ESC rolls out new practice guidelines

October 2012

ESC rolls out new practice guidelines

FORUM

DEPRESSION Short-term fluoxetine, venlafaxine efficacious for depression

Health policies need to foster right environment

NEWS

AFTER HOURS PPIs safe for long-term use

Singapore’s Gardens by the Bay

Please visit www.isrd.org for further details

Hosted by:

Chinese Alliance Against Lung Cancer (CAALC) Shanghai Respiratory Research Institute Supported by:

ISRD 2012 The 100 very Academic first joint scientific sessions Nearly Speakers, with the American ThoracicTopics Society 15 Sessions and 6 Special

American Thoracic Society (ATS) Keynote Speakers:

English Sessions Highlights：

• • • Prof. Chunxue Bai President of the 8th ISRD & ATS in China Forum 2012 Professor of Medicine and Chairman of Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University

Prof. Monica Kraft President of American Thoracic Society Professor of Medicine, Vice Chair of Research for Department of Medicine and Director of the Duke Asthma, Allergy and Airway Center at Duke University Medical Centre

Dr. Asrar Malik Distinguished Professor and Head of the Department of Pharmacology, University of Illinois College of Medicine Schweppe Familly Distinguished Professor of Pharmacology

• • • • • •

Mechanical Ventilation Sleep Apnea Update Biomarkers and Therapeutic Strategies in Airway Diseases State-of-the-art Ventilation Strategy Highlight on COPD Management ALI Forum - Mechanism and New Drug Target Plenary Session - Message from ATS Infection and Immunity Translational Respiratory Medicine

Congress Secretariat Office： UBM Medica Shanghai E-mail: [email protected]

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October 2012

ESC rolls out new practice guidelines Elvira Manzano

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ive new practice guidelines from the European Society of Cardiology (ESC) recommend new agents, devices and therapeutic options for managing valvular disease, ST segment elevation myocardial infarction (STEMI), heart failure (HF), atrial fibrillation (AF) and cardiovascular disease (CVD) prevention. A consensus statement was also issued on the latest universal definition of myocardial infarction (MI). For valvular disease, the importance of a collaborative approach between cardiologists and cardiac surgeons working as a “heart team” has been emphasized. For the first time, transaortic valve implantation (TAVI) is recommended in patients with severe symptomatic aortic stenosis (AS) who are unsuitable for surgery, but only in hospitals with cardiac surgery on site. TAVI should not be performed in patients at intermediate risk for surgery. Mitral valve repair is the preferred technique in mitral regurgitation, when the repair is considered durable. Mitraclip device may be considered in high-risk or inoperable patients resistant to optimal medical therapy. In HF, the key changes from the 2008 ESC guidelines include a new indication for mineralocorticoid antagonist (MRA) eplenerone in patients with systolic HF and mild symptoms, broadening the indication to essentially all HFREF patients remaining symptomatic despite treatment with a beta-blocker and ACE inhibitor or ARB. Ivabradine is now recommended to be added to an ACE inhibitor, beta-blocker and MRA for HF-REF patients in sinus rhythm with a persistently high heart rate (>70 bpm).

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

The use of cardiac resynchronization therapy (CRT) has been expanded to patients with mild symptoms. Those with a left ventricular ejection fraction (LVEF) of 35 percent or lower, sinus rhythm, and left bundle-branch block QRS morphology, however, benefit the most from the device. The guidelines also recognize the increasing importance of cardiac MRI and include mid-regional proBNP as a ‘rule-out’ blood test in patients with acute HF. Reperfusion therapy is recommended for all STEMI patients within 12 hours of first symptoms, and beyond the 12-hour window period if there is persistent pain and ECG changes. Clopidogrel and aspirin are recommended for fibrinolysis. Dual antiplatelet therapy is indicated for up to 12 months in those having primary PCI, a minimum of 1 month for those receiving a bare metal stent and 6 months for a drug-eluting stent. For stroke prevention, the use of CHA2DS2VASc score instead of the CHADS2 score is now recommended for identifying at-risk patients, and new oral anticoagulants such as

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October 2012

dabigatran, rivaroxaban or apixaban are now considered preferable to vitamin K antagonists (Class IIA). Dual antiplatelet therapy with aspirin and clopidogrel, or aspirin only, may be considered in patients who refuse anticoagulation. Percutaneous closure of the left atrial appendage (LAA) may be considered in those with thromboembolic risk who cannot be managed with oral anticoagulants in the long term. Vernakalant has been introduced as a new antiarrhythmic agent for rapid cardioversion of recent onset AF, with few exceptions. The guidelines also highlight the revised use of dronedarone for paroxysmal or persistent AF. However, it is contraindicated in permanent AF and heart failure.

Catheter ablation is advised for patients with symptomatic paroxysmal AF who have failed antiarrhythmic medications (Class IA). The guidelines on CVD prevention focus on CVD risk, why prevention is needed, and who should benefit from it. CV risks are classified as very high, high, moderate and low. Strong recommendations are given on diet, smoking, hypolipidemic medications, exercise and other behavioral risk factors. The ESC also released the latest definition for five types of MI and their clinical implications. The consensus document now recognizes that small amounts of myocardial injury or necrosis can be detected by biochemical markers and imaging.

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October 2012

Forum

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

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ealth is intrinsically related to wealth. The Prospective Urban Rural Epidemiological (PURE) study, a survey of 153,996 adults from 628 urban and rural communities in 17 countries, has highlighted the discrepancies in lifestyle and diet between high-income and low-income nations. The average fruit and vegetable consumption per day should be 500 grams or 5 servings, but surprisingly, our analysis of PURE showed that one-third of the countries of the world are not consuming adequate amount. The consumption of fruits and vegetables increased among nations with a higher gross domestic product (GDP) and wealth index, but this was offset by an increase in the amount of energy obtained from total and saturated fats, as well as from protein. Energy from total fat, saturated fats and protein increased almost linearly with increasing incomes. Carbohydrate intake, on the other hand, made up approximately 65 percent of energy from diets in poor nations – this is because carbohydrates are a cheap source of energy – with the percentage declining in wealthier nations. Regarding smoking, the decision to smoke in women depends not only on GDP or wealth but also on cultural factors, including religion. In men, there is a clear inverse

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

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

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Forum

this increase was offset by a reduction in the amount of obligatory physical activity that is transport-related, job related and household-related activity required for physical labor. Overall, the net result was a reduction of approximately 2,000 [metabolic equivalent task] METS/minute/week, or 2.7 hours of brisk walking every day, among countries with higher incomes. There is no way – unless you are a marathon runner – that we are going to overcome the decrease in activity due to the changing environment. The obesity epi-

demic really requires a change in environment. We can yell at people and say, ‘exercise’ 30 minutes a day. But it is not going to be enough. It’s about one-fourth of the difference of lost physical activity which means that in the future, we will all be on treadmills. While there are creative solutions, the key point is to understand that recreational exercise won’t solve the problem and the entire environment needs to be redesigned. That’s where policy comes in. We really need to create the right environment.

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Indonesia Focus

Local events calendar

The 9th Congress of Asian Pacific Federation of Societies for Surgery of the Hand in Conjunction with The 5th Congress of the Asian Pasific Federation of the Societies for Hand Therapist Bali, 11-13 Oktober 2012 Grand Hyatt Bali Sekr : Jl. Pucang Anom Timur III No. 65, Surabaya, Jawa Timur, Indonesia Tel : 021-63869502 Fax : 021-63869503 Email : apfssh2012@pharma- pro.com Website : www.apfssh2012.org The 35th Annual Scientific Meeting of Indonesian Urological Association Jakarta, 12-14 Oktober 2012 Hotel Gran Melia, Jakarta Sekr : Departemen Urologi, RSCM, Jl. Diponegoro No.71, Jakarta 10430 Tel : 021-3152892, 3923631 Fax : 021-3145592 PIT IKA V Bandung, 13-17 Oktober 2012 Hotel The Trans Luxury, Bandung Sekr : Ikatan Dokter Anak Indonesia, Cabang Jawa Barat Departemen Ilmu Kesehatan Anak, Fakultas Kedokteran Unpad RS Dr. Hasan Sadikin Jl. Pasteur No.38 Bandung – 40161 Tel : 022-2039512 Website : www.pitika5.com Weekend Course on Cardiology (WECOC) 2012 Jakarta, 19-21 Oktober 2012 Sekr : National Cardiovascular Centre

Harapan Kita, Diklat Bldg 5th Fl, Jl. Letjen S Parman Kav 87, Slipi, JakBar 11420 Tel : 021-5684093 ext 1554 & 3505 Fax : 021-5608902 Current Concepts In Heads & Neck Surgery and Oncology Jakarta, 20-22 Oktober 2012 Hotel Shangri-La, Jakarta Sekr : THT Fakultas Kedokteran Universitas Indonesia, Rumah Sakit Cipto Mangunkusumo, Jakarta Tel : 021 - 3910701 Fax : 021 - 3914154 Email : ifnosjakarta2012@ gmail.com 10th Asia and Oceania Thyroid Association Congress Bali, 24-27 Oktober 2012 Discovery Kartika Plaza Hotel, Bali Sekr : Divisi Endokrin, Fakultas Kedokteran Universitas Padjajaran Jl. Pasteur 38, Bandung 40161 Tel /Fax : 022-2033274 Email : [email protected] Website : www.aota2012.com Muktamar Perhimpunan Ahli Bedah Onkologi Indonesia IX 2012 Yogyakarta, 1-3 November 2012 Hotel The Rich Jogja, Yogyakarta Sekr : SMF Bedah RSUP Dr. Sardjito, Yogyakarta, Jl. Kesehatan No.1 Sekip, Yogyakarta Tel : 0274-581333 Email : [email protected]

25th Indonesian International Hospital Medical, Pharmaceutical Clinical, Laboratories Equipment & Medicine Exhibition Jakarta, 7-10 November 2012 Jakarta Convention Center Sekr : PT. Okta Sejahtera Insani. Perkantoran Aries Niaga Blok A1 No.1P, Jl. Taman Aries, Jakarta Barat 11620 Tel : 021- 58907366/68 Fax : 021-58906819/20 Email : hospital.expo@gmail. com Website : www.hospital-expo. com KOPAPDI XV Medan Medan, 12-15 Desember 2012 JW Marriot International, Aryaduta, Grand Aston, Medan Sekr : Departemen Penyakit Dalam Fakultas Kedokteran Universitas Sumatera Utara /RS Umum Pusat H. Adam Malik Lt. III , Jl. Bungalau 17, Medan Tel/Fax : 061-4528075 Email : papdicabsumut@gmail. com Website : www.kopapdimedanxv. com

www.MIMS.com Smart Rx. Every Time.

