

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hronic hyperglycemia can damage the heart beyond its effects on the development of clinical atherosclerotic coronary disease. This was a key finding of a US study which examined the association between different levels of HbA1c, a marker for diabetes, and cardiac troponin T (cTnT), a blood marker for myocardial injury, in 9,661 patients without clinically evident coronary heart disease or heart failure. [J Am Coll Cardiol 2012;59:484-489] Using a novel high-sensitivity (hs) cTnT assay, the researchers found that higher baseline values of HbA1c were associated with increasingly higher levels of cTnT

(P<0.001 for the trend). After adjusting for traditional risk factors, patients with HbA1c levels in the ranges of 5.7 to 6.4 percent and ≥6.5 percent were 1.26 (95% CI: 1.01 to 1.56) and 1.97 (95% CI: 1.44 to 2.70) more likely to have elevated cTnT levels compared with those with HbA1c levels <5.7 percent, respectively. Compared with patients with HbA1c 5.7 percent, hs-cTnT values were 25 percent higher in persons with HbA1c 5.7 percent to 6.4 percent and 70 percent higher among participants with HbA1c levels ≥6.5 percent. In fully adjusted models, every 1-percentage point higher HbA1c value was associated with a 0.7 ng/L higher value of hs-cTnT (95% CI: 0.5 to 1.0; P<0.001).

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March 2012

“Our results suggest that chronically elevated glucose levels may contribute to heart damage,” said senior author Dr. Elizabeth Selvin, associate professor in the department of epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, US. The levels of cTnT detected were about one-tenth of those usually found in patients diagnosed with a heart attack. This suggests that hyperglycemia may be related to cardiac damage independent of atherosclerosis. The relationship was present at HbA1c levels even below the threshold used to diagnose diabetes. “Our study hints at other potential pathways by which diabetes and elevated glucose are associated with heart

disease,” said Selvin’s colleague Mr. Jonathan Rubin, an internal medicine fellow at the school and the lead study author. “Mainly, glucose might not only be related to increased atherosclerosis, but potentially elevated glucose levels may directly damage cardiac muscle.” When asked about the findings’ relevance for Asian populations, Selvin said there is no reason to believe the relationship would be any different in Asians. “The hs-cTnT test is not yet approved for clinical use, but may be in the future. These data help in our understanding of the clinical implications of this novel hs test for cardiac troponin and suggest that hyperglycemia may contribute directly to myocardial damage,” she said.

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March 2012

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Turf wars: Resolving interdisciplinary conflict in cardiovascular imaging Professor Douglas Vaughan Chair, Department of Medicine Feinberg School of Medicine Northwestern University Chicago, Illinois, US

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attles, discussions and conflicts have existed between departments for decades over management and development of cardiovascular imaging and institutions. Unfortunately, departmental organization into separate “silos” can devastate organizations, killing productivity and push people out the door. It also jeopardizes achieving corporate, medicine, and academic goals. Such separation is also not helpful in terms of building a program or serving patients. There are three main contributors to interdisciplinary conflict related to cardiovascular imaging: radiology, cardiology and administration. Radiologists may say things like “it’s my machine” or “I was here first.” Cardiologists may lay claim to patients and the administration of a hospital holds the funds. You can see how that conversation doesn’t get very far. The silo mentality that still exists in many academic institutions and practices is representative of early 20th century organization of labor that really isn’t fit for the way we operate and try to work today in the 21st century. Many fascinating techniques in imaging that are improving the field such as nuclear imaging, computed tomography angiography or cardiovascular magnetic

resonance imaging are often areas around which there is turf conflict because it is unclear who manages the imaging. Traditionally, most of the imaging field was populated by radiologists. CT and MRI scanning have become highly adopted in the cardiovascular world now, even though radiologists have been using those devices for decades. These departments can go head-tohead and toe-to-toe to determine who has control over such imaging modalities. In the case of the irresistible force versus the immovable object, you can imagine there’s going to be a collision and somebody is going to get hurt. The reality in 2012 is further complicated by the fact that our imaging modalities are constantly evolving. In the very near future, the field will be adding new imaging strategies and techniques to our repertoires that allow us to do molecular imaging, to image stem cells and other things we only dreamed of a decade ago. As we see with tissue echocardiography, CT and MRI scanning, these are areas where we can do battle or partner and grow these programs. As a high stakes game, perhaps game theory should be applied to the conversation when we think about how to create interdisciplinary practice with respect to cardiovascular imaging. Cardiovascular imaging accounts for nearly one-third of all the diagnostic images performed annually in the US. Another third of that one-third are probably

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inappropriate or questionable procedures. And while the number of imaging procedures continues to grow, revenues for studies continue to fall. If we think people used to battle when there was healthy reimbursement a decade ago, imagine what the battle will be like when reimbursement falls even further. Technology is complex and evolves rapidly. This is an important determinant in who is involved in performing imaging procedures at any institution. Too often we see individuals interested in gaining control and sacrificing success. However, even with greater numbers of imaging centers that improve access to cardiac CT scans, we cannot be sure this adds to overall patient health. But there are many stakeholders in the conversation about cardiac imaging beyond radiology and cardiology. Hospitals need capital to invest in imaging equipment and keep it updated over time. Individual departments are involved, especially in a world where we live in our own financial bubbles without interdisciplinary funds flow or multispecialty practice groups. Faculty are involved as they need to do work that will advance their own careers and practices. Doctors in training need to be proficient in imaging techniques to develop their careers in investigation and clinical practice. Patients contribute to the conversation. They want safe tests that can give them a prognosis about the state of their health, but they may not know which test is best or provides the most information. Payers are vitally interested, especially with reduced reimbursements, as they can be gatekeepers of cardiovascular imaging.

So how do we solve the problem? In general, such issues are best dealt with prospectively rather than retrospectively. Developing imaging practices and setting guideline benchmark with frank, fair understanding between parties ahead of time can save trouble later. Departments should commit to operating on principles rather than politics. It is difficult to put toothpaste back in a tube if there are preexisting arrangements between parties. For example, during my time at the Vanderbilt integrated cardiovascular institute in Nashville, Tennessee, US, everything lived in that institute — MRI, CT, echocardiology, nuclear and every other kind of imaging. All professional revenues flowed to the institute and people were paid based on activity and their productivity. The result was less fighting over revenues and less fighting over who had to pay for devices. That was a healthy environment for growing a program, allowing vigorous and robust activity rather than a divisive attitude. In general, institutions have to grow partnerships between interested parties. It makes a big difference at the end of the day whether all players have healthy, satisfactory relationships with positive partners when dealing with complex issues like cardiovascular imaging. Integrating clinical and financial goals can work and we’re seeing more of that today than we did a decade ago. Building walls is not a good strategy for growth and success. Walls divide the haves and have nots. Tearing down walls can make for thriving, robust environment for opportunity and success.

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March 2012

Indonesia Focus

Kebutuhan cairan pada DBD Hardini Arivianti

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epanjang tahun 2011 berdasarkan data Departemen Kesehatan RI, di Indonesia terdapat lebih dari 60.500 penderita demam berdarah dengue (DBD) dengan jumlah angka kematian sekitar 1 persen dari total penderita, atau mencapai lebih dari 500 orang. Salah satu penyakit tropik ini tak lepas dari aksi virus dengue di dalam darah. Penyakit yang ditularkan oleh gigitan nyamuk Aedes aegypti itu pertama kali menjadi wabah di Indonesia pada tahun 1968 dan ada empat varian virus dengue yakni virus DEN 1, 2, 3, dan 4. “Ke-4 varian tersebut sudah ada di Jakarta sejak tahun 1970,” tukas dr.Leonard Nainggolan, SpPD-KPTI, dalam acara ‘Pocari Sweat Conference’ 2012 di Jakarta beberapa waktu lalu. Sampai saat ini untuk penderita yang telah pernah terjangkit DBD tidak ada jaminannya memiliki antibodi untuk tidak tertular lagi, karena virus yang ada di Indonesia akan berbeda dengan jenis virus di negara lainnya. Kadar trombosit dari pemeriksaan darah dinilai sangat penting pada pasien DBD. Padahal, peningkatan hematokrit (Ht) jauh lebih penting dalam menentukan kegawatan kasus DBD ini. Nilai Ht menjadi penanda adanya kebocoran plasma yang bisa berakibat fatal. Biasanya kebocoran plasma terjadi pada hari ke-3 hingga ke-4 yang bisa menjadi masa kritis akibat kemungkinan adanya kebocoran plasma yang tidak ditangani dengan tepat bisa menyebabkan syok atau kematian. “Sebenarnya derajat beratnya DBD dilihat dari nilai Ht dan kadar

trombosit merupakan sebagai ‘petunjuk arah,” jelas pakar penanganan demam berdarah dan penyakit infeksi tropik FKUI ini lebih lanjut. Saat terjadi gigitan nyamuk, tubuh akan memberikan reaksi imun yang menyebabkan pelepasan zat-zat sitokin. Mekanisme inilah yang menyebabkan gejala demam, pegal, atau sakit kepala. Sitokin itu bermuara ke pembuluh darah kapiler yang sangat tipis sehingga terjadilah kebocoran plasma. Dikatakan suspek DBD bila ada demam mendadak disertai 2 atau lebih gejalagejala lain seperti sakita kepala, nyeri di belakang mata, nyeri otot, nyeri tulang, ruam kulit, tanda perdarahan, lekosit <5000/mm3, trombosit < 100.000/mm3, nilai Ht meningkat dan uji serologi DBD (+). Terapi DBD Penderita DBD akan mengalami kekurangan cairan tubuh yang signifikan, sehingga asupan cairan tubuh yang cukup sangat diperlukan terutama yang mengandung air, gula, dan elektrolit yang mirip dengan cairan pada tubuh. Seperti diketahui, cairan tubuh merupakan komponen terbesar tubuh, yang mencapai 55-65% berat badan. Cairan tubuh ini tidak hanya terdiri dari air biasa, tetapi juga ion positif dan negatif guna mempertahankan keseimbangan cairan tubuh. Apabila pasien masih dapat minum berikan minum sebanyak 1-2 liter/hari. Parasetamol dapat diberikan bila suhu >38,5°. Pada pasien yang tidak bisa minum (muntah terus menerus), berikan infus NaCl (0,45%):dekstrosa (5%)

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Indonesia Focus

dengan tetesan rumatan (sesuai berat badan). Lakukan pemeriksaan Ht, Hb, setiap 6 jam dan trombosit setiap 2 jam. Bila terjadi perbaikan klinis dan laboratorium, boleh dipulangkan. Namun bila kadar Ht cenderung meningkat dan trombosit menurun, infus dengan ringer laktat

dengan tetesan disesuaikan. Hingga saat ini belum ada antivirus untuk membunuh virus dengue. Mengenai vaksinasi, dr. Leonard menjelaskan saat ini vaksinasi DBD sedang di uji coba di Koja dan diharapkan akan selesai tahun 2014 nanti.

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March 2012

Indonesia Focus

Pertemuan Ilmiah Pulmonologi dan Ilmu Kedokteran Respirasi (PIPKRA) ke-10, Februari 9-10, 2012, Jakarta

Peningkatan jumlah pasien kanker paru Hardini Arivianti

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esuai data dari RS Persahabatan, jumlah pasien kanker paru yang berobat di RS ini mencapai 800-1000 (25% perempuan dan 75% laki-laki) pasien selama 2 tahun terakhir dan diperkirakan mencapai 1300 pada tahun 2013. Jumlah ini meningkat 20% setiap tahunnya. Kondisi pasien biasanya sudah mencapai stadium lanjut dan dari data di atas. Sembilan dari sepuluh pasien kanker paru diantaranya memiliki riwayat perokok. Hal ini menjadi salah satu bahasan pada Pertemuan Ilmiah Pulmonologi dan Ilmu Kedokteran Respirasi (PIPKRA) ke-10, awal Februari lalu. Peningkatan jumlah pasien dibarengi dengan peningkatan jumlah perokok di Indonesia (peringkat ke-3 di dunia) yang tidak dibarengi dengan peningkatan angka harapan hidup bagi mayoritas pasien kanker paru. Angka kematian akibat kanker paru di Indonesia adalah 20,5 per 100.000 orang, menduduki peringkat 58 dari 192 negara di dunia. “Kesadaran masyarakat akan kanker ini masih rendah, dan hanya 1,3 per seratus pasien yang berhasil mendeteksi dini kanker paru ini,” jelas dr. Achmad Hudoyo, SpP(K). Standar penatalaksanaan kanker tak bergejala ini masih sama dengan yang konvensional yaitu operasi, radioterapi dan kemoterapi. Bila hal ini sudah dilakukan dan hasilnya belum memuaskan, ditambahkan dengan krioterapi. Namun bila sudah masuk dalam stadium 3 dan 4, terapinya berupa paliatif atau ditambah

dengan paradigma pengobatan baru yaitu terapi target. Efek samping terapi target berbeda dengan kemoterapi. Terapi ini menimbulkan efek samping berupa ruam kulit, diare, kulit menjadi kering dan jerawat. Obat ini diberikan sekali sehari. “Bila ada jerawat, justru menandakan ada mutasi pada epidermal growth factor receptor (EGFR) dan merupakan pertanda respon yang bagus,” tukas dr. Hudoyo. Penelitian yang membandingkan kemoterapi dan terapi target (tanpa dikaitkan dengan mutasi) maka hasilnya sama. Namun pada pasien dengan mutasi, hasilnya jauh lebih bagus pada terapi target. Selain itu, penelitian juga menunjukkan pada stadium 3 atau 4, sulit untuk menggunakan 5 years survival dan menggunakan median survival. Kira-kira 50% pasien masih dapat bertahan hidup. Pada pasien dengan mutasi yang menjalani kemoterapi, median survival stadium 3 dan 4, diperkirakan 5,4 bulan. Bila dibandingkan dengan terapi target, median survival ini menjadi 10,8 bulan. Perbedaan survival ini tergantung pada genetik, psikologis, dll. Tipe utama kanker paru adalah small cell lung cancer carcinoma (SCLC) dan nonsmall cell lung cancer carcinoma (NSCLC). NSCLC mencakup 75-80% dari semua kasus kanker paru dan terdiri dari adenokarsinoma, sel skuamosa dan large cell. Adenokarsinoma merupakan jenis kanker paru yang tersering dan yang paling banyak memiliki mutasi EGFR. Membedakan jenis ini sangat penting karena terapi yang

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Indonesia Focus

Pertemuan Ilmiah Pulmonologi dan Ilmu Kedokteran Respirasi (PIPKRA) ke-10, Februari 9-10, 2012, Jakarta diberikan berbeda. Hampir 70% kasus NSCLC terdiagnosis pada stadium lanjut pada saat kanker sudah menyebar. Pada tahap ini, sekitar 15-35% pasien akan hidup hingga satu tahun, dan hanya 2% pasien yang dapat bertahan hidup hingga lima tahun. Rerata angka harapan hidup pasien NSCLC stadium lanjut hanya sekitar 4 bulan. “Kanker paru perlu perhatian khusus. Bila tidak dibedakan stadium dan jenisnya, overall survival (5 years survival) sesuai dengan angka dunia, mencapai 13%,” lanjut dr. Hudoyo. Sebenarnya kanker paru ini bisa dicegah yaitu dengan tidak merokok. Sekitar 20% kanker paru tidak dihubungkan dengan kebiasaan merokok, namun ada faktor-faktor lainnya. Prevalensi perokok di Indonesia sekitar 69%. Perokok pemula mengalami peningkatan terutama remaja perempuan. Perokok pasif memiliki risiko terkena kanker paru sebesar 2 kali lipat dengan

suami non perokok. Bila pasangannya merokok, perokok pasif memiliki peningkatan risiko terkena kanker paru 25%. Sedangkan orang yang terpapar asap rokok di lingkungan kerja, risiko meningkat 17%. Untuk bebas risiko kanker diperlukan 15 tahun setelah stop merokok dan pada yang sudah berhenti merokok ini, kemungkinan terkena kanker hampir sama dengan yang tidak merokok. Perkembangan PIPKRA Selaku Ketua PIPKRA 2012, Prof. dr. Wiwin H Wiyono, PhD, SpP(K), memaparkan perkembangan terbaru pada PIPKRA tahun ini adalah pada Penyakit Paru Obstruksi Kronik (PPOK) yang didiagnosis tidak hanya berdasarkan dari hasil spirometri, namun dilihat juga faktor esksaserbasi dan risiko tinggi eksaserbasi. Sedangkan pada kanker paru, bila ditemukan mutasi EGFR maka terapi target dapat digunakan sebagai lini pertama pengobatan kanker paru.

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March 2012

Indonesia Focus

Jenjang subspesialisasi dalam RUU Dikdok Hardini Arivianti Sekitar awal Februari 2012 lalu, dalam sebuah diskusi “RUU Pendidikan Kedokteran”, Pengurus Besar Persatuan Ahli Penyakit Dalam Indonesia (PB PAPDI) menyoroti upaya penghapusan pendidikan dokter jenjang subspesialis (konsultan) di Indonesia dalam Rancangan UndangUndang Pendidikan Kedokteran (RUU Dikdok) yang saat ini tengah dibahas di DPR. “Jika pendidikan jenjang subspesialis tidak disebutkan dalam RUU Dikdok, maka yang akan terjadi adalah pendidikan kedokteran hanya akan sebatas sampai spesialis saja (magister). Efek sampingnya, masyarakat tidak akan mendapatkan dokter subspesialis yang kompeten,” tukas Dr dr Aru Sudoyo, SpPD-KHOM. Oleh karena itu memang selayaknya pendidikan subspesialis termasuk yang disebut di dalam UndangUndang Pendidikan Kedokteran. “Jika kita tidak mempersiapkan dokter subspesialis dengan baik melalui proses yang terstruktur, maka kita akan kekurangan dokter konsultan yang baik sehingga rumah sakit akan diisi oleh para tenaga subspesialis atau konsultan kesehatan asing,” tukas Ketua PB PAPDI ini lebih lanjut. Selanjutnya, Ketua Bidang Advokasi PB PAPDI, Dr. dr. Ari Fahrial Syam, SpPD-KGEH menjelaskan, dalam pasal 26 RUU tersebut di-terangkan jika hanya ada dua jenjang pendidikan kedokteran. Yaitu program pendidikan akademik dan program pendidikan profesi. Untuk program pendidikan profesi, terdiri dari dokter umum, dokter gigi, dokter spesialis, dan dokter gigi spesialis. “RUU Dikdok ini sangat berkepentingan

terhadap kelanjutan pendidikan dokter di tanah air, dan dikhawatirkan dengan tidak dicantumkannya pendidikan dokter konsultan atau sub spesialis dalam RUU dapat membuat regenerasi dokter konsultan terputus dan jumlahnya akan semakin berkurang.” Lebih jauh ia menjelaskan, program pendidikan kedokteran subspesialis memiliki tujuan untuk menyediakan tenaga dokter dan konsultan yang kompeten. Sejalan dengan itu, program pendidikan ini juga untuk memenuhi kebutuhan dokter subspesialis di rumah sakit tersier atau rumah sakit rujukan. Menurut dr. Sukman Tulus Putra SpA(K), ada beberapa pihak yang keberatan dengan masuknya pendidikan sub spesialis ke dalam UU. Salah satunya, sebagian dokter spesialis sendiri merasa bahwa masalah ini belum mendesak. Namun jika pendidikan sub spesialis tidak ada dalam UU, maka sama level kompetensinya tidak akan diakui pemerintah maupun masyarakat. “Memang saat ini UU Dikdok masih berupa rancangan tetapi pembahasannya sudah tahap finalisasi dan diperkirakan akan disahkan dalam dua bulan mendatang,” jelas Ketua Program Studi Sub Spesialis Jantung Anak FKUI-RSCM ini