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Indonesia Focus

Tablet tambah darah bagi ibu hamil anemia Hardini Arivianti

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umlah 90 tablet selama masa kehamilan tersebut sesuai dengan program suplementasi untuk penanggulangan anemia pada ibu hamil di Indonesia. Walau kebijakan tersebut sudah ada sejak tahun 1970an, tetapi tetap saja prevalensi anemia pada ibu hamil masih tinggi. “Prevalensi ibu hamil dengan anemia sekitar 40-50%, berarti 5 dari 10 ibu hamil mengalami anemia,” ujar dr Elvina Karyadi, MSc, PhD, dalam acara “Paparan Penelitian Diseminasi Anemia pada Ibu Hamil dan Tablet Tambah Darah” beberapa waktu lalu. Kondisi ini tentu saja berdampak bagi janin yang dikandung dan juga ibu hamil itu sendiri. Jika anemia berat maka risiko pendarahan akan meningkat yang bisa memicu kematian ibu, sedang pada bayi berisiko prematur dan berat badan bayi lahir rendah (BBLR). “Suplemen TTD tetap diperlukan pada seseorang dengan anemia, karena jika hanya mengandalkan makanan saja maka sulit untuk mengejarnya,” tukas direktur ‘Micronutrient Initiative Indonesia’ (MI) ini lebih lanjut.

Penelitian di Kabupaten Lebak dan Purwakarta Sejak Maret 2012 lalu Puslitkes FKM-UI bekerjasama dengan MI melakukan penelitian di 4 kecamatan di Kabupaten Lebak dan Purwakarta yang menjadi tempat percontohan. Beberapa poin yang didapat dari penelitian tersebut, dapat dilihat pada tabel. ”Hasil temuan lainnya adalah fokus program tersebut masih pada distribusi TTD dan bukan pada kepatuhan minum TTD,” jelas Kusbandriyo, SKM selaku Kepala Bidang Kesehatan Masyarakat Kabupaten Lebak. Pada tahun 2011 kematian ibu di Lebak cukup tinggi yakni 42 orang/tahun, 22 diantaranya disebabkan oleh perdarahan. Pada tahun 2007 sekitar 35% ibu hamil mengalami anemia. Sedangkan kematian bayi pada tahun 2011 mencapai 245 bayi, akibat BBLR/asfiksia (96 kasus) dan prematur (38 kasus). ”Salah satu yang berkontribusi terhadap tingginya angka kematian ibu adalah Banten dan Jawa Barat karena populasinya cukup banyak. Lebak dan Purwakarta menjadi daerah pecontohan untuk dijadikan pembelajaran ke depan perbaikan program dan menjadi acuan guna meningkatkan program ini di kabupaten

Temuan (ibu hamil) * Minum TTD setiap hari * Anemia ringan Anemia berat * Pernah diperiksa kadar Hb * Trimester 2 dan 3 yang mendapat program > 60 tablet * Yang pernah minum TTD * Merasakan mual * Berhenti minum TTD * Trimester 1 dan mengeluh mual

Purwakarta (%) 26,3 29,3 24,8 11,0 23,5 80,3 65,5 70,9 95,0

Lebak (%) 55,1 71,1 9,1 11,8 42,9 90,4 51,5 43,2 70,6

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lain,” jelas Tomi Herutomo, MKes, sebagai Kepala Seksi Promosi Kesehatan Kabupaten Purwakarta. Ada kendala Lebih lanjut dr. Ridwan Gustiana, MPH selaku Ketua IBU Foundation menuturkan beberapa hal yang menjadi kendala masih rendahnya asupan suplemen TTD ini yaitu masalah pada distribusi sehingga suplemen yang sudah digratiskan oleh pemerintah ini tidak sampai sepenuhnya ke tangan para ibu hamil dan pengetahuan masyarakat yang rendah sehingga masih banyak persepsi negatif mengenai suplemen ini, salah satunya ada persepsi bayi akan menjadi hitam atau menjadi besar jika minum suplemen ini, padahal kenyataannya tidak.

Efek samping mual setelah minum suplemen juga menjadi kendala dan membuat banyak ibu berhenti, padahal manfaat yang bisa didapat ibu hamil akan jauh lebih besar jika mengonsumsi suplemen ini.“Kita perlu memperbaiki sistem suplainya agar semua terjangkau dan pelatihan bidan agar dapat memberikan komunikasi yang efektif,” ungkapnya. Program Penguatan Suplementasi Zat Besi dan Asam Folat pada ibu hamil tersebut bertujuan untuk meningkatkan cakupan dan konsumsi suplementasi TTD pada ibu hamil serta peningkatan pengetahuan dan perilaku ibu hamil mengenai pentingnya suplementasi kedua zat gizi tersebut dan pentingnya asupan gizi sebelum dan selama kehamilan.

Vscan, perangkat mini penunjang diagnosis Hardini Arivianti

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ekitar akhir September lalu, GE Healthcare meluncurkan Vscan 1.3 yakni perangkat genggam berteknologi ultrasonografi berukuran mini. Perangkat ini memungkinkan para dokter melakukan pemeriksaan non-invasif guna mendapatkan visualisasi sehingga dokter mampu menentukan tindakan optimal yang dapat dilakukan dan memberikan perawatan yang cepat, efisien dan tepat sesuai kebutuhan pasien. Berdasarkan riset yang pernah dilakukan oleh GE Healthcare di Indonesia tahun 2012, pasien yang memerlukan layanan pemeriksaan dengan ultrasonografi mencapai 25% dari seluruh total jumlah pasien setiap bulan.

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Indonesia Focus

Menurut Indra W. Suwardi, selaku direktur GE Healthcare Indonesia, alat ini menggunakan baterai sehingga cocok untuk dipakai di daerah yang belum ada fasilitas listrik. Ukurannya juga mini dan memiliki berat hanya 390 gram. Peran penting teknologi USG “Indonesia memerlukan teknologi terkini guna mendukung pelayanan kesehatan primer baik di puskesmas maupun di titiktitik layanan kesehatan lainnya di seluruh nusantara, untuk membantu dokter mengidentifikasi penyakit sedini mungkin dan merekomendasikan tindakan bagi pasien,” tukas Dr. dr. Tb Rachmat Sentika, SpA, MARS. Selaku staf ahli Kementerian Koordinator Kesejahteraan Rakyat untuk Percepatan Pembangunan Milenium ini memaparkan upaya menurunkan angka kematian ibu (AKI) masih merupakan tantangan karena Indonesia masih menjadi salah satu negara dengan angka tertinggi di kawasan Asia Pasifik. Dengan terobosan baru ini, diharapkan dapat berkontribusi terhadap sistem rujukan kesehatan untuk menyelamatkan lebih banyak ibu dan bayi lahir di Indonesia. “Pemeriksaan USG penting untuk memastikan berbagai kelainan kehamilan seperti plasenta previa, yang tidak memungkinkan bagi ibu hamil untuk

melahirkan normal.” Saat ini diperlukan sekitar 1.347 alat USG untuk dipasang di Puskesmas. Selain perlunya penyediaan alat USG, perbaikan sistem rujukan di rumah sakit juga perlu dilakukan dan ditingkatkan. “Kematian pada persalinan biasanya terjadi karena faktor 3T yaitu keterlambatan mendeteksi, keterlambatan mengenali tanda, dan keterlambatan mencari fasilitas kesehatan,” jelas dr.Prijo Sidipratomo, SpRad (K) pada acara yang sama. “Penyebab kematian ibu adalah perdarahan (28%) yang diakibatkan oleh anemia dan kekurangan energi kronis. Prevalensi plasenta previa sebesar 6 dari 1000 persalinan. Penyebab kedua kematian ibu adalah eklamsia,” papar Ketua IDI ini lebih lanjut. Namun menurut dr. Judi Januadi Endjun, SpOG, alat bantu baru ini tidak bisa disamakan kemampuannya dengan USG yang ada di rumah sakit. Dengan Vscan bisa diketahui posisi bayi, letak plasenta, jumlah air ketuban, taksiran usia bayi, dan juga melihat detak jantung. Selain itu, Vscan sangat berguna untuk digunakan di daerah-daerah yang belum terjangkau USG dan dapat digunakan oleh dokter umum di layanan primer serta dapat membantu mengetahui kondisi ibu saat/ setelah melahirkan. “Alat ini sangat membantu dengan durasi selama 2 jam, padahal sekali periksa pasien hanya memerlukan waktu sekitar 3 menit.”