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Indonesia Focus

1st National Congress of ISHMO/PERHOMPEDIN 2012, Jakarta, 2-5 February 2012

Tantangan pengobatan kanker Hardini Arivianti

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ntuk mempermudah pasien kanker mendapatkan penanganan yang lebih mudah, Perhimpunan Dokter Hematologi Onkologi Medik Penyakit Dalam Indonesia (PERHOMPEDIN) mengupayakan peningkatan peran dokter penyakit dalam (internis) agar dapat bekerja sebagai mitra dokter KHOM dalam menangani pasien kanker. Hal ini menjadi salah topik utama pada Kongres Nasional PERHOMPEDIN tanggal 2-5 Februari lalu dengan topik ‘The Role of Internist in Cancer Management’. Penanganan pasien kanker memerlukan serangkaian terapi yang memerlukan pendekatan multidisiplin, yang berbeda dengan penanganan pasien dengan penyakit tidak menular lainnya. Penanganan pasien kanker secara profesional adalah dengan memberikan informasi secara komprehensif, skrining, diagnosis, pembedahan, radiasi, terapi sistemik, pengelolaan efek samping dan mengedepankan keselamatan dan keamanan pasien. Untuk terapi sistemik seperti di negara-negara maju lainnya, disiplin keahlian dengan kompetensi tertinggi adalah Onkologi Medik. Namun rasio jumlah dokter yang memiliki kompetensi tersebut dengan pasien kanker, tidak berbanding secara proporsional. “Itu sebabnya kami melakukan pelatihan internis di Jakarta dan sejumlah daerah lainnya secara bertahap,” tukas Prof. Dr. dr. A Harryanto Reksodiputro, SpPD-KHOM. Tujuan pelatihan ini untuk memberikan akses penanganan terapi sistemik kanker secara tepat dan profesional,

khususnya bagi pasien di daerah-daerah di luar jangkuan dokter keilmuan onkologi. Kini pengobatan kanker mengalami kemajuan pesat dan hal luar biasa ini bisa dicapai berkat kemajuan dalam penggunaan obat sitostatika. Namun obat tersebut memiliki keterbatasan sehingga menimbulkan tantangan tertentu pada dokter. “Untuk itu dokter tersebut harus memiliki kompetensi yang dibantu oleh kolega-kolega lainnya sehingga bisa mengombinasikan beberapa jenis obat atau bekerjasama dengan divisi lain serta para ahli bedah sehingga dapat memberikan pelayanan terpadu dan efisien,” jelas Ketua PERHOMPEDIN ini lebih lanjut. Mengingat jumlah KHOM yang masih

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kurang, langkah pertama yang perlu dibuat adalah membuat sistem rujukan khusus kanker antara KHOM di rumah sakit dengan para internis yang ada di sekitarnya. Program ini adalah ‘Internis Plus’, dengan cara KHOM di rumah sakit tertentu akan mencari internis di sekitarnya. “Dengan pelatihan ini internis memiliki dasar hukum saat memberikan pengobatan dan kini lebih terprogram dengan adanya kurikulum dan sertifikat untuk waktu tertentu saja agar pengobatan lebih efisien dan efektif.” Wewenang internis setelah mengikuti progam ini, disesuaikan dengan ujian dan sertifikasinya. Ada yang hanya boleh memberikan pengobatan dasar saja dan ada yang tidak boleh melebihi protokoler pengobatan kanker tertentu. Mengenai pelatihan internis ini, Dr. dr. Aru Sudoyo, SpPD-KHOM menjelaskan, kemitraan ini dapat membantu meringankan kendala pasien secara fisik dan ekonomi dalam upayanya mencapai tujuan terapi. “Salah satu kriteria program internis plus ini harus dalam jarak

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jangkauan propinsi agar dapat berkomunikasi dan disupervisi oleh propinsi,” tambah Ketua PAPDI ini. Para internis yang sudah ‘comitted’ tersebut akan mendapatkan pelatihan cara pemberian sitostatika dan menjadi pelaksana. Sistem yang berlaku, tetap berkonsultasi dengan KHOM. Program ini sudah dimulai di Jogjakarta dengan kursus kemoterapi (selama 20 minggu) dan jumlah peserta pelatihan ini mencapai 20 orang. Biaya terapi kanker secara menyeluruh tidak murah, yang mungkin masih ditambah pula dengan biaya perjalanan pasien dan keluarga untuk menemui dokter dan menjalani terapi. Padahal mayoritas masyarakat tidak memiliki perlindungan keuangan. Mengenai hal ini, Prof. dr. Hasbullah Thabrany, MPH menjelaskan, pemerintah sedang mempersiapkan sebuah sistem jaminan agar pasien kanker dapat berobat secara komprehensif. Namun masyarakat perlu tahu siapa yang perlu mereka temui untuk berobat agar dapat mencapai tujuan pengobatan

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March 2012

Indonesia Focus

7th International Symposium and 10th International Course on Metabolism and Clinical Nutrition, February 18-19 2012, Jakarta

Pentingnya peran nutrisi pada penyakit kronik Hardini Arivianti

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esuai dengan data Riset Kesehatan Dasar (RISKESDAS) tahun 2007, kematian karena penyakit menular terutama disebabkan oleh tuberkulosis, penyakit hati, pneumonia dan diare. Sedangkan kematian karena penyakit tidak menular disebabkan oleh stroke, hipertensi, diabetes, tumor dan iskemik. Hal ini diungkapkan oleh Dr. Minarto, MPS, selaku selaku Direktur Bina Gizi Masyarakat, Ditjen Bina Kesehatan Masyarakat, Departemen Kesehatan pada presentasinya yang berjudul ‘Early Life Nutrition: Fetal Programming for Chronic Diseases in Adult’. Topik tersebut diangkat dalam plenary lecture pada ‘7th International Symposium and 10th International Course on Metabolism and Clinical Nutrition’ (ISCMCN) tanggal 18-19 Februari 2012 lalu. Tahun ini, ISCMCN bertemakan ‘Nutrition in Chronic Disease: from Bench, Bedside, Epidemiology toward Healthier Life’ dan bekerjasama dengan dua universitas dari Perancis yaitu Universite Joseph Fourier dan Universite d’Auvergne. Mengenai kondisi nutrisi sesuai data RISKESDAS 2010, Dr. Minarto mengungkapkan status gizi di Indonesia, dengan prevalensinya, stunting (35,6%), kurus (13,3%) dan obesitas (14,2%). “Kita sudah berhasil menurunkan prevalensi gizi kurang namun kita dihadapkan dengan isu stunting, gizi kurang dan kegemukan pada saat yang bersamaan dan ini merupakan tantangan kita bersama, baik pemerintah dan institusi

pendidikan lainnya.” Intervensi utama pembangunan gizi memiliki 3 poin utama, yaitu 1. perubahan perilaku (ASI eksklusif, MP-ASI, cuci tangan dengan sabun), 2. pemberian zat gizi mikro dan kecacingan, dan 3. makanan pendamping dan makanan pemulihan gizi buruk. Untuk poin ke-2, meliputi: zat gizi mikro bagi anak, seperti vitamin A, zink dan bubuk tabur gizi dan pemberian obat cacing; suplementasi gizi bagi ibu hamil seperti zat besi dan kapsul yodium (jika diperlukan); dan fortifikasi bagi masyarakat seperti garam beryodium dan fortifikasi besi pada bahan pangan pokok. Nutrisi pada kanker Hal yang harus diperhatikan pada pasien kanker umumnya adalah penurunan berat badan dan malnutrisi akibat anoreksia dan rendahnya asupan makanan. Anoreksia, bila tidak diatasi dan ditangani dengan tepat akan menimbulkan kondisi yang lebih berat lagi, yaitu cancer cachexia, yang merupakan salah satu faktor penting penyebab kematian pada pasien kanker. Kebutuhan nutrisi pada pasien kanker harus disesuaikan dengan status nutrisi dan terapi pasien. Pada umumnya dianjurkan meningkatkan asupan energi hingga 35 kkal/kg, protein 1,5-2,5 g/kg dan lemak kurang dari 30% dari total energi. Dan pasien kanker memerlukan suplementasi vitamin dan mineral. Hal ini dikemukakan oleh dr. Sri Sukmaniah, MSc, pada presentasinya berjudul ‘Specific Nutrients for Cancer’.

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Nutrisi pada PPOK ‘Nutrition in COPD’ menjadi topik berikutnya yang dipresentasikan Prof. dr. Wiwien H Wiyono, SpP(K). Masalah nutrisi perlu diperhitungkan menjadi sebagai salah satu komponen penatalaksanaan Penyakit Paru Obstruksi Kronik (PPOK) karena insiden malnutrisi sejalan dengan beratnya penyakit. Semakin berat malnutrisi pada pasien maka semakin berat derajat penyakitnya. “Malnutrisi menjadi salah satu faktor prognostik pada PPOK sehingga PPOK yang disertai dengan malnutrisi dan low free fat mass akan dapat meningkatkan mortalitas.” Mekanisme malnutrisi pada PPOK, menurutProf.Wiwien,adanyainteraksiketidakseimbangan energi disertai dengan perubahan metabolisme, meningkatnya sitokin (akibat inflamasi sistemik), adanya hipoksia jaringan dan penggunaan kortikosteroid. Malnutrisi yang terjadi bisa dipahami karena pasien mengalami gangguan dalam proses asupan makanan akibat sesak yang dialami. Sebaliknya kebutuhan energi dalam keadaan istirahat ternyata lebih tinggi

dibandingkan dengan orang normal dengan usia dan jenis kelamin yang sama. Malnutrisi ini dapat menimbulkan perubahan pada komposisi tubuh, sel parenkim paru, kapasitas fisik dan meningkatkan angka kesakitan dan kematian. Bagaimana menyikapi malnutrisi ini? Dokter perlu mengukur indeks massa tubuh. Berkurangnya berat badan 10% dalam 6 bulan atau 5% dalam 1 bulan, hal ini menandakan terjadinya malnutrisi. Dengan menggunakan resting energy expenditure (REE) kebutuhan energi pasien lebih tinggi dan ditambahkan sekitar 10%. Dianjurkan dikalikan dengan 1,3 (REE x 1,3) yang digabung dengan pemberian tinggi protein dan karbohidrat. “Dengan ini, diharapkan dapat meningkatkan berat badan, kekuatan otot lengan atas dan meningkatkan aktivitas fisik yang nantinya dapat meningkatkan kualitas hidup pasien,” tukas Prof. Wiwien. Rekomendasi pemberian kalori terdiri dari karbohidrat (20%), lemak tak jenuh (20-40%), dan protein (40%) serta diberikan dalam porsi kecil namun sering. Selain itu, omega-3 dikatakan dapat menurunkan inflamasi dan produksi sitokin.

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Indonesia Focus

Kursus Penyegar dan Penambah Ilmu Kedokteran (KPPIK) Jakarta, 17-18 Maret 2012 Hotel Grand Sahid Jaya, Jakarta Sekr : Fakultas Kedokteran Universitas Indonesia Lt. 2, Jl. Salemba Raya No.6, Jakarta Tel : 021-3106737 Fax : 021-3106443 Email : kppik2012.cmefkui@ gmail.com Website : http://cmefkui.com, http://cme.fk.ui.ac.id Post Satelite Meeting International Symposium On Atherosclerosis 2012 ’Atherosclerosis & Metabolic Syndrome in Managemernt of Cardiocerebrovasculer Disease’ Bali, 30-31 Maret 2012 Sanur Paradise Plaza Hotel, Bali Sekr : Indonesia C ardiocerebrovascular Society Tel : 021-31934636 Fax : 021-3161467 Email : [email protected] website : www.postisa2012- bali.com The 21st Annual Scientific Meeting of the Indonesian Heart Association (21st ASMIHA) Jakarta, 6-8 April 2012 Hotel Ritz Carlton, Jakarta Sekr : PP PERKI, Wisma Harapan Kita Lt.2, Jl. Letjen S Parman Kav 87, Jakarta Tel : 021-5681149, 5684093 ext 1441 & 1440 Fax : 021-5684220 Email : [email protected]

Website : w ww.asmiha.org 7th SIOP Asia Congress Yogyakarta, 21-24 April 2012 Sekr : Subdivisi Hematologi dan Onkologi, Departemen Ilmu Kesehatan Anak, F akultas Kedokteran, Universitas Gadjah Mada / Dr. Sardjito General Hospital K esehatan St., Yogyakarta 55284, Indonesia Tel : 0274-553142 Fax : 0274-583745 E-mail : l ocalcommittee@ s iopasia2012.com, siopasia2012@yahoo. co.id website : w ww.siopasia2012.com Jakarta Antimicrobial Update 2012 (JADE 2012) Jakarta, 27-29 April 2012 Hotel Sahid, Jakarta Sekr : Divisi Tropical dan infectious Disease, FKUI , RSCM, Jl. Salemba Raya No.6, Jakarta Tel : 021-3920185, 39801573, 925491, 3929106 Fax : 021-3911873, 39921 06 Email : [email protected]. dide, [email protected], l oemni [email protected] 3rd National Symposium Cardiovascular Anesthesia Semarang, 9-12 Mei 2012 Hotel Gumaya Tower, Semarang Sekr : PT. Ginong Prati Dina, Jl. Kebalen V No.24 A Kebayoran Baru, JakSel

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Tel : 021-70602664,7246720, 7254424 Fax : 021-7396261 Email : gpd@gpdindonesia. com PIR PDPI Bandung, 11-13 Mei 2012 Hotel Aston Primera Pasteur, Bandung Sekr : PT TrendMICE Jl Veteran No.40 Bandung Tel : 022-4215427 Fax : 022-4215422 Email : sekretariat.pdpijabar@ yahoo.com , t rendmice@ cbn.net.id American Thoracic Society International Conference 2012 (ATS 2012) San Fransisco, USA, 18-23 May 2012 Tel : 212- 315 8652 Email : conference@thoracic. org Website : www.thoracic.org/go/ international-conference The 3rd Asia Oceanian Conference of Physical and Rehabilitation Medicine Bali, 21-24 Mei 2012 Hotel Discovery Kartika Plaza, Bali Sekr : Jl. Cakalang Raya No.28 A, Rawamangun, Jakarta T imur Tel / Fax : 021-47866390 Email : aocprm2012bali@ pharma-pro.com Website : www.aocprm2012.org Perhimpunan Respirologi Indonesia (Pertemuan Ilmiah Respirasi 3 Makassar)

Makassar, 25-27 Mei 2012 Hotel Grand Clarion Makassar Sekr : Division of Respirology & Clinical Respiratory D isease, Department o f internal medicine, Department of pulmonology & respirastory medicine , Faculty of medicine, U niversity of asanudin, nd 2 Fl, Infection Center Bldg, RS dr. Wahidin Sudirohusodo, Jl. Perintis Kemerdekaan km.11 , Tamalanrea, Makassar 902145 Tel / Fax : 0411-582002 Email : k onasperparimakasaar@ gmail.com KONAS PDPI XIII Surabaya, 4-7 Juli 2012 Shangri-la Surabaya Sekr : Bagian / SMF Ilmu Penyakit Paru, RSUD Dr. Soetomo Surabaya Jl. Mayjen Prof. Dr. Moestopo No. 6-8 Surabaya 60286 Telp/Fax : 031 - 5036047 Email : konaspdpixiiisurabaya@ yahoo.co.id Website : http://www. konaspdpi2012. com The 9th Congress Of Indonesian Society of Endocrinology Manado, 5-7 Juli 2012 Hotel Grand Kawanua Convention Centre, Manado Sekr : Bagian Ilmu Penyakit D alam

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Fakultas K edokteran Universitas Indonesia /RSUP Nasional Dr. Cipto Mangunkusumo Jalan Salemba 6, Jakarta 10430 Telp : 021-3100075, 3907703 Fax : 021-3928658, 3928659 Email : [email protected] Website : www.perkeni.net 7th Symposium on Nutri Indonesia in conjunction with 1st International Symposium on Nutrition (From Evidence to Practice) Jakarta, 5-8 Juli 2012 Hotel Acacia, Jakarta Sekr : Pacto Convex Ltd Lagoon Tower, Level B1, The Sultan Hotel Jl. Jend. Gatot Subroto, Jakarta 10270 Tel : 021-5705800 Fax : 021-5705798 Email : secretariat@ nutriindonesia.org Website : www.nutriindonesia.org PIN X PB PAPDI (Emergency in Internal Medicine) Balikpapan, 29 Juni-1 Juli 2012 Hotel Gran Senyiur, Balikpapan Sekr : Gedung ICB Bumiputera, Ground Floor 2B, J l. Probolinggo No.18 , Gondangdia, Menteng , Jakarta 10350 Tel : 021-2300818 Fax : 021-2300755/2300588 Email : pin9pbpapdi@gmail. com ; pin9pbpapdi@ yahoo.co.id ; pb_ [email protected]

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Non-drug approaches help alleviate cancer pain Elvira Manzano

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on-pharmacological, psychosocial interventions are a valid and effective option for the treatment of pain in patients with cancer, according to a recently published meta-analysis. “Pain is one of the most common, burdensome and feared symptoms experienced by patients with cancer,” said Dr. Paul B. Jacobsen, lead study author and associate director for Moffit’s Division of Population Science, Tampa, Florida, US. “The positive findings from this meta-analysis considerably advance support for the importance of psychosocial interventions in reducing pain in cancer patients.” Jacobsen and colleagues analyzed 37 randomized controlled studies of psychosocial interventions involving a total of 4,199 adult patients with cancer. The studies were published between 1966 and 2010. [J Clin Oncol 2012. Jan 23. Epub ahead of print] Across the studies, psychosocial interventions were found to provide weighted averaged effect sizes of 0.34 (95% CI 0.23-0.46; P<0.001) for pain severity and 0.40 (95% CI 0.21-0.60; P<0.001) for pain interference. In interpreting their results, the authors concluded that such interventions provided medium-sized effects in statistical terms, in terms of reducing pain severity and the degree to which pain related to cancer and its treatment interfered with patients’ lives. They also revealed that skill-based approaches, for example relaxation and hypnosis, tended to be more effective

Relaxation and hypnosis reduce pain in cancer patients.

at reducing pain severity compared with educational approaches, such as teaching patients how to use their medications. “Psychosocial interventions on the whole do work,” said Professor Cynthia Goh, senior consultant, department of palliative medicine, National Cancer Center Singapore. “The findings are relevant because the article looks at how good the evidence is for psychosocial interventions to alleviate cancer pain,” she said. “It is very important for patients to understand their pain and learn how to control it with the help of their doctors and therapists.” Sometimes, a simple explanation repeated as necessary is enough to help a patient learn how to take their medicines for pain and for treatment of side effects, or how to avoid certain situations which

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make the pain worse so they can feel they are in control, Goh explained. “But in some chronic pain situations, patients need more than explanations given at a medical consultation. Sometimes, they need to go through certain kinds of training to help them think about their pain in a different way, or change their behavior which makes the pain worse.” She said these kinds of training may be done in a group, or individually. “I have seen patients who have undergone cognitive behavior therapy and benefited from it.” Other interventions include more contact with a nurse or a therapist for followup and education about their pain. Goh said the study has been carefully

done and the information it provides is valuable and adds to existing knowledge. “I think it is important that any interventions be properly evaluated through randomized controlled trials, and meta-analyses of such trials. But it is particularly important when it comes to psychosocial interventions, as there is less standardization of such interventions, and many medical doctors, who are more used to prescribing drugs or doing operative procedures, are less convinced of their efficacy.” Up to one-third of cancer patients suffer from moderate to severe pain which interferes with sleep, daily life activities, enjoyment of life, work ability and social interactions.