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Waspadai TN penyebab nyeri luar biasa Hardini Arivianti

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enyebab trigeminal neuralgia (TN) adalah penekanan pada N. trigeminalis (N V) yang mengatur perasa pada wajah atau sensorik wajah. Ciri umum penderita TN adalah rasa sakit luar biasa pada daerah bagian gusi, gigi, mulut dan wajah. Itu sebabnya selama ini penderita TN menduga gigi adalah pemicu rasa sakit tersebut. Hal ini dijelaskan oleh dr. M Sofyanto, SpBS beberapa waktu lalu. Nyeri bisa terjadi secara spontan namun lebih sering timbul akibat sentuhan atau aktivitas tertentu, seperti menggosok gigi, mengunyah, mencuci muka, makan, minum, bahkan air liur sendiri pun bisa menjadi pemicu nyeri. Ciri khas nyeri akibat TN dilukiskan dengan suatu nyeri yang mendadak/spontan, akut, unilateral dan ada pemicunya. Nyeri dilukiskan seperti sengatan listrik, menusuk dan biasanya pada salah satu sisi wajah. Pada kebanyakan penderita, kadang nyeri berkurang pada malam hari atau pada saat berbaring. ”Gigi, stres, kelelahan, kecemasan bukan penyebab TN, justru kondisi tersebut dapat memperberat reaksi bukan sebagai pemicu,” tukas pakar bedah saraf dari RS Bedah Surabaya ini lebih lanjut. Mengenai prevalensi TN, dr. Sofyanto menjelaskan, diperkirakan sekitarr 107,5 pada pria dan 200,2 pada wanita per satu juta populasi. Sisi kanan wajah lebih sering dibandingkan sisi kiri (3:2) dan seringkali dialami oleh usia di atas 40 tahun (10% kasus), walau ada kasus yang menyerang usia 22 tahun. TN ini memiliki 2 kategori yaitu klasik dan sekunder. TN klasik disebabkan gesekan pembuluh darah yang menekan nervus trigeminal

– lapisan myelinnya sudah rusak – sehingga mengganggu transmisi sinyal dan menimbulkan rasa nyeri. TN dikategorikan sekunder bila ada penyakit yang mendasarinya, seperti sklerosis multipel dan penyakit lain yang dapat menimbulkan kerusakan mielin. TN sekunder lebih jarang terjadi. Diagnosis TN ditegakkan berdasarkan MRI, dan penanganannya dengan dekompresi mikrovaskular karena pendekatan, retraksi dan komplikasinya minimal. Saraf dan pembuluh darah yang bersinggungan/menempel dilepaskan atau dipisahkan lalu diganjal dengan serabut berbahan teflon. Tindakan operasi ini hanya butuh waktu satu setengah hingga tiga setengah jam dengan 1-2 hari pemulihan. Serabut berbahan teflon yang disematkan tersebut, tidak diserap, tidak menimbulkan alergi, tidak berubah dan tidak menyebabkan infeksi. Namun tindakan key hole ini pada beberapa pasien menimbulkan efek samping tertentu diantaranya tinitus, pusing, perubahan tekanan intrakranial, rasa baal/kebal di lidah/pipi. Rekurensi nyeri didapat pada 2% pasien pasca operasi. Penentu efek samping pasca operasi adalah usia dan trauma pasca operasi. Status recovery pada usia muda dan tua berbeda. Untuk perawatan tertentu pasca operasi, dr. Sofyanto memberikan analgesik selama 5 hari. Bila penderita memiliki kontraindikasi terhadap operasi misalnya ada kelainan jantung dan paru, dapat diberikan golongan antikonvulsan (karbamazepin) sebagai pengobatan lini pertama. Namun obat ini kadang menimbulkan resistensi. “Bila sudah resistensi, lini kedua adalah gabapentin yang diberikan seumur hidup. Obat ini akan memblokade sinyal nyeri sehingga dapat mengurangi frekuensi dan intensitas nyerinya.”

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

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

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Penatalaksanaan penyakit metabolik pada layanan primer Anna Dewiyana

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aat ini dislipidemia, DM tipe 2, obesitas dan hipertensi semakin banyak dijumpai. Sebagai lini pertama layanan ke-sehatan masyarakat, dokter umum dihadapkan pada tantangan untuk mengatasi masalah kesehatan tersebut sehingga pasien terhindar dari risiko sindroma metabolik. Untuk meningkatkan mutu pelayanan dan menambah wawasan dokter umum seputar sindroma metabolik, PDUI bekerjasama dengan MIMS Indonesia telah menyelenggarakan simposium sehari Penatalaksanaan Penyakit Metabolik pada Layanan Primer, pada tanggal 15 September 2012 lalu bertempat di Surabaya. Dislipidemia merupakan kelainan metabolisme berupa kelebihan maupun kekurangan lipoprotein, yang ditandai dengan peningkatan kadar kolesterol, LDL kolesterol, dan trigliserida serum, serta rendahnya kolesterol HDL. Demikian Dr. dr. Sri Adiningsih, MS, MCN mengawali presentasinya. Panduan NCEP (National Cholesterol Education Program) memberikan 2 langkah diet untuk manajemen dislipidemia : diet step 1 dengan asupan asam lemak jenuh 8-10%, kolesterol < 300 mg/hari, dapat menurunkan sampai 3-14%; diet step 2 dengan asupan asam lemak jenuh < 7% dari kalori total, kolesterol < 200 mg/hari, menurunkan sampai 3-7%. Pada kedua langkah diet tersebut pasien dianjurkan membatasi konsumsi lemak tak jenuh tunggal < 15% dan lemak tak jenuh ganda < 10%. Hindari daging berlemak, iga, buntut, jerohan, daging/ayam/

ikan go-reng, kuning telur (termasuk kue), makanan yang mengandung telur, whole milk, yogurt/keju reguler, es krim/whiping cream reguler, minyak kelapa/kelapa, santan, susu coklat, sayur dioles mentega/digoreng/bertabur keju, dan buah dengan keju. Dislipidemia pada pasien diabetes meningkatkan kejadian atau mortalitas kardiovaskuler. Oleh karena itu, upaya pengendalian dislipidemia pada DM sebagai ekivalen penyakit jantung koroner (PJK) harus agresif. Penurunan LDL yang agresif (<100 mg/dL atau <70

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Indonesia Focus

mg/dL) dengan terapi statin tanpa menghiraukan kadar awal akan memberikan manfaat kardiovaskuler. Penyandang diabetes memiliki faktor risiko kardiovaskuler yang lebih tinggi karena dislipidemianya, ditandai dengan peningkatan LDL yang didominasi lemak dengan densitas kecil, peningkatan apoB, rendahnya HDL dan hipertrigliseridemia. Lemak yang kecil lebih mudah menembus dinding dan menancap di intima, juga lebih mudah teroksidasi. Demikian disampaikan oleh dr. Panji Mulyono, SpPD-KEMD pada sesi lunch symposium [Astra Zeneca Indonesia] yang merupakan bagian dari Simposium PDUI MIMS ini. Modifikasi gaya hidup selalu menjadi langkah awal tata laksana dislipidemia pada orang dewasa dengan diabetes, seperti yang dinyatakan oleh American Diabetes Association (ADA). Pasien dianjurkan untuk mengurangi asupan lemak jenuh, lemak trans dan kolesterol, menurunkan berat badan, meningkatkan aktivitas fisik dan berhenti merokok. Pada individu tanpa penyakit kardiovaskuler yang jelas, terapi statin diberikan untuk menurunkan LDL sampai 30-40%, dengan target primer LDL < 100 mg/dL. Sedangkan pada individu dengan penyakit kardiovaskuler yang jelas, statin diberikan dalam dosis tinggi untuk mencapai target LDL < 70 mg/dL. Lalu apakah semua statin memberikan manfaat yang sama? CORALL (Compare the effect of Rosuvastatin with Atorvastatin in ApoB/ ApoA-I ratio in patients with type 2 diabetes meLLitus and dyslipidemia) menunjukkan bahwa rosuvastatin lebih poten dibandingkan atorvastatin dalam mereduksi kolesterol LDL. Dengan dosis yang sama (80 mg), penurunan LDL pada rosuvastatin lebih tinggi dibandingkan simvastatin maupun atorvastatin (63% vs 48% dan 55%), tetapi peningkatan transaminase

lebih banyak dijumpai pada pemberian simvastatin dan atorvastatin. Dari studi STELLAR (Statin Therapies for Elevated Lipid Levels compared Across doses to Rosuvastatin) diketahui perubahan kolesterol HDL pada rosuvastatin 10, 20 maupun 40 mg lebih tingi dibandingkan atorvastatin 80 mg. Pembicara kedua pada sesi lunch symposium [Astra Zeneca Indonesia] yang dimoderatori oleh dr. J. Nugroho Eko Putranto, SpJP, FIHA adalah Prof. dr. Mohammad Yogiarto, SpJP(K), FIHA, FASCC, yang menyampaikan presentasi mengenai aplikasi pengobatan pasien dislipidemia pada pasien risiko tinggi. Dari 10 faktor risiko penyebab komplikasi kardiovaskuler, ada 3 yang utama, yaitu hiperkolesterol, merokok dan hipertensi. Makin tinggi kolesterol akan menyebabkan aterogenesis yang lebih berat berupa penyempitan di otak, mata, jantung, pembuluh perifer, tergantung predileksinya. Penelitian meta analisis menunjukkan bahwa penurunan kadar kolesterol bisa menurunkan angka kematian umum dan khususnya penyakit jantung koroner (PJK). Yang menjadi pertanyaan adalah, seberapa jauh menurunkan kolesterol? Derajat penurunan LDL tergantung pada komorbiditas yang ada. Makin tinggi risiko kardiovaskuler,

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maka harus makin rendah kadar LDLnya bahkan sampai 70 mg/dL. Apakah berlaku the lower the better? Belum tentu, karena bagaimanapun juga, kolesterol tetap diperlukan tubuh. Lalu bagaimana memilih obat yang bagus dan aman untuk mencapai target? Dislipidemia merupakan faktor risiko utama terjadinya penyakit kardiovaskuler, sehingga penatalaksanaannya harus diperhatikan, terutama pada pasien risiko tinggi. Pasien dengan sindroma koroner akut, DM tipe 2, TIA/stroke, aterosklerosis, hiperlipidemia dengan risiko tromboembolik, wanita dengan penyakit kardiovaskuler, HDL rendah, termasuk ke dalam pasien risiko tinggi. Pasien risiko tinggi memerlukan pengobatan intensif, yaitu target kolesterol LDL < 100 mg/ dL atau bahkan < 70 mg/dL. Kolesterol HDL bukan target khusus tetapi HDL yang rendah merupakan faktor risiko penyakit kardiovaskuler independen yang kuat. DM dengan dislipidemia dianggap sebagai ekivalen PJK karena dislipidemianya bersifat aterogenik sehingga penurunan LDL harus lebih agresif. Studi MERCURY (Measuring Effective Reductions in Cholesterol Using Rosuvastatin Therapy) menunjukkan, bila dibandingkan dengan atorvastatin 10-20 mg, rosuvastatin 10 mg bisa mencapai target sampai 40-50%. Selain menurunkan LDL, juga meningkatkan HDL dan menurunkan trigliserida sehingga pemberian rosuvastatin mencapai 3 tujuan. Sedangkan dari studi ANDROMEDA (A raNdomized, Double-blind study to compare Rosuvastatin [10 & 20 mg] and atOrvastatin [10 & 20 Mg] in patiEnts with type II DiAbetes) diketahui rosuvastatin bisa menurunkan apoB sampai 50%. Penelitian juga menunjukkan bahwa rosuvastatin 5, 10 dan 20 mg cukup poten menurunkan trigliserida. Rosuvastatin 20 mg berpotensi sama den-

gan atorvastatin 80 mg dalam hal menurunkan LDL dan rasio apoB/apoA-1. Perbedaan dosis ini akan mempengaruhi efek samping. Rosuvastatin terbukti memiliki efikasi yang besar karena dengan 20 mg bisa menurunkan LDL sampai target, mengurangi apoB dan rasio apoB/apoA-1. Bahkan dengan dosis yang lebih kecil, 5 mg, rosuvastatin dibandingkan dengan atorvastatin 10 mg dan simvastatin 20 mg, bisa menurunkan LDL lebih besar. Rosuvastatin 5 mg memiliki potensi yang cukup bagus, dengan efek terapeutik yang cukup bagus dan efek samping yang minimal. Karena makin tinggi dosis maka efek samping terhadap fungsi hati, otot dan ginjal makin besar. Rosuvastatin dengan dosis rendah memliki efek samping yang sangat minimal dibanding statin lain. Penurunan LDL cukup bagus, fungsi ginjal tidak terganggu, mialgia tidak banyak, efek miositis paling minimal. Rosuvastatin juga memperbaiki laju filtrasi glomerulus. Dari beberapa data yang tersebut diatas dapat disimpulkan bahwa dengan dosis kecil, rosuvastatin sudah dapat mengontrol kadar lemak darah dan menurunkan risiko kejadian kardiovaskuler, dan efeknya tidak sekedar menurunkan lipid tetapi juga menyebabkan regresi plak dan mengurangi volume ateroma. Demikian Prof. Yogi mengakhiri presentasinya. DM dalam kehamilan Simposium PDUI MIMS ini juga diisi dengan clinical mentoring mengenai diabetes melitus (DM) dalam kehamilan yang disampaikan oleh Prof. dr. I. Oetama Marsis, SpOG. Di bidang layanan obstetri, DM merupakan problem yang besar karena angka lahir mati terutama pada DM yang tidak terkendali, dapat terjadi 10 kali lipat kehamilan normal. Di klinik yang maju sekalipun, angka kematian dil-

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Indonesia Focus

aporkan 3-5% dengan angka morbiditas fetal 4%. Diabetes gestasional merupakan diabetes yang diketahui pada waktu hamil dan menghilang setelah melahirkan. Keadaan ini terjadi karena adanya resistensi insulin dan hiper insulinemia pada ibu. Diagnosis dini diabetes gestasional meliputi anamnesis, laboratorium (GDS > 200 mg/dL, GDP 126 mg/dL, urin dipstik, HbA1c > 6%), dan tes toleransi glukosa oral (penapisan dan diagnosis dilakukan secara universal dengan menggunakan one step approach dengan beban glukosa 75 gram). Pada DM yang terkendali, mo-nitor dilakukan setiap minggu (gula darah, USG, CTG). Jika janin sehat maka persalinan normal dapat dilakukan sampai usia kehamilan mencapai 40 minggu. Jika terjadi gawat janin, makrosomia atau IUGR, maka dilakukan tindakan terminasi. Pada DM yang tidak terkendali, sejak usia kehamilan 34-36 minggu, ibu dirawat dan dilakukan pemeriksaan rutin gula darah, USG dan CTG, juga amniosentesis. Jika paru-paru janin telah matang, maka dilakukan terminasi; jika paru-paru janin belum matang perlu diberikan steroid terlebih dahulu lalu kemudian dilakukan terminasi. Persalinan per vaginam dapat dilakukan pada usia kehamilan preterm, tinggi/berat janin tidak terlalu besar, dan risiko rendah; sedangkan seksio sesar dilakukan bila makrosomia > 4500 gram dan terdapat penyulit seperti kelainan vaskularisasi, nefropati diabetes, retinopati diabetes. Menyiasati obesitas dr. Achmad Yuniari Heryana, SpA menyatakan bahwa di Indonesia terjadi peningkatan angka kejadian obesitas anak, terutama di daerah perkotaan. Penelitian Multisenter (2004) di 10 ibukota propinsi daerah Jawa, Sumatera dan Sulawesi menunjukkan angka

kejadian obesitas pada anak sebesar 2.5–25 %. Obesitas merupakan gangguan multifaktorial keseimbangan penggunaan energi yang ditandai dengan ada nya penumpukan jaringan lemak. Faktor-faktor endogen yang dapat menyebabkan terjadinya obesitas antara lain faktor genetik, perubah an lingkungan intrauterin dan endokrinopati yang disertai obesitas. Bayi yang lahir dengan kondisi Intrauterine Growth Retardation (IUGR) akan tumbuh menjadi individu yang resisten terhadap insulin, menderita penyakit kardiovaskuler dan sindroma metabolik. Meskipun mekanisme pastinya belum diketahui tetapi diduga perubahan lingkungan intrauterin menimbulkan perubahan permanen pada set poin aksis hipotalamus-hipofisis-adrenal, sehingga ada kecenderungan bayi-bayi yang lahir dengan kondisi IUGR menjadi obesitas di kemudian hari. Kriteria obesitas pada anak ditentukan berdasarkan klinis dan antropometris. Menurut dr. Nur Aisiyah Widjaya, SpA Nutrisi, secara fisik wajah terlihat membulat, pipi tembem, leher pendek, perut buncit, din ding perut berlipat, akantosis nig rikans, gerakan panggul terbatas, penis kecil. Untuk mengetahui apakah obesitas atau overweight, untuk anak usia < 2 tahun digunakan kurva BMI dari WHO, untuk anak usia 2-18 tahun digunakan kurva BMI dari CDC. Tata laksana umum adalah menejemen diet dan aktivitas fisik. Pengaturan makan dimodifikasi dengan pemberian kalori yang sesuai dengan umur. Terapi medis dan pembedahan jarang dilakukan pada anak. Tahap pertama merupakan pencegahan plus, dimana anak dianjurkan mengonsumsi lebih ba nyak serat karena jumlah kalorinya sedikit tetapi anak tetap merasa kenyang, mengurangi minum manis, mengurangi ke-

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Indonesia Focus

biasaan nonton televisi/main game (maksimal 2 jam/hari), menambah aktivitas fisik main (minimal 30-60 menit/hari). Jika tahap pertama tidak berhasil, maka tahap kedua adalah manajemen berat badan terstruktur, yaitu kalori ditentukan sesuai kebutuhan berdasarkan usia, jadwal makan ditentukan, aktivitas fisik ditingkatkan, batasi nonton maksimal 1 jam/hari. Jika tahap kedua gagal, terapkan tahap ketiga yang melibatkan beberapa ahli diantaranya psikolog, perawat, terapis, ahli THT/pulmo, tergantung komplikasi yang terjadi. Biasanya ada keluhan obstructive sleep apnea syndrome (OSAS), penurunan performa belajar, tidak aktif. Tata laksana tahap 4 umumnya diberikan kepada remaja obesitas berat yang gagal pada tahap 3, bisa diberikan obat-obatan (sibutramin jika usia > 16 tahun, orlistat untuk usia > 12 tahun). Efektivitas farmakoterapi tidak sebaik merubah gaya hidup, tetap harus didukung diet yang teratur. Berikan diet sangat rendah kalori yaitu 400800 kal/hari. Dalam presentasinya yang berjudul Management Obesity : Focus on medical treatment, dr. Sony Wibisono M, SpPD-KEMD, FINASIM menyampaikan bahwa pengobatan kelebihan berat badan atau obesitas mencakup dua proses, yaitu penilaian dan tata laksana. Ketika melakukan penilaian, dokter akan menentukan tingkat keparahan obesitas (apakah termasuk overweight BMI 25,0-29,9, obesitas BMI 30-39,9 atau obesitas ekstrim BMI ≥ 40) dan komorbiditas (penyakit lain). Tata laksana tidak hanya mengenai bagaimana menurunkan berat badan (BB), tetapi juga bagaimana mempertahankan BB dan mengendalikan faktor risiko lainnya. Jika BMI > 25 atau lingkar pinggang besar (pria > 90 cm, wanita > 80 cm), lakukan pemeriksaan klinis dan laboratorium (tekan-

an darah, denyut jantung, glukosa puasa, profil lemak) untuk menilai komorbiditas, juga penilaian dan penapisan untuk depresi atau kelainan makan/mood. Obati komorbiditas dan risiko kesehatan lain yang ditemukan. Target penurunan berat badan adalah 5-10% dari berat badan atau 0,5-1 kg/minggu, selama 6 bulan. Program modifikasi gaya hidup meliputi terapi nutrisi (mengurangi asupan energi sampai 500-1000 kkal/hari), aktivitas fisik (30 menit berjalan kaki setiap hari) dan terapi perilaku-kognitif. Farmakoterapi diberikan kepada pasien dengan dengan BMI ≥ 27 disertai faktor risiko atau BMI ≥ 30, sedangkan jika BMI ≥ 35 disertai faktor risiko atau ≥ 40, pertimbangkan bedah bariatrik. Standar kompetensi era SJN-BPJS Sesi terakhir dari simposium diisi oleh Presidium Nasional PDUI, dr. Dyah A. Waluyo. Beliau menyampaikan, dengan Standar Jaminan Sosial Nasional (SJSN) diharapkan layanan kesehatan secara keseluruhan akan berubah, berbeda sekali dengan saat ini. Jika pada saat ini sistem pembiayaan terutama dari pribadi, nantinya akan berlaku universal coverage dimana seluruh masyarakat Indonesia akan mendapat layanan kesehatan yang sama dan dijamin oleh layanan berbasis asuransi kesehatan, yaitu SJSN. Saat ini ma sing-masing kelompok sudah mulai, yaitu PNS oleh Askes, ABRI oleh Askes ABRI, pekerja sektor formal oleh Jamsostek, golongan yang tidak mampu oleh Jamkesmas/ Jamkesda; nanti semua akan menjadi satu. Problemnya adalah masing-masing memiliki aturan, syarat premi dan layanan yang berbeda. Menyatukan diatas kertas sudah terwujud dalam bentuk SJSN, dan telah dibentuk badan pelaksananya yaitu Badan Pelaksana Jaminan Sosial (BPJS).