Endometriosis increases risk of IBD Radha Chitale

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n analysis of over 37,000 Danish women showed that inflammatory bowel disease (IBD) is 50 percent more common among women with endometriosis. Prior to this study, the potential risk relationship between IBD, which

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are sometimes used as differential diagnoses which could lead to a missed diagnosis. “The two diseases (IBS, endometriosis) have been discussed as potentially differential diagnoses and have therefore been described in case reports of one disease mimicking the other,” the researchers said. “An initial diagnostic

Restricting analysis to women with surgically verified endometriosis resulted in even stronger risk associations

encompasses Crohn’s disease [CD] and ulcerative colitis, and the inflammatory gynecological disorder had not been explored. Researchers suggested that evident shared symptoms and localization may point to possible prognostic value. Importantly, endometriosis and IBD

mistake between endometriosis and IBD is possible… However, the differential diagnostic problem [between atypical CD and endometriosis] does not explain the observed increased risk of IBD decades after a diagnosis of endometriosis.” The analysis identified 320 women with IBD — 228 with ulcerative colitis

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and 92 with CD – from a national registry of 37,661 Danish women hospitalized between 1977 and 2007. [Gut 2011 Dec 19. Epub ahead of print] The women were monitored for a mean 13.1 years. Based on these data, the risk of developing IBD was 50 percent greater in women with endometriosis compared to the general population. The risk of developing ulcerative colitis or CD increased 50 percent and 60 percent, respectively. “Restricting analysis to women with surgically verified endometriosis resulted in even stronger risk associations,” the researchers said. They acknowledged that the cohort was biased against women who were diagnosed in an ambulatory care setting as opposed to a hospital or outpatient clinic. “However, surgically verified endometriosis represents the most valid diagnosis, and such cases were all included in this study,” the researchers said. Endometriosis involves endometrial cells implanting outside the uterus without being cleared by the immune system. The condition can affect up to 10 percent of reproductive-age women and often presents as raised cytokine levels, decreased cell death and B- and T-cell abnormalities similar to those observed in autoimmune diseases. Endometriosis is caused by retrograde menstruation, which is thought to be more common in women with impaired immune systems. In addition to underlying autoimmunological similarities between endometriosis and IBD, the researchers suggested

The risk of developing IBD was 50 percent greater in women with endometriosis vs. the general population.

that oral contraceptives used to treat endometriosis may increase the risk of developing IBD. One possibility would be to treat endometriosis as an autoimmune disease similar to the way in which IBD and rheumatoid arthritis are already treated, to avoid further disease progression with oral contraceptives in women with both diseases. “It is also of both immunological and clinical interest to know whether patients with IBD with endometriosis have a different prognosis from that of other IBD patients,” which warrants further study, the researchers concluded.

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Coffee may reduce fibrosis risk in patients with NASH Elvira Manzano

I

ncreased intake of coffee may hold the key to decreasing the risk of advanced fibrosis – scarring – in people with fatty liver disease, research suggests. In a study of 306 patients with nonalcoholic steatohepatitis (NASH), high consumption of coffee significantly decreased the formation of excess fibrous connective tissue in their liver. [Hepatology 2012; 55(2):429-36. doi: 10.1002/hep.24731] “Our study is the first to demonstrate a histopathologic correlation between fatty liver disease and estimated coffee intake,” said study author Dr. Stephen Harrison, lieutenant colonel in the US Army based at Brooke Army Medical Center in Fort Sam Houston, Texas, US. “Moderate coffee consumption may be a benign adjunct to the comprehensive management of patients with NASH.” Harrison and his team studied the coffee consumption of participants from a previous non-alcoholic fatty liver disease (NAFLD) study and NASH patients treated at the center’s clinic and categorized them into four groups – patients with no sign of fibrosis (controls), steatosis, NASH stage 0-1, and NASH stage 2-4. There was a significant difference in the caffeine consumption of patients with steatosis compared to patients with NASH stage 0-1 (P=0.005). Additionally, coffee consumption was significantly greater in patients with NASH stage 0-1 than with NASH stage 2-4 (58 percent versus 36 percent of caffeine intake from regular coffee, P=0.016).

“There was a stepwise decrease in coffee consumption as fibrosis increase,” Harrison explained. “This would suggest that other properties of coffee beyond caffeine may affect disease progression in NASH patients.” Caffeine intake has long been associated with a reduced risk of hepatocellular carcinoma, and reduced fibrosis and cirrhosis in patients with chronic liver diseases such as hepatitis C. [Hepatology 2009;50:1360; Hepatology 2010;51:201] It has also recently been suggested that coffee may protect against diabetes and endometrial cancer. “Knowing the beneficial effects of coffee intake on liver diseases, future prospective research should examine the amount of coffee intake on clinical outcomes,” Harrison concluded. Commenting on the study, Dr. Vincent Wong, professor, department of medicine and therapeutics director, Center for Liver Health, The Chinese University of Hong Kong said the current paper “adds to the existing literature showing that the same phenomenon is observed in NAFLD patients. “The study has a relatively large sample size. The existing literature is rather consistent on the association between coffee intake and liver injury. However, limited by the nature of observational studies, causal relationship is difficult to establish,” he said. “For example, instead of direct causal effect, coffee intake may be associated with less liver fibrosis through differences in smoking, alcohol use and physical activity.”

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Tai chi improves balance, reduces falls in Parkinson’s Radha Chitale

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ai chi exercises proved better at improving balance and reducing the risk of falls among adults with Parkinson’s disease compared with strength training or simple stretching, according to a study. “Physical activity has been shown to retard the deterioration of motor functions and to prolong functional independence,” the study authors said. Patients with the neurodegenerative disease are left with impaired balance, less stability, gait dysfunction, poorer quality of life due to reduced functional abilities and an increased risk of falls. These symptoms are largely unaffected by drug therapy and exercise is recommended. However, the researchers note that resistance training, which has been shown to address balance and strength deficits, requires monitoring and equipment. “We hypothesized that tai chi would be more effective in improving postural stability in limits-of-stability tasks than a resistance-based exercise regime or low impact stretching,” they said. A group of 195 patients with mild-tomoderate Parkinson’s disease were randomly assigned to receive twice-weekly 60-minute sessions of tai chi, resistance training or stretching (control) for 24 weeks. [N Engl J Med 2012;366:511-9] The tai chi protocol was designed to tax balance and gait by focusing on symmetric and diagonal movement, weight shifting, controlled center of gravity displacement, ankle sways, and anterior-posterior and

lateral stepping. Resistance training focused on the muscles important for posture, balance and gait, including squats, lunges and heel and toe raises, using weighted vests and ankle weights. Seated and standing stretches for the upper body and legs provided a low intensity control group. Tai chi patients performed better than the resistance and stretching groups in the primary outcome measures testing the limits-of-stability, which assesses how far patients can lean in a number of directions without falling, and at directional control, which measures movement accuracy. There were 381 falls in 76 patients overall but the incidence rate was 67 percent lower for the tai chi group compared with the stretching group (0.22 vs 0.33, P=0.005). Tai chi patients experienced marginally fewer falls than the resistance training group, whose incidence rate was 0.47, but this was not significant (P=0.05). Tai chi patients performed better in all secondary outcome measures compared with the stretching group, including gait, knee movement, functional reach, and time to stand from sitting. They performed better than the resistance group at stride length and functional reach. The effects were maintained 3 months after completing intervention. The trial did not measure the net gain of tai chi exercise but only as compared to low intensity, low impact stretching regimes. “Clinically, these changes indicate increased potential for effectively

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Dosage and duration 500 mg QD, 7-14 days

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a MDRSP (multidrug-resistant S. pneumoniae) isolates are strains resistant to two or more of the following antibiotics: penicillin (MIC >2 μg/mL), second-generation cephalosporins (eg, cefuroxime), macrolides, tetracyclines and trimethoprim/sulfamethoxazole. b Efficacy of this alternative regimen has been demonstrated for infections caused by S. pneumoniae (excluding MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae and Chlamydia pneumoniae. c Where Pseudomonas aeruginosa is a documented or presumptive pathogen, combination therapy with an antipseudomonal β-lactam is recommended.

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performing daily life functions, such as reaching forward to take objects from a cabinet, transitioning from a seated to a

standing position (and from standing to seated), and walking, while reducing the probability of falls,” the researchers said.

Daily milk boosts brain power Elvira Manzano

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requent intake of dairy food – an important step to building strong bones and preventing osteoporosis – also enhances cognitive functioning, recent research has shown. A cross-sectional meta-analysis of the dietary habits and mental functioning of 972 adults in the US has found that individuals who consumed dairy products once a day had significantly higher scores in memory and other cognitive tests compared with those who never or rarely consumed dairy food. Individuals with high milk consumption were also five times less likely to fail the tests compared with nonmilk drinkers. [International Dairy Journal 2011.DOI:10.1016/j.idairyj.2011.08.001] While little is known about the underlying mechanisms of dairy’s benefits on cognitive functioning, the authors said its unique nutrient content might play a role. “Dairy foods contain a number of important nutrients such as calcium, whey protein, vitamin D, magnesium and phosphorus,” said lead researcher Ms Georgina Crichton, from the Nutritional Physiology Research Centre, University of South Australia, Adelaide, Australia. Adult subjects aged 23 to 98 who were included in a community-based study of cardiovascular disease (CVD) risk factors and cognitive functioning were put through a series of brain and cognitive challenges to assess their visual-spatial, verbal and

working memory, scanning tracking and executive function. Those who scored the highest across all tests consumed the most milk and dairy products, the study found. Cognitive performance scores increased linearly across increasing categorical levels of dairy food intake for 7 out of 8 outcome measures. Milk drinkers also maintained healthier diets overall compared to non-drinkers. “Frequent dairy food intake was associated with better cognitive performance across a range of cognitive domains in this dementia-free, community dwelling population,” the authors said. The association between greater dairy food intake and better cognitive performance remained significant even after adjusting for several cardiovascular risk factors such as CVD prevalence, hypertension and wait circumference. While the authors said the study has a number of strengths, including large community sample, longitudinal studies are still needed to improve understanding of the association between dairy intake and cognitive function. “As brain disorders are most likely to impact upon more than a single cognitive ability or behavior, cognitive function needs to be assessed with a thorough neuro-psychological test measuring a range of cognitive abilities.” Frequent intake of dairy products such as milk, cheese and yoghurt has also been shown to help reduce weight and control blood pressure and diabetes, all of which are risk factors for CVD that increase the likelihood of cognitive dysfunction.