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Tetapi tentu tidak mudah untuk mereali sasikannya sehingga periode sekarang adalah saat untuk bargaining, mana yang akan dipakai. Apakah sama dengan Askes, apakah sama dengan Jamsostek atau berbeda sama sekali. Yang pasti, ada atau tidak adanya SJSN/BPJS, sebagai dokter layanan primer harus tetap mengupgrade diri sehingga ketika sistem apa pun yang nantinya dipakai, kita sudah siap. Tidak semua layanan akan masuk ke dalam SJSN karena akan ada mandat dan kontrak deng-an BPJS, syaratnya adalah standar kompetensi dan standar pela yanan. Kemenkes 2011 menyatakan bahwa ada 2 layanan yang diakui, yaitu klinik pratama (layanan kesehatan umum) dan klinik utama (spesialis). Praktek mandiri diharapkan bergabung menjadi satu layanan primer, membentuk suatu sistem jaringan layanan dokter umum. Mulai pikirkan untuk bergabung praktek bersama karena praktek mandiri tidak akan diikutsertakan dalam

SJSN sebab yang diliihat adalah fasilitas layanan kesehatan. Mulai pikirkan untuk membentuk klinik yang terstandar, klinik pratama yang mandiri dan kolektif (mengajak keperawatan dan kebidanan). Konsepnya ada klinik-klinik kecil, minimal dengan 2 dokter dibantu 1 perawat lalu ada klinik yang lebih lengkap sehingga berjejaring antar klinik, jadi rujukan tidak hanya vertikal tetapi horisontal. Klinik utama memiliki peralatan yang lebih lengkap, ada USG dan pemeriksaan laboratorium sederhana. Juga didorong terbentuknya koperasi sehingga dokter tidak hanya menjadi karyawan klinik yang dapat disepelekan oleh pemilik klinik. Dokter umum hendaknya bekerja di klinik dengan bargaining menjadi bagian dari pemilik, dimana ada sebagian modal yang diberikan kepada okter yang berpraktek di klinik tersebut. Sehingga profesi ini mampu menghidupi anggotanya, dan terwujud dokter yang bermartabat dan masyarakat yang sehat.

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October 2012

Depression

Depression, other mental disorders increase risk of early death Radha Chitale

M

ental disorders such as depression, bipolar disorder and schizophrenia, which may not require hospitalization due to severity, can still increase risk of premature death, according to a long-term study of Swedish patients. “Mental disorders have been associated with increased mortality, but the evidence is primarily based on hospital admissions for psychoses,” said the researchers, who compiled data from psychiatric interviews with Swedish men of mean age 18.3 years who were conscripted for military service over a mean 22.6 years of follow up through national registries. When diagnosed at conscription, depression was associated with double the risk of premature death (age-adjusted hazard ratio of 1.81) and the presence of bipolar disorder increased the risk of death by more than 5 times (age-adjusted hazard ratio of 5.55). [Arch Gen Psychiatry 2012;69:823-831] In total, 1.09 million men were conscripted between 1969 and 1994 of which 5.6 percent were diagnosed at conscription with a mental disorder. Compared with men without mental illnesses, men who were diagnosed later upon admission to a hospital had mortality hazard ratios of 5.46 for neurotic and adjustment disorders and 11.2 for substance abuse disorders not including alcohol. Men admitted to hospital for psychiatric reasons following conscription numbered 60,333,

10,665 of whom were already diagnosed during conscription. The mortality risk associated with other diagnoses after adjusting for age, socioeconomic status, blood pressure, body mass index, intelligence, and education included hazard ratios of 1.53 for depression, 5.19 for bipolar disorder, 2.52 for schizophrenia, 1.88 for personality disorders, 1.62 for other non affective psychoses, 1.48 for neurotic and adjustment disorders, 2.38 for alcohol-related disease and 2.68 for other substance abuse. The associations were partially attenuated by adjusting for smoking, alcohol intake, intelligence, education and late-life socioeconomic status but were not affected by early-life socioeconomic status, body mass index or blood pressure. During the follow up period, 15,110 men died. Age stratification of the 4,879 men who were diagnosed during hospitalization who died subsequently showed that mortality risk was five to 11 times higher for men born between 1951 and 1958 and seven to 29 times higher for men born between 1968 and 1976. The mortality risk remained significantly elevated even after excluding about 20-32 percent of deaths considered suicide. This might be due to more severe disease, particularly in the group diagnosed early, the researchers noted. The results of the all-male study population were further limited by potentially unmeasured factors such as comorbid illness, lifestyle, medications and varying access to healthcare, the researchers said.

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October 2012

Depression

Heart attack increases spouse depression, anxiety Elvira Manzano

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he death of a spouse from heart attack increases the risk of depression and anxiety in the surviving partner, requiring an increased use of psychotropic medications, a large Danish study has found. “Losing a spouse or having a spouse experiencing a non-fatal MI is a major public health issue for which there is very little awareness among physicians and policy makers,” said study author Dr. Emil Fosbøl, a cardiologist and researcher at Denmark’s Gentofte University Hospital, Hellerup, Denmark. “People involved with patient care should be aware of spouses’ mental reactions after a life-threatening event such as an MI. I would like to see a more formal way of screening spouses for depression in relation to the event, but also subsequently.” Using data from Danish national registries, Fosbøl and colleagues compared the incidence of hospital system contact (hospital admission or ambulatory visit), use of antidepressants and benzodiazepines, and suicide among spouses of patients who had fatal and non-fatal MI (16,506 and 44,566, respectively) for the first time with those whose spouses died or were hospitalized for other causes (49,518 and 131,564, respectively). The study found the incidence of depression was significantly higher among spouses of patients who had myocardial infarction (MI), fatal or nonfatal, compared with those whose spouses had non-MI events (pre-post, P<0.0001). Overall, the use of antidepres-

sants was higher in the year after MI deaths (incident rate ratio [IRR] 3.30, 95% CI 2.97– 3.68) compared with the year before, peaking at 2 months post event (IRR 5.72, 95% CI 4.85-6.74). The use of benzodiazepines also increased a month after MI deaths (IRR 46.4, 95% CI 42.2–50.0). The results also applied to spouses of patients who had non-fatal MI (P<0.001). Moreover, spouses of patients who died from MI were more likely to commit suicide than those who lost them to other causes (0.24 vs. 0.17 percent, P=0.07). [Eur Heart J 2012. Epub ahead of print] A standardized mental screening program could potentially prevent many spouses from being depressed or taking their own lives, Fosbøl told Medical Tribune. “It would also be interesting to see in a formalized study [to determine] whether screening could reduce depression in spouses after a fatal or non-fatal MI.” Although previous studies have shown that the death of a spouse can affect an individual’s health and life expectancy, death from MI – which can often occur suddenly and unexpectedly – appears to have a larger psychological impact on the spouse than death from other causes.“One does not have time to prepare psychologically for the death compared with, for example, cancer,” Fosbøl said. The study implies that clinical attention needs to be paid to both the patient, who is suffering from the physical and mental trauma, and the spouse, who has to live through the event alongside the patient, the authors concluded.

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October 2012

Depression

Short-term fluoxetine, venlafaxine efficacious for depression Rajesh Kumar

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he antidepressants fluoxetine and venlafaxine are efficacious as short-term therapy for major depressive disorders in all age groups, according to a large meta-analysis. The researchers pooled data from more than 9,100 patients of all ages with major depressive disorder who had been included in a total of 41 randomized clinical trials of fluoxetine (N=20 trials) and venlafaxine (N=21 trials). They carried out a reanalysis of all person-level longitudinal data for the first 6 weeks of active treatment. [Arch Gen Psychiatry 2012;69:572-579] They found that patients in all age groups had significantly greater improvement compared with those receiving placebo, although the differential rate of improvement was largest for adults receiving fluoxetine (34.6 percent greater than those receiving placebo). Youth had the largest difference in response rates (24.1 percent in treated vs. control) and remission rates (30.1 percent), with adult differences generally in the 15.6 percent (remission) to 21.4 percent (response) range. Geriatric patients had the smallest drugplacebo differences, an 18.5 percent greater rate of improvement, 9.9 percent for response and 6.5 percent for remission. Also, immediate-release venlafaxine produced larger effects than extended-release venlafaxine, and baseline severity did not affect symptoms.

This is the first research synthesis in this area to use complete longitudinal personlevel data from a large set of published and unpublished studies. Most studies included in the meta-analysis were designed for achieving regulatory approval and do not demonstrate the maximum effect a drug can produce. Some studies were as short as 6 weeks whereas the maximum effect during an acute treatment episode is likely 12 weeks or longer, the researchers argued. “The [current] study highlights many of the limitations of meta-analysis that combine evidence from multiple RCTs,” concluded the researchers. “It further highlights advantages of more complete personal-level analysis when such data are available and increases the need for caution regarding interpretation of meta-analytic results when person-level data are not available.”

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October 2012

News

Tai chi can benefit patients with COPD Elvira Manzano

A

modified tai chi program may improve the exercise capacity and quality of life of patients with chronic obstructive pulmonary disease (COPD), new research has shown. In a randomized controlled trial, patients assigned to tai chi were, on average, able to walk 55 meters (95% CI 31 to 80) farther and 384 seconds (95% CI 186 to 510) longer at 12 weeks compared with a control group. [Eur Respir J 2012; DOI:10.1183/09031936.00036912] “An important finding from our study was the significant improvement in balance and muscle strength following Sunstyle tai chi training, which has the potential to reduce the risk of falls in people with COPD,” said one of the study authors Dr. Jennifer Alison, from the University of Sydney, Australia. Lower limb muscle weakness and impaired gait and balance are common in people with COPD and are major risk factors for falls. In the study, patients were randomized to a 12-week tai chi program, consisting of a 2-hour session each week, or standard COPD treatment without exercise. The majority of the patients were males. Average age was 73, with co-morbidities that included osteoarthritis, hypertension, dyslipidemia and coronary heart disease. On days when patients were not on sessions, they practiced tai chi at home for 30 minutes. Compared with the control group, patients on tai chi exercise performed 75 percent better in the walking test and had a significantly higher score in the Chronic Respiratory Dis-

Tai chi improved muscle strength and balance in study patients.

ease Questionnaire, which indicates better quality of life. Additionally, tai chi was associated with moderate intensity exercise as demonstrated by a 53-percent reserve in oxygen consumption. Significant improvements in balance, strength and performance were also observed in the tai chi group. The effects of tai chi were comparable to what can be achieved during conventional pulmonary rehabilitation. “This is good news for people with COPD because it gives them more fitness choices,” said lead study author Ms. Regina Wai Man Leung of Concord Repatriation General Hospital and the University of Sydney, Australia. “With increasing numbers of people being diagnosed with COPD, it is important to provide different options for exercise that can be tailored to suit each individual,” added

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News

Leung, a cardiorespiratory physiotherapist. The authors said the study provides compelling evidence that tai chi may be an effective alternative training modality for people with COPD who have limited or no access to

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

PPIs safe for long-term use Saras Ramiya

S

elected proton pump inhibitors (PPIs) are safe for long-term use in patients with chronic gastrointestinal (GI) conditions, a study shows. The new landmark international study looked at the long-term effects of pantoprazole in patients with chronic GI conditions such as peptic ulcers and reflux esophagitis. [Aliment Pharmacol Ther 2012;36(1):37-47] Following healing of peptic ulcers or reflux esophagitis during 4 to 12 weeks’ treatment with pantoprazole (40 to 80 mg/day), patients received open-label maintenance treatment with pantoprazole (40 to 160 mg/day) for up to 15 years in a single center combined study. Safety assessments were conducted using endoscopy, clinical examination and laboratory investigations. The safety set, which comprised 142 adults who received continued pantoprazole treatment for over 15 years, showed healing rates of 95.8 percent after 12 weeks without increased risks of specific serious conditions like stomach cancer. “This study shows that pantoprazole effectively controls the production of acid and heals upper gastrointestinal ulcers and wounds in the long term without identifiable side effects,” said principal investigator Professor G.

Expanding waistlines across Asia have contributed to increased incidence of severe and chronic gastrointestinal conditions.

Brunner, of the Division of Gastroenterology and Hepatology, University Medical School, Hannover, Germany, in a press release based on a regional GI media summit organized by Takeda Pharmaceutical Company Limited in Kuala Lumpur. “In light of this longest safety data on pantoprazole, doctors and patients have even more assurance that PPI therapy is safe for long term treatment of severe GERD and gastrointestinal conditions,” he added. GI problems on the rise GI disorders in Asia have been increasing in prevalence, as shown in studies. “As a result of dietary changes, rising obesity and stress in many parts of Asia, doctors are now seeing a rising number of cases of severe and chronic GI conditions, such as GERD, peptic ulcers

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October 2012

News

and heartburn,” said Dr. Denis C. Ngo, of the University of Santo Tomas (UST) Hospital, Manila. [J Gastroenterol Hepatol 2008:23:8-22] In the Philippines, the prevalence of erosive esophagitis rose from 2.9 percent to 6.3 percent over 6 years; in Malaysia, the incidence rose from 2.0 percent to 8.4 percent over a 10year period; time trend studies showed that esophagitis rates in Taiwan more than doubled from 5.0 percent to 12.6 percent over a 7-year period. [J Gastroenterol Hepatol 2007;22:1650-5, Aliment Pharmacol Ther 2009;29:774-80, J Clin Gastroenterol 2009;43:926-32] The prevalence of symptom-based GERD in Eastern Asia (China, Japan, Korea and Taiwan) rose from 5.2 percent in 2005 to 8.5 percent in 2010. [BMC Gastroenterol 2010;10:94] In Malaysia, the incidence of reflux esophagitis increased from 2.7 percent to 9.0 percent during the time period from 1991-1992 to 20002001, while Indonesia’s Cipto Mangunkusumo Hospital reported the prevalence of GERD increasing from 5.7 percent in 1997 to 25.1 percent in 2002. [Gastroenterology 2004;126:A443,

Canc Res Treat 2003;5:83] Currently, 2.5 percent to 4.8 percent of Asians experience weekly symptoms of heartburn and/or acid regurgitation. [Gut 2005;54:710-7] Besides heartburn, patients with GERD and gastrointestinal disorders suffer difficulty swallowing (dysphagia), reduced vitality, disturbed sleep and considerable lower quality of life greater than that observed in other chronic conditions such as diabetes, arthritis or congestive heart failure. [Dig Dis 2004;22(2):108-14] There is a high prevalence of GERD in individual Asian countries, ranging from 12.4 percent in Taiwan and up to 17 percent in China, and 29.8 percent in Hong Kong. [J Neurogastroenterol Motil 2011;17(1):14-27, World J Gastroenterol 2004;10:1647-51, Aliment Pharmacol Ther 2003;18:595-604] “These conditions are so severe that patients do not require just quick relief for GI conditions, but more sustained control with proton pump inhibitors (PPIs) over the long term,” said Ngo.

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Surgery superior in patients with carpal tunnel syndrome Rajesh Kumar

T

 reatment with surgery was significantly more effective than local steroid injection in alleviating symptoms of carpal tunnel syndrome (CTS) over a 2-year follow up period, a Spanish study has found. In the prospective, randomized clinical trial, researchers studied the effects of surgical decompression versus local steroid injection by randomly assigning 80 wrists to surgical decompression and 83 to local steroid injection following a clinical diagnosis and neurophysiological confirmation of CTS in 101 patients. [Rheumatology 2012;51:1447-1454] The primary end point at 2-year follow-up was the percentage of wrists that reached a >20 percent improvement in the visual analogue scale score for nocturnal paresthesia. Both treatment groups had comparable severity of CTS at baseline. Fifty-five wrists in the surgery group and 48 wrists in the injection group completed the follow-up. In the intent-to-treat analysis, 60 percent of the wrists in the injection group and 69 percent in the surgery group achieved a 20 percent response for nocturnal paresthesia (P<0.001). Although the clinical relevance of those differences remains to be defined, the findings are not entirely unexpected as each of the two procedures has its own benefits and disadvantages, said Dr. Chew Li-Ching, consultant in the department of rheumatology and immunology at Singapore General Hospital (SGH). “The injection can be easily… delivered at the point of care. However, usually, it provides temporary relief only compared with surgery. At

Wrist surgery is more effective at treating carpal tunnel syndrome than local steroid injections.

SGH, we are well supported by hand surgeons, [therefore] access to surgery has not proven to be an issue,” said Chew. “Injection is still an acceptable standard of care for CTS, especially if the patient’s symptoms and findings on neurophysiological testing are mild to moderate. The more severe cases such as those associated with weakness and muscle wasting would usually warrant surgery.” Although randomization based on wrists rather than patients could be considered the study’s limitation, CTS is often a bilateral condition and the approach is consistent with the standard of care in clinical practice which consists of treating both wrists in cases of bilateral CTS, said the researchers. “We also felt that by randomizing only the most symptomatic wrist in the bilateral cases, we could have a biased selection [and] the results of the study would not represent the real severity of CTS in the general population…it would transform CTS into a more severe disease than it really is.”

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Higher vitamin C intake may help reduce heart disease, stroke Rajesh Kumar

T

he recommended dietary allowance (RDA) of vitamin C should be raised to at least 200 milligrams per day for adults to prevent heart disease and stroke, experts have suggested. The current RDA for this vitamin in most countries is less than half of what it should be, because medical experts insist on evaluating this natural but critical nutrient the same way they do pharmaceutical drugs and reach faulty conclusions, said lead author Dr. Balz Frei, professor and director of the Linus Pauling Institute at Oregon State University in Corvallis, Oregon, US. [Crit Rev Food Sci Nutr 2012; 52:815-829] Rather than just prevent the vitamin C deficiency disease of scurvy, Frei said it is appropriate to seek optimum levels that will saturate cells and tissues, pose no risk, and may have significant effects on public health at almost no expense. “Significant numbers of people around the world are deficient in vitamin C, and there’s growing evidence that more of this vitamin could help prevent chronic disease,” he said. Studying micronutrients the same way as testing pharmaceutical drugs, through phase III randomized placebo-controlled trials, almost ensures that scientists will find no beneficial effect, said the researchers. Such trials are ill suited to demonstrate the disease prevention capabilities of substances that are already present in the human body and are required for normal metabolism, they added. Some benefits of micronutrients in lower-

ing chronic disease risk also show up only after many years or even decades of their optimal consumption – a factor often not captured in shorter-term clinical studies, they pointed out. The US and European researchers reviewed metabolic, pharmacokinetic, laboratory and demographic studies and concluded higher levels of vitamin C could help reduce chronic diseases such as heart disease, stroke, cancer, and the underlying issues that lead to them, such as high blood pressure, chronic inflammation, poor immune response and atherosclerosis. Even marginal deficiency of vitamin C can lead to malaise, fatigue, and lethargy, the researchers noted, while healthier levels can enhance immune function, reduce inflammatory conditions such as atherosclerosis, and significantly lower blood pressure. Critics have suggested that some of these differences are simply due to better overall diet, not vitamin C levels, but the researchers noted that some health benefits correlate even more strongly to vitamin C plasma levels than fruit and vegetable consumption alone. Dr. Amber Bastian, dietician at the Centre of Excellence (Nutrition), Health Promotion Board Singapore, said her organization updated its RDA for vitamin C earlier this year. “It is 105mg for men and 85mg for women, which is quite progressive as it is higher than Australia (45mg), US (75mg females, 90mg males), WHO (45mg) and Malaysia (70mg),” said Bastian. “[This RDA] was developed based on cur-

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rent evidence of the amount needed to provide antioxidant protection, rather than to prevent scurvy which is what was traditionally used,” she said, adding that the board regularly reviews its dietary recommendations to provide up-to-date recommendations based on the most recent evidence.