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Mortality predictors not ready for clinical use Radha Chitale

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espite the existence of a variety of prognostic indices to determine the risk of death among older adults, researchers who reviewed them cited insufficient evidence for use of these tools in widespread clinical practice. “By our measures, no study was completely free from potential sources of bias… even if [data] quality barriers are overcome, important limitations remain,” they said. The survey included 16 validated indices that predicted the absolute risk of allcause mortality in patients whose average age was 60 or older. The clinical settings included hospitals, nursing homes and communities but excluded indices estimated from cohorts in intensive care units, those that were disease specific and those that were in-hospital. [JAMA 2012;307:182-192] The greatest challenge for such indices, the researchers noted, was the inability to account for all factors that can affect survival. Key factors such as comorbid conditions, genetics and social supports are omitted. Less common comorbid conditions, such as Parkinson’s disease or dementia, tended not to be included in the indices. The indices did not account for genetics in life span and did not include relevant information on parent or sibling ages of death. Conversely, protective factors such as social supports and community involvement were also not considered. The researchers said the purpose of prognostic indices is to allow clinicians to shift to more sophisticated clinical decision making when treating older adults rather

than falling to arbitrary age-based cutoffs. However, only very high or very low mortality risk is likely to influence clinical decisions. “There may be a limited role for the highest-quality indices in the right settings,” the researchers said. “If patient characteristics align closely with those of the development or validation cohorts, clinicians may find prognostic information useful to help inform, though not replace, their clinical judgment. Prediction rules have been shown to outperform clinicians in terms of prognostication, whereas human prediction on its own is fraught with bias.” However, only three indices predicted greater than an 80 percent risk of mortality in the highest risk group. In an accompanying editorial, Dr. Thomas Gill, of the Yale School of Medicine, New Haven, Connecticut, US, was not optimistic about the potential for mortalitybased indices, because of the burden of meticulous data collection in order to achieve an accurate assessment. [JAMA 2012;307:199-200] “Given the central role of prognosis in clinical decision making, waiting for the ideal index to be developed, validated, and rigorously tested would not be prudent,” he said. The best predictors of mortality in older people are comorbidities and functional status. Instead of mortality, Gill suggested focusing on predicting life expectancy. “A preferred alternative is a single [developed and validated] prognostic index (or perhaps a small number of indices) based on estimated life expectancy, a metric that is familiar to both physicians and patients.”

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Physical activity lowers CV risk, better in moderation? Elvira Manzano

M

ild-to-moderate levels of exercise may be more beneficial than strenuous exercise when it comes to preventing heart attack in the long term, according to a recent study. Researchers analyzed data from INTERHEART – a long-running case-control study on heart attacks involving 24,000 patients from 52 countries in Asia, Europe, the Middle East, Africa, Australia and North and South America – and found that only mild-to-moderate physical activity at work was protective against MI. [Eur Heart J 2012; DOI:10.1093/eurheartj/ehr432] However, all levels of intensity of exercise during leisure time reduced the risk of heart attack. The odds of acute MI were lower with mild exercise (OR 0.87) and moderate to strenuous exercise (OR 0.76). The risk was even lower in patients who exercised 30 minutes or less a week. Surprisingly, no further risk reduction was seen in patients who exercised more than 60 minutes a week. “Given previous reports indicating a dose-response protective effect of exercise duration, this result was somewhat unexpected,” said lead author Dr. Claes Held from Uppsala Clinical Research Center, in Uppsala, Sweden. For occupational activity, both light and moderate activities were associated with decreased odds of acute MI compared with being sedentary (ORs 0.78 and 0.89, respectively). However, heavy physical labor (OR 1.02) did not lower the risk of

heart attack. Held and colleagues included in the study 10,043 individuals who had an MI and 14,217 controls. Compared to controls, individuals who had an acute MI were more likely to be sedentary during leisure time and at work (P<0.001 for both). Sedentary lifestyle was associated with greater risk of MI after adjusting for age, sex, country level income, smoking, alcohol, education, hypertension, diabetes and other factors. Interestingly, people who owned a car and a television were at greater risk of MI than those who had none of these machines (P=0.054). While Held acknowledged that a TV and a car increase physical inactivity, he said a prospective trial is needed to validate their study. The authors said their findings highlight the protective effect of physical activity across all country income levels in addition to the known benefits of modifying traditional risk factors. “It’s an interesting finding that goes with the theme… Daily moderate physical activity should be encouraged for both men and women of all ages as a protective act against cardiovascular disease,” the authors said. “Walking and bicycling is recommended as a method to promote physical activity.” They attributed the increase in sedentary lifestyle to increasing urbanization, mechanization at work, motorized transportation, easy access to activity-limiting devices (cars, escalators, elevators) and appliances (TV, computers), which all promote sedentary behavior.

33

March 2012

Conference Coverage

53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011, San Diego, California, US

Optimizing treatment for H. pylori infections Leonard Yap

S

electing better antibiotic therapy strategies for Helicobacter pylori infections and educating patients about compliance with their medications is the best way to avoid antibiotic resistance, says an expert. Using a combination of antibiotics with the right duration of therapy, in addition to improving patient compliance to these medications, will prevent H. pylori resistance to antibiotics, said Dr. Francis Megraud, professor of bacteriology, University Victor Segalen Bordeaux 2 and head of the National Reference Center for Helicobacters, France. Currently, clarithromycin is a commonly used antibiotic for H. pylori infections, but “the burden of clarithromycin resistance is steadily increasing.” Resistance of H. pylori to metronidazole and clarithromycin has been reported, with metronidazole resistance being very common. This has an important clinical impact on dual antibiotic therapies and standard triple therapies, which include the use of a

proton pump inhibitor (PPI) and two antibiotics. When PPI-based triple therapies with amoxicillin or clarithromycin and metronidazole are used, the resistance could be overcome in up to 75 percent of cases. [Gut 1998;43 (suppl 1):S61-5] “Several factors influence eradication failure. Obviously, if you don’t take the drug, [there is] lack of compliance [resulting in a decrease in the eradication rate], and, if you have [high] gastric acidity, especially if you are an extensive metabolizer of PPI, you decrease your eradication rate. It has also been shown that when you have a high bacterial load you are less likely to eliminate the bacteria – possibly, the presence of intracellular bacteria or the impact of altered immunity [can decrease the eradication rate of H pylori],” Megraud said. The Second Asia-Pacific Consensus Conference was convened to review current information on H. pylori management and a set of updated consensus statements was issued. (Box 1) [J Gastroenterol Hepatol 2009;24:1587-600].

Box 1: Consensus statements on H. pylori management. • In Asia, the currently recommended first-line therapy for H. pylori infection is PPI, amoxicillin and clarithromycin for 7 days. • There is an increasing rate of resistance to clarithromycin and metronidazole in parts of Asia. This has led to reduced efficacy of PPI-based triple therapy. • Fourteen-day triple therapy confers limited advantage over 7-day triple therapy in H. pylori eradication rates.

34

March 2012

Conference Coverage

53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011, San Diego, California, US • Bismuth-based quadruple therapy is an effective alternative to first-line therapy for H. pylori eradication. • There are currently insufficient data to recommend sequential therapy as an alternative first-line for H. pylori therapy in Asia. • Salvage therapy for H. pylori eradication includes: (i) a standard triple therapy that has not been previously used; (ii) bismuth-based quadruple therapy; (iii) levofloxacin-based triple therapy; and (iv) rifabutin-based triple therapy. • CYP2C19 polymorphisms may affect H. pylori eradication rates in PPI-based triple therapy. Choice of PPI or increasing the dose is a more practical approach than CYP2C19 genotyping in the clinical setting to overcome CYP2C19 polymorphisms in the context of salvage therapy. • Smoking adversely affects the outcome of H. pylori eradication therapy.

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35

March 2012

Conference Coverage

53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011, San Diego, California, US

Liver enzyme polymorphisms may affect drug response Leonard Yap

C

ytochrome P450 2C19 (CYP2C19) polymorphisms may play a significant role in the success or failure of treatments for Helicobacter pylori, say a panel of experts. CYP2C19 polymorphisms have been known to affect the metabolism of certain types of pharmaceuticals, said Associate Professor Varocha Mahachai, Division of Gastroenterology, Chulalongkorn University, Bangkok, Thailand. This is particularly true of proton pump inhibitors (PPI), which are commonly used to control gastric acidity in H. pylori infec-

“Three studies, one from Japan, one from Taiwan and one from Korea, show that the CYP2C19 [polymorphisms] were a factor [in H. pylori eradication].” PPIs such as omeprazole and lansoprazole are mainly metabolized by CYP2C19 in the liver. There are three types of CYP2C19 polymorphisms: extensive, intermediate and poor metabolizer. Extensive metabolizers are typically less responsive as they metabolize PPIs much faster than the intermediate and poor metabolizer. Therefore, eradication rates for H. pylori are typically lower for extensive metabolizers. [Clin Pharmacol Ther 2001;69(3):158-68]

‘‘

CYP2C19 polymorphisms may affect H. pylori eradication with standard triple therapy. The way to overcome this effect is to increase the dose of the PPI or change to a PPI that is less affected by CYP2C19 tions. Patients who have the ‘extensive metabolizer’ polymorphism tend to have poor control of gastric acid as they metabolize the drug too quickly before the PPI can do its job, she said. [Aliment Pharmacol Ther 1999;13 Suppl 3:27-36] Professor Fock Kwong-Ming, of the Faculty of Medicine, National University of Singapore and senior consultant gastroenterologist at Changi General Hospital said, “CYP2C19 polymorphisms may affect H. pylori eradication with standard triple therapy. The way to overcome this effect is to increase the dose of the PPI or change to a PPI that is less affected by CYP2C19.

The Second Asia-Pacific Consensus Guidelines for H. pylori infection includes this statement: “CYP2C19 polymorphisms may affect H. pylori eradication rates in PPI-based triple therapy. Choice of PPI or increasing the dose is a more practical approach than CYP2C19 genotyping in the clinical setting to overcome CYP2C19 polymorphisms in the context of salvage therapy*.” [J Gastroenterol Hepatol 2009;24:1587-600] *Salvage therapy: therapy after multiple (at least two) treatment failures with different regimens.