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

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October 2012

Conference Coverage

European Society of Cardiology Congress, 25-29 August, Munich, Germany

Aspirin can be dropped in PCI patients on oral anticoagulants Christina Lau

P

atients on oral anticoagulants (OAC) undergoing percutaneous coronary intervention (PCI) should be treated with clopidogrel, but not aspirin, according to the first randomized trial to assess optimal antithrombotic therapy in this high-risk group of patients. The trial showed that dual therapy with OAC and clopidogrel causes less bleeding than triple therapy with OAC, aspirin and clopidogrel, and is safe with respect to preventing thrombotic and thromboembolic complications. “Long-term OAC therapy is obligatory in most patients with atrial fibrillation (AF) and in those with mechanical heart valves. Over 30 percent of these patients have concomitant ischemic heart disease and, if they need to undergo PCI, aspirin and clopidogrel are indicated,” said lead investigator Professor Willem Dewilde of the TweeSteden Hospital in Tilburg, the Netherlands. “Until now, no prospective randomized data were available on the optimal antithrombotic therapy for these patients,” he continued. “Although triple therapy seems logical for the prevention of stroke and stent thrombosis, it often causes serious bleeding complications and the need to discontinue aspirin and clopidogrel.” The WOEST* study included 573 patients from the Netherlands and Belgium, who were already on OAC for AF or mechanical valves and were undergoing PCI. The primary endpoint was occurrence of all bleeding events after 1 year, classified according to the TIMI (Thrombosis in Myocardial Infarction) bleeding criteria. Second-

ary endpoints were the combination of stroke, death, MI, stent thrombosis and target vessel revascularization, and all individual components of the primary and secondary endpoints. “At 1 year after PCI, patients in the dual therapy group had significantly lower incidence of bleeding (19.5 vss 44.9 percent; HR=0.36; P<0.001] and overall mortality [2.6 vs. 6.4 percent; HR=0.39; P=0.027) than those in the triple therapy group,” reported Dewilde. “They had no increase in thrombotic or thromboembolic events compared with those on triple therapy.” Although the trial was open-label and had a limited number of patients, Dewilde suggested that the findings have important implications for future treatment and guidelines. “We propose that a strategy of OAC plus clopidogrel, without aspirin, could be applied in this group of highrisk patients on OAC when undergoing PCI,” he said. Commenting on the findings, discussant Dr. Marco Valgimigli from Ferrara, Italy pointed out that one bleeding event could be avoided by omitting aspirin in only four patients. “While the reductions were mostly in minimal [6.5 vs. 16.7 percent] and minor bleeding [11.2 vs. 27.2 percent], the difference in major bleeding between the dual and triple therapy groups might have become significant with larger numbers,” he said. “With the important findings from WOEST, the taboo of discontinuing or omitting aspirin in the contemporary environment has been broken.” *WOEST: What is the Optimal antiplatElet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing

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October 2012

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Investigational drug shows promise in HF Christina Lau

A

novel angiotensin receptor neprilysin inhibitor – LCZ696 – has demonstrated beneficial effects in heart failure (HF) patients with preserved ejection fraction in a phase II trial. LCZ696 is a first-in-class agent comprising the molecular moieties of a neprilysin inhibitor and the angiotensin receptor inhibitor (ARB) valsartan as a single compound. Its dual mechanism of action is believed to restore the altered neurohormonal balance in HF with preserved ejection fraction. In the PARAMOUNT* study, the efficacy and safety of LCZ696 was compared with that of valsartan in 308 patients from 13 countries. [Lancet 2012; DOI:10.1016/S01406736(12)61227-6] “HF with preserved ejection fraction accounts for up to half of HF cases, and is associated with substantial morbidity and mortality. However, no therapies have been shown to improve clinical outcomes in this condition,” said lead investigator Professor Scott Solomon of the Harvard Medical School and the Brigham and Women’s Hospital in Boston, Massachusetts, US. Results showed that after 12 weeks of therapy, LCZ696 significantly reduced levels of NT-probBNP by 23 percent compared with valsartan (P=0.005). “NTproBNP is a marker of cardiac wall stress, and levels are increased in HF patients,” explained Solomon. “The greater reduction in NT-proBNP achieved with LCZ696 was sustained to 36 weeks, although the

difference vs. valsartan was no longer significant.” Patients treated with LCZ696 also had reduced left atrial size and improved symptoms (as measured by New York Heart Association [NYHA] Functional Classification), both of which became significant vs. valsartan by week 36. “LCZ696 was generally well tolerated, with fewer serious and overall adverse events than valsartan,” said Solomon. “Results from PARAMOUNT are encouraging, and LCZ696 is currently being tested in a trial of 8,000 HF patients with reduced ejection fraction.” In another study, spironolactone was shown to improve cardiac function and structure, and reduce neuroendocrine activation in 422 patients with symptomatic diastolic HF. “In the international phase IIb AldoDHF trial, 12-month treatment with the aldosterone receptor antagonist improved diastolic function, induced structural reverse remodeling, and reduced NT-proBNP levels and blood pressure compared with placebo,” reported Professor Burkert Pieske of the Medical University of Graz in Austria. “However, the treatment did not improve exercise capacity, NYHA class or quality of life.” Spironolactone was shown to be safe, without severe adverse events. “The drug can be considered in patients with diastolic HF, for improving cardiac function and blood pressure control,” suggested Pieske. *PARAMOUNT = Prospective compArison of ARNI with ARB on Management Of heart failUre with preserved ejectioN fraction **Aldo-DHF = Aldosterone Receptor Blockade in Diastolic Heart Failure

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Niacin/laropiprant well tolerated in HPS2-THRIVE trial Alexandra Kirsten

M

ore than three-quarters of patients taking long-term extended release niacin/laropiprant (ERN/LRPT) in the HPS2-THRIVE* trial have tolerated treatment, according to preliminary results. HPS2-THRIVE is the largest study so far to assess whether adding ERN/LRPT to statin therapy can further lower cardiovascular risk. In the trial, a total of 25,673 patients with occlusive arterial vascular disease from the UK, Scandinavia and China were randomized to receive long-term treatment with either ERN/LRPT 2 mg or placebo, in addition to simvastatin therapy. The primary endpoint included major vascular events after a median follow-up of 4 years. The preliminary results suggest that about 76 percent of the patients can tolerate long-term ERN/LRPT treatment. A safety analysis suggested that myopathy occurred in 0.5 percent of patients treated with simvastatin 40 mg and ERN/LRPT, however, the vast majority of these cases were found in patients with Chinese descent.

‘‘

The preliminary results

suggest that about 76 percent

of the patients can tolerate long-term ERN/ LRPT treatment

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

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

Medicine at the University of Oxford, England, addingthatpatientsofChinesedescentshouldnot receive simvastatin 80 mg with cholesterolmodifying doses of niacin-containing products. Niacin did not show any clear adverse effects on the liver in the trial, but known cutaneous and gastrointestinal side effects were confirmed. Niacin has been shown to be an effective HDL-raising agent, but randomized trial evidence for beneficial cardiovascular effects is limited. Most previous studies have been performed using fibrates, which raise HDL cholesterol only modestly, and those studies produced mixed results. Moreover, the tolerability of niacin has been limited by flushing and cutaneous side-effects, which appear to be mediated largely by prostaglandin D. These side effects can be substantially reduced by laropiprant, a selective prostaglandin D receptor antagonist. Further results from the HPS2-THRIVE are expected to be released in 2013. *HPS2-THRIVE: Heart Protection Study 2 -Treatment of HDL to Reduce the Incidence of Vascular Events

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October 2012

Conference Coverage

European Society of Cardiology Congress, 25-29 August, Munich, Germany

Aliskiren use not advised in type 2 diabetics with renal impairment Alexandra Kirsten

A

liskiren, a direct renin inhibitor, should not be used to lower blood pressure in type 2 diabetics at high risk of cardiovascular and renal events, according the findings of the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE). “The treatment may even be harmful in these patients,” said lead study author Professor Hans-Henrik Parving from the University of Copenhagen, Denmark In the ALTITUDE study, a total of 8,561 patients with type 2 diabetes and renal impairment were randomized to double-blind treatment with either aliskerin 300 mg or placebo once daily, in addition to an angiotensin coverting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). The primary analysis was the time to the first event for the composite endpoint of cardiovascular death, resuscitated death, non-fatal myocardial infarction and stroke, unplanned hospitalization for heart failure, onset of end-stage renal disease or doubling of baseline creatinine. After the monitoring committee found an increased rate of side effects associated with active treatment, the trial was stopped prematurely. At a median follow-up of 32 months, the primary endpoint had occurred in 767 patients taking aliskiren (17.9 percent) and in 721 assigned to placebo (16.8 percent) [95%

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

CI 0.98-1.20, P=0.14]. Corresponding rates of stroke in each group were 3.4 percent and 2.7 percent, respectively (95% CI 0.98-1.60, P=0.070). Laboratory results showed albuminuria levels to be 14 percent lower in aliskirentreated patients, while increases in serum creatinine appeared similar in the two groups. Patients in the aliskiren group experienced significantly increased serum potassium levels of 6 mmol/L (8.8 percent vs. 5.6 percent for placebo), and higher rates of hypotension (12.1 percent vs. 8.0 percent, respectively). “These results do not support the administration of aliskiren on top of standard therapy in type 2 diabetic patients at high risk for cardiovascular and renal events,” concluded Parving. Aliskiren is the first in the class of drugs called direct renin inhibitors. It was approved in 2007 in the EU and US under the brandnames Rasilez and Tekturna, respectively, for the treatment of essential (primary) hypertension either as monotherapy or in combination with other medications.