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37

March 2012

Conference Coverage

53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011, San Diego, California, US

H. pylori eradication alters appetite hormone levels Malvinderjit Kaur Dhillon

A

change in Helicobacter pylori colonization status can potentially induce changes in ghrelin and leptin levels, thus influencing metabolic status and body weight, says an expert. Dr. Fritz Francois, a gastroenterologist at the New York University Langone Medical Centre, New York, US, said, “Our group began to look at the functional elements of the gut as they relate to satiety hormones, and we focused on two in particular: leptin (an anorectic peptide which signals you when you have had enough to eat and, in fact, has a very strong anorectic effect) and ghrelin, perhaps one of the only known orexigenic peptides, one that stimulates appetite.” “We are looking at the issue not only from the perspective of what is going on in H. pylori positive and negative [subjects], but also the impact of eradication on a meal. Ultimately, what you really want to know is the change – when you give somebody a meal, when somebody eats, what happens to these particular hormones before and after?” he added. The study by Fritz and his team involved a group that were primarily male and in their 60s. Blood was drawn at baseline and the subjects were fed a standardized meal. Blood was drawn an hour later and underwent eradication of H. pylori. The procedure was repeated after 6 weeks. “There is a drop in ghrelin levels

Varying studies demonstrated different effects of H. pylori eradication on preprandial and postprandial ghrelin and leptin levels.

post-meal, which is exactly what you would expect. After the eradication treatment, ghrelin levels are higher pre-meal compared to the pre-eradication group. Compared to the post-meal levels, there isn’t a drop that you would expect. As for leptin, we found an increase in leptin levels in both instances,” he said. Fritz and his group also looked at body mass index (BMI) changes of these patients over a span of 18 months and found a positive co-relation between fasting ghrelin and change in BMI. As ghrelin levels increased with eradication, BMI levels also increased. [BMC Gastro 2011;11:37]

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39

March 2012

In Practice

Advancements in the management of anal fistulas Anal fistula is usually the result of a chronic infection in select individuals who happen to have intra-sphincteric or extrasphincteric glands. In this article, Drs. Koh Poh Koon, Francis Seow-Choen, Lim Jit Fong and Ho Kok Sun, colorectal surgeons at the Novena Colorectal Centre in Singapore, elucidate on the cause of this painful condition and review latest advancements in its clinical management.

Dr. Koh

Dr. Seow-Choen

Dr. Lim

Introduction Most cases of anal fistula are a result of a chronic infection of an anal crypt gland or so called cryptoglandular infection.1-3 These infections can only occur in people with intra-sphincteric or extrasphincteric anal glands and therefore not everyone can develop anal fistula as most people only have anal glands in the intramucosal plane.4 The worldwide incidence of anal fistula is estimated to be about 9 cases per 100,000 people.5 The condition usually starts as an infection or abscess at the anal region, characterized by a redness and swelling with throbbing pain and sometimes fever.4 When the pus drains externally, a small channel between the anal canal and the skin near the anus is formed. The external end of a fistula then appears as a hole on the skin from which pus, blood or stool may discharge. Repeated unsuccessful attempts by the body to heal may lead to a hard nodule at the external opening that occasionally

Dr. Ho

closes up, causing debris entering the internal opening to be trapped in the tract and setting up recurrent episodes of perianal sepsis.5 Anal fistulae are classified as simple or complex, or according to their anatomy— inter-sphincteric, trans-sphincteric, supra-sphincteric or extra-sphincteric. Transsphincteric and ‘high’ fistulas are more likely to occur in females, and in patients with previous perianal sepsis or surgery for fistula. External openings close to the posterior midline almost always underlie simple fistulas, whereas postero-lateral external openings are predictive of complex fistulas.1 Cryptoglandular anal fistula are not associated with infection by extraordinary organisms.6 Nearly twice as common in men than in women, an anal fistula can also be caused by inflammatory bowel disease such as Crohn’s disease or specific infection, for example in tuberculous fistula. People with HIV are also at increased risk of developing the condition. Other specific causes include birth related injuries

40

March 2012

In Practice

with ano-vaginal fistula and prostatic and urethral injuries leading to ano-urethral and ano-prostatic fistulas. These fistulas are normally not considered together with cryptoglandular anal fistula. Diagnosis For effective treatment of a cryptoglandular anal fistula, the following information must be ascertained: 1. The presence of a specific cause for the fistula 2. The location of the internal opening and its relation to the dentate line 3. The morphology of the tract and the amount of anal sphincter muscles involved 4. The presence of any other secondary tracts

Treatment of specific fistulas The exclusion of a specific cause for the anal fistula like tuberculosis is important as the specific treatment of these causative factors will cure the fistula without need for surgery. Similarly ano-vaginal or ano-urethral fistula should be treated specifically if healing is to ensue. While the external opening of the channel is clearly visible, finding the internal opening can be more challenging. The anatomy of a simple tract is usually easily defined by an examination under anesthesia and using the following instruments: • Fistula probe — An instrument specially designed to be inserted through a fistula. The most efficacious and commonly used around the world is the Lockhart-Mummery fistula probe.

State-of-the-art clinic equipped with the latest technologies for the management of patients with anal fistulas.

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March 2012

In Practice

This is a series of about four probes with various angles of the probe head enabling the surgeon to probe tracts of varying complexities. • Anoscope — To view the anal canal. • S urgeon’s digit — Many doctors forget that one of the best methods to determine the anatomy of any anal fistula is the well trained index finger of the surgeon. Bi-digital palpation with the thumb outside and the index inside the anus is important for accurate understanding of the patho-anatomy of the fistula. The relationship of the fistula to the sphincters and the direction and presence of any secondary tracts can be assessed as well with the well trained finger.7 For more complicated fistulae, visualization of the tract morphology can be complemented by the use of: • D  iluted methylene blue dye — Dye is injected into the fistula in an operating room. Whilst methylene blue may be used by some surgeons, we do not normally recommend it as it sometimes stains normal tissues making identification of tracts from normal tissues even more difficult.1 • Fistulography — Injection of a contrast solution into a fistula followed by an X-ray of the affected area. This sort of radiological examination is favored by some surgeons but we have not found it useful as the tracts seen on radiographs are not easily translated into the anatomy seen during surgery. • Magnetic resonance imaging (MRI) — This examination is often reserved for the most complex fistulae and expert radiological interpretation can often give a good idea of the complexity of

tracts that are present. However the problem again is similar to that of translating those radiological interpretations into useable information at surgery. • Endoanal ultrasound – A useful tool for surgeons who need a simple and inexpensive method of confirming what his skilled fingers are already telling him regarding the anatomy of the complex fistulas.7 Endoanal ultrasound is also good for assessment of anal sphincter function before surgery both to determine anal function adequacy and for medico-legal protection. Treatment options Cryptoglandular fistulas are treated surgically. Specific fistulas may require specified treatment, for example tuberculous fistula or Crohn’s fistula. Simple fistulas may be treated by fistulotomy or simple lay open, but complex or high fistulas that may implicate a significant amount of sphincter muscles require careful evaluation and more complex surgical procedures. In all instances, the objective should be to eradicate the fistula without compromising fecal continence. Important considerations include the complexity of the fistula and the strength of the anal sphincter muscle. Acute perianal abscesses should be laid open as soon as practicable and if a fistula is present this should be laid open if the internal opening is easily found.8-11 Fistulotomy is a common surgical procedure in which the surgeon cuts open the whole length of the fistula, from the internal opening to the external opening and drains out all the contents. Curettage of all granulation tissue is important to allow the wound to heal. This then heals into a

42

March 2012

In Practice

flat scar. Fistulotomy essentially opens a “tube” into a “ravine” which then fills up in time to heal. For simple low-lying fistulae, this is often all that is sufficient. Long tracts heal faster when the wound edges are marsupialized.12 For more complex fistulae or fistulae with a very high internal opening, the following options may be employed:

A fistuloscope for video-assisted anal fistula treatment (VAAFT)

Cutting/Loose Seton Techniques: In the loose seton technique, the surgeon uses a surgical suture called a seton to help drain the fistula and further establish the tract. This seton can be left in situ as long as drainage is good and the patient is happy without acute flare-ups or abscess recurrence. Cutting or tight setons are setons that are tightened around the anal muscles and inserted into fistula tracts in an attempt to force the seton to cheesewire out and result in a high tract moving progressively lower with each tightening. Setons can be difficult to manage and both tight setons and ayurvedic medicated setons can be very painful.13-16 Fibrin glue: This is a less invasive surgical option where the surgeon uses fibrin glue, made of plasma protein, to plug the cavity and seal the fistula. The fibrin plug then

promotes ingrowth of tissue to obliterate the tract. Whilst initial results were promising, this technique has fallen out of general favor due to a very high recurrence rate. Anal fistula plug: As the name suggests, the technique uses a collagen tissue to plug the fistula and acts as a scaffold to promote healing. Initial reports of 80 percent success rates have not been repeated by other investigators and this technique might be useful only in simple tracts without side tracts or secondary extensions. Advancement Flap Procedure: The internal opening of the tract is excised and a flap of the rectal mucosa or better still mucosa plus rectal muscle wall is elevated and used to close the internal opening. The external tract is curetted and allowed to drain through the external opening. This method is used frequently for high tracts as it results in better results than using either anal fistula plug or fibrin glue. Flaps may be advanced outwards or inwards but length should not exceed width by more than twice the distance. However failure is not infrequent and may result in a bigger defect than was present originally. LIFT Procedure: Ligation of InterSphincteric Fistula Tract (LIFT) involves the careful delineation of the anatomy of the fistula tract using injections and probes and the isolation of the tract as it traverses within the inter-sphincteric space. The portion of the tract within the intersphincteric space is then ligated and excised, disconnecting the tract from the internal opening. The internal opening is ligated closed and therefore does not allow further ingress of faecal matter therefore allowing healing to progress. This leaves behind the external opening to drain and gradually heal over time. However there is a significant

43

March 2012

In Practice

wound in the inter-sphincteric space that sometimes causes problems with healing although most cases heal well. VAAFT: A new technique, video-assisted anal fistula treatment (VAAFT) is a minimally invasive and sphincter-saving technique for treating complex fistulas. The main feature of this technique is the ability to view the fistula from the inside of the tract so that it can be eradicated under direct vision using a fistuloscope. The procedure allows for accurate identification of the internal opening and the secondary tracts or abscess cavities with formal closure of the internal opening. It obviates the need for blind probing of the tract and minimizes the risk of iatrogenic creation of false tracts. Because it affords direct visualization of the tract anatomy, there is no longer any need for expensive imaging using MRI. This technique comprises diagnostic and operative phases and is performed as a day surgery under regional or general anaesthesia. Conclusion Abscess management is fairly straightforward with incision and drainage being the hallmark of therapy. But the management of fistula itself is much more complicated. It requires striking a balance between rates of healing and potential alteration of fecal continence. Up to 20 percent of patients may develop some level of incontinence after fistula surgery using the traditional techniques. This can potentially be vastly reduced with the use of novel VAAFT technique which does not sacrifice sphincter muscle integrity. Although no single technique is appropriate for all patients and all fistula types, appropriate selection

of patients and choice of repair technique should yield higher success rates with lower associated morbidity.

References 1. Br J Surg 1992;79:197-205 2. Br J Surg 1993;80:1627 3. Sem Colon Rectal Surg 1999;9:157 4. Dis Colon Rectum 1994;37:1215-8 5.  Chapter In: Anal Fistula. Chapman and Hall. 1996 6. Br J Surg 1992;79:27-8 7. Br J Surg 1991;78:445-7 8. Aust NZ J Surg 1993;63:485-9 9. Dis Colon Rectum 1996;39:1415-7 10. Dis Colon Rectum 1997;40:1130-31 11. Dis Colon Rectum 1997;40:1435-1438 12. Br J Surg 1997:105–107 13. Br J Surg 1994;81:1214 14. Br J Surg 1995;82:426 15. Tech Coloproctol 2001;5:137-141 16. Colorectal Disease 2003;5:373

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March 2012

Calendar

March 68th Annual Meeting of the American Academy of Allergy, Asthma and Immunology 2/3/2012 to 6/3/2012 Location: Orlando, Florida, US Info: American Academy of Allergy, Asthma and Immunology Tel: (1) 414-272-6071 Email: [email protected] Website: www.aaaai.org 2012 Highlights of ASH® in Asia 3/3/2012 to 4/3/2012 Location: Singapore Info: ASH Customer Relations Department Tel: (1) 202-776-0544 Email: [email protected] Website: www.hematology.org/ Meetings/Highlights/6836.aspx 20th Annual Meeting of the Asian Society for Cardiothoracic Surgery 8/3/2012 to 11/3/2012 Location: Bali, Indonesia Info: Asian Society for Cardiothoracic Surgery Tel: (1) 62-21-566-5993 Email: [email protected] Website: www.ascvtsbali2012.org 61st American College of Cardiology Annual Scientific Session 24/3/2012 to 27/3/2012 Location: Chicago, Illinois, US Info: American College of Cardiology Tel: (1) 202 375-6000

Email: [email protected] Website: www.acc.org 15th World Congress of Anesthesiologists 25/3/2012 to 30/3/2012 Location: Buenos Aires, Argentina Info: WF SA World Congress of Anesthesiologists Email: [email protected] Website: www.wca2012.com 9th European Congress on Menopause 28/3/2012 to 31/3/2012 Location: Athens, Greece Info: European Menopause and Andropause Society Email: [email protected] Website: www2.kenes.com/emas/pages/ default.aspx

April World Congress of Cardiology Scientific Sessions 18/4/2012 to 21/4/2012 Location: Dubai, UAE Info: World Congress of Cardiology Email: [email protected] Website: www.world-heart-federation. org 24th European Congress of Ultrasound in Medicine and Biology 22/4/2012 to 24/4/2012 Location: Madrid, Spain Tel: (34) 913 61 2600

46

March 2012

Calendar

Fax: (34) 913 55 9208 Email: [email protected] Website: www.euroson2012.com III NWAC World Anesthesia Convention (NWAC 2012) 24/4/2012 to 28/4/2012 Location: Istanbul, Turkey Tel: (41) 22 908 0488 Fax: (41) 22 906 9140 Email: [email protected] Website: www.nwac.org

May American Thoracic Society International Conference 2012 (ATS 2012) 18/5/2012 to 23/5/2012 Location: San Francisco, California, US Tel: (1) 212 315 8652 Email: [email protected] Website: www.thoracic.org/go/international-conference 19th WONCA Asia Pacific Regional Conference 24/5/2012 to 27/5/2012 Location: Jeju, Korea Tel: (82) 2 566 6031 Email: [email protected] Website: www.woncaap2012.org

Upcoming 2012 American Society of Clinical Oncology Annual Meeting 01/6/2012 to 05/6/2012 Location: Chicago, Illinois, US Tel: (571) 483 1300 Email: [email protected] Website: chicago2012.asco.org 10th Royal College of Obstetricians and Gynecologists International Scientific Congress 05/6/2012 to 08/6/2012 Location: Kuching, Malaysia Tel: (603) 6201 1858 Email: [email protected] Website: www.rcog2012.com 15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012) 03/10/2012 to 06/10/2012 Location: Florence, Italy Tel: (41) 22 908 0488 Fax: (41) 22 906 9150 Email: [email protected] Website: www.kenes.com/esid 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

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48

March 2012

After Hours

Mayan ruins

– remnants of a lost civilization Yen Yen Yip recounts walking among ancient Mayan monuments, lasting reminders of one of the world’s greatest lost civilizations.

T

he Mayans introduced chocolate, corn and squash to the world. They also developed the mathematical concept of zero and were experts in astronomy without the aid of telescopes. Their civilization, established around 1800 BC, influenced life in present day Mexico, Honduras, Guatemala and Northern El Salvador, but started to decline during 8th and 9th centuries. The monuments of the ancient Mayans remain today as testaments to their advanced state of development. In the Mexican states of Yucatan and Quintana Roo, three archeological sites provide fascinating insights into the Mayan way of life thousands of years ago. Chichen Itza Chichen Itza, a UNESCO World Heritage site, is often the focal point of Mayan lore, and with good reason. Its structures served a varied range of purposes that illustrate the complexities of ancient Mayan

culture, rituals and practices. At the height of its prominence from AD 900 to 1050, Chichen Itza was the centre of economic, religious and cultural activities – a regional capital for north and central Yucatan. The crown of the monuments in Chichen Itza is El Castillo (The Castle) – an imposing, square-based pyramid that showcases Mayan knowledge of mathematics, astronomy and architecture. About 30m high, it was built integrating

49

March 2012

After Hours

Mayan ruins

– remnants of a lost civilization elements of the Mayan calendar: each stairway had 91 steps, which when multiplied by four sides, plus the top platform, gave 365 (the number of days in the solar year). Each side of the pyramid had 18 terraces flanking the stairways (18 being the number of months in a Mayan religious calendar), which featured a total of 52 panels (52 being the number of years it takes to converge the religious and solar calendars). Every year during the spring and fall equinox, the rays of a setting sun align the shadows on the northern stairway to form a gleaming diamond-backed rattlesnake slithering down the pyramid. El Castillo was designed with acoustic effects as well: by clapping at the base of the pyramid, sound waves rebound along the steps of the pyramid in a chirping echo – imitating the call of the Quetzl bird sacred to Mayans. The peak of the pyramid provides a bird’s eye view of other buildings of Chichen Itza – the ball court, where the ancient Mesoamerican ball game was played and the captain of the winning team would have been decapitated

in an honor sacrifice; the Temple of the Warriors, where hundreds of square and round columns were built to distinguish the achievements of generals and warriors; and the Wall of Skulls, where it was believed that the heads of sacrificial victims were placed. Tulum Nestled on 12-meter-high cliffs, the coastal ruins of Tulum are impassive and enduring against the glittering azure Caribbean waves. Iguanas stretch out on its ancient sun-baked craggy stone blocks,

50

March 2012

After Hours

Mayan ruins

– remnants of a lost civilization their beady lizard eyes peering out of leathered brown faces. Palm fronds sway to winds blowing in from the seas while the camera lenses of countless tourists click away in an excited rhythm. Tulum was first mentioned in 1518, when a contingent of Spanish conquistadors following the coast of the Yucatan peninsula spotted the city and compared its grandeur to that of Seville in Spain. It is believed that the Spanish also introduced Old World diseases that eventually wiped out the city; the site was abandoned by the end of the 16th century. Modern day archeological investigations determined that Tulum flourished between the 13th and 15th centuries. Artifacts that were excavated suggested that the city served as an important confluence point for land and maritime trade routes, where merchants bought and sold flint and ceramics, copper rattles and rings, and obsidian – products that originated from a range of cities from Central Mexico to Central America. Religion was an important facet of Mayan life. Among the

various deities, the Descending God was a figure distinct to Tulum. Worshipped for his association to the setting sun and the planet Venus, the Descending God is always depicted upside down above the doorways of Tulum structures. His feet and legs, spread open in a U shape, point upwards, and his hands are clasped together with his head diving downwards. At Tulum, the Temple of the Descending God is another testament to Mayan expertise in architecture and astronomy. During the winter and summer solstices, a porthole in the

51

March 2012

After Hours

Mayan ruins

– remnants of a lost civilization oceanfront wall of the temple allows the dawn light to shine through and hit the corners of other structures close by in a starburst effect. Coba About 45 km from Tulum lies another Mayan site – Coba. Its highlight is the temple pyramid of Nohoch Mul. At 42 meters tall, Nohoch Mul rears up like an island above the green canopy of the encroaching jungle. Tourists clamber to the peak of the pyramid on all fours like insects, stabilizing their bodies with their hands grasping for handholds as their feet balance on the lower steps. 120 steep steps later, a look down from the top delivers an alarming jolt of vertigo: the ground looks so far away. A verdant expanse stretches out into the horizon – there are no other tall buildings in sight – and what were tall trees at ground level now look like bushy green twigs. This could easily have been the view commanded by Mayan high priests performing rituals at the top of Nohoch Mul. A significantly larger site than Tulum, Coba encompasses

an area of 80 km2. It had trade relations with the coastal city, though its size suggests that Coba likely rivaled Chichen Itza in social and political status. Coba is estimated to have held about 50,000 inhabitants at its height. Despite its present day remoteness in an area overgrown with jungle, Coba must once have been a prosperous trade center that maintained contact with other Mayan cities through road works called sacbe. Some of these ancient highways reached the Caribbean coast, and the longest traveled 100 km to the precincts of another city, Yaxuna.

www.eastmeetswest.org.hk

14th Hong Kong Diabetes and Cardiovascular Risk Factors –

East Meets West Symposium 1 – 2 October 2012 • Hong Kong Convention and Exhibition Centre

A forum for healthcare professionals to work towards the common goal of prevention and management of diabetes. Take the opportunity to learn more about recent advances in diabetes care, obesity and management of atherosclerotic diseases. Enquiry:

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53

March 2012

Humor

“Don’t worry about the hallucinations you’ve been having lately, it’s only your imagination!”

“I know your condition is very serious, but think of all the other serious conditions you don’t have!”

“I’m the Doctor here, so I will decide if you’re sick or not!”

“Excessive consumption of seafood like lobster, for example, can increase bad cholesterol levels or something much, much more serious!”

“He’s going to live, but he still thinks you should remarry!”

“There you are. Been waiting long?”

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