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October 2012

Conference Coverage

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

First global standards on assessing lung function Rajesh Kumar

T

he first global standards on assessing lung function in different age groups and ethnicities, established through international collaboration, promise to revolutionize the way physicians diagnose and manage lung disease. Spirometry is the standard test for measuring lung function. In the absence of a global benchmark for interpreting its results, someone described as abnormal in one clinic can be labeled as normal in another. Also, an adolescent can see his/her level of lung function decrease dramatically when the care is transferred from pediatric to adult clinic. Similar errors can occur if the individual patient’s ethnicity and associated difference in body composition or stature are not taken into account. Multinational researchers part of the Global Lung function Initiative (GLI) 2012, set up by the European Respiratory Society to establish a consensus on the topic, assessed data from 74,187 healthy nonsmokers aged 3 to 95 years to derive reference spirometric prediction equations for Caucasians (N=57,395), African Americans (N=3,545), and North (N=4,992) and Southeast Asians (N=8,255), including appropriate age-dependent lower limits of normal. [ERJ 2012: DOI: 10.1183/09031936.00080312] Forced expiratory volume in 1 second

(FEV1) and forced vital capacity (FVC) between ethnic groups differed proportionally from that in Caucasians. For individuals not represented by the above four groups, or of mixed ethnicity, a composite equation taken as the average of the above equations was established. “The first standard lung growth chart developed as a result of these equations will help better identification of children most likely to benefit from treatment, thereby avoiding unnecessary medication for those who don’t need it,” said Dr. Janet Stokes of the Great Ormond St Hospital in London, UK, while describing the clinical implications. The chart will also improve diagnosis and management of chronic obstructive pulmonary disease, thus enhancing independence and quality of life in the elderly, said Stokes. The GLI-2012 lung growth chart will also allow patients to understand the health of their lungs and more effectively manage their condition, or take steps to prevent development or progression of lung disease, added Ms. Monica Fletcher, chair of the European Lung Foundation in Sheffield, UK. Subsequent additional data from the Indian subcontinent, Arab, Polynesian, Latin American countries, and Africa will further improve the equations in the future. However, their widespread use will depend on timely implementation by manufacturers of spirometry devices, said the researchers.

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October 2012

Conference Coverage

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

Home factors impact on kids’ asthma medication compliance Elvira Manzano

F

amily lifestyle and issues at home may negatively affect children’s adherence to asthma medication. In a study of 93 children with asthma conducted in the Netherlands, 72 percent used >80 percent of prescribed doses for asthma. However, almost 30 percent had poor adherence rates. Barriers to adherence include parental and financial problems, as well as having busy parents. Another common and striking finding was that children (8 to 12 years) were given full responsibility to take their medication without parental support or supervision, resulting in poor adherence. [ERJ 2012. E-pub ahead of print] The findings emphasized how crucial it is for health care professionals treating children with asthma to carefully assess these potential barriers so that appropriate interventions can be put in place to correct the problems, said lead study author Dr. Paul Brand, from the University Medical Centre, Groningen, Netherlands. “Good adherence is achievable. In fact, median adherence rate in the study was 93 percent at first month and 90 percent at third month. But when we conducted in-depth interviews on 20 parents, 12 with low adherence and 8 with high adherence, as to what might be preventing their children from following their treatment plan, they presented several lifestyle factors,” Brand said.

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

Some parents, the “delegators” and “ strugglers,” did not succeed in getting their children to take their medication properly. They said a range of things going on in their lives prevented their children from adhering to the treatment plan. Their responses included: “when he was 8, we felt that he got to take [the medication] himself.” One parent even said: “Forcing never works… it becomes a struggle, and we never do that.” Their answers were compared using an electronic monitoring system. Although parents in the low adherent group expressed intentions to strictly follow the treatment plan at the outset, they failed to do so during the course of the study, Brand said. “Struggling families therefore require tailored support.”

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He said comprehensive asthma care may prevent intentional non-adherence, and addressing parental illness and medication beliefs is important. “Excessive responsibility for medicines to school-aged children drives non-adherence,” he concluded. The results were supported by Mr. David Supple, a parent of an asthmatic child. Speaking about his own experience, he said:

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

Inhaled glutathione may help cystic fibrosis patients Radha Chitale

A

preliminary trial on inhaled glutathione (GSH) showed that it can improve lung capacity in cystic fibrosis (CF) patients with moderate to severe airways obstruction. CF is a chronic genetic disease that causes mucus to build up in the lungs, digestive tract, and other areas of the body, and affects about 70,000 people worldwide, many of them children. Glutathione is an antioxidant therapy used as a first-line defense for the lungs against oxidative stress. Lead researcher Dr. Cecilia Calabrese of Second University of Naples in Italy reported that three previous studies on inhaled GSH in CF patients have shown promising outcomes in terms of forced expiratory volume in 1 second (FEV1) and peak expiratory flow, but these were performed on a limited number of patients and only one study was placebo-controlled. In the current trial, 94 CF patients from Italy over age 6 were divided into a pedi-

atric group (6-18 years) and an adult group (>18 years) and randomized to inhaled GSH (10 mg/kg) or placebo. Patients were excluded from the trial if they demonstrated a decrease in FEV1 greater than 15 percent during a GSH inhalation test, where FEV1 is evaluated before inhalation and 10 and 60 minutes after inhalation. FEV1 was evaluated with spirometry at months 1, 3, 6, 9 and 12. Patients were questioned about their lifestyle, frequency of exacerbations, hospital admissions and antibiotic use at months 1, 6 and 12. Preliminary results showed that inhaled GSH is well tolerated by both pediatric and adult CF patients. Pediatric patients on GSH therapy did not demonstrate significant increases in FEV1 at 3 and 6 months after beginning therapy compared with the placebo group. Mean FEV1 levels at months 0, 1, 3 and 6 were 95.6 ± 22.6 percent, 96.3 ± 23.1 percent, 96.4 ± 19.5 percent and 97.1 ± 20.8 percent in the GSH group, respectively, and 101.1 ± 17.8 percent, 98.3 ± 15.3 percent, 100.4 ± 18.7 percent and

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98.6 ± 19.3 percent in the placebo group, respectively. Adults did show moderate increases in FEV1 with GSH therapy compared with placebo but this trend did not reach significance after 6 months. Mean FEV1 levels at months 0, 1, 3, and 6 were 63.3 ± 15.3 percent, 68.1 ± 17.4 percent, 67.3 ± 16 percent and 67.0 ± 16.5 percent in the GSH group, respectively, and 66.7 ± 21.3 percent, 66.5 ± 18 percent, 64.5 ± 18.9 percent and 64.0 ± 20.2 percent in the placebo group,

respectively. However, pooled data on all patients with FEV1 ≤80 percent showed that significant improvement persisted 6 months after beginning therapy. Mean FEV1 increased to 62.6 ± 15/1 percent at 6 months from 58.3 ± 13.2 percent at baseline (P=0.04). “Preliminary results seem to show that inhaled GSH therapy is able to induce a significant increase of FEV1 in CF patients affected by moderate to severe airway obstruction,” Calabrese said.

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October 2012

Conference Coverage

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

Long-distance running raises pulmonary edema risk Dr. Yves St. James Aquino

A

recent study found that marathon running can trigger pulmonary edema, which may be associated with physical signs of breathlessness, severe cough and heart attack or respiratory failure in severe cases. “Marathon running is worldwide. Halfa-million people ran the marathon in the United States this past year and in 2010. And therefore, this is a big topic,” said lead author Dr. Gerald Zavorsky. Researchers from the US and Italy aimed to determine if pulmonary edema develops from long-distance running, characterizing its incidence and severity. In addition, researchers wanted to determine if the resulting edema is related to finishing time. The study involved 26 runners who participated in the 2011 Steamtown Marathon held in Scranton, Pennsylvannia, US. The marathon started at an elevation of 452 meters above sea level, with a net drop to 291 meters at the finish line. The study noted that all runners finished with times between 142 and 289 minutes. To quantify the presence of edema, posteroanterior and lateral chest radiographs of the runners were taken the day before the race, then 19, 56 and 98 minutes after finishing the race. Three radiologists were tasked to do the radiograph interpretation. The readers worked independently and were not in contact with each other. They were also not told

Half of runners tested within 20 minutes of completing a marathon had some level of pulmonary edema.

which radiographs were taken before or after the race. Four radiographic characteristics were assessed, including peri-bronchial cuffing, loss of definition of vascular markings, pulmonary opacification and blurring of hilar silhouette. The quantification of edema ranged from 0 or no edema to 8 or severe edema. The scores from each reader were then averaged. Results showed that 50 percent of runners had some level of pulmonary edema 20 minutes after the race, and 20 percent of those runners develop moderate to severe pulmonary edema. In four runners (15 percent), mild to moderate pulmonary edema was even retained 1 hour after finishing the

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Conference Coverage

marathon. Upon further evaluation, the study found that women were at 13 times higher risk compared with men in the development of pulmonary edema (odds ratio 12.8, r2 0.31, P=0.038). No correlation was established between marathon time and the development of pulmonary edema, which suggests the risk of edema may be prevalent across all abilities. However, none of these athletes with radiologic finding of pulmonary edema exhibited signs such as difficulty of breathing or coughing of blood.

According to Zavorsky, potential causes may include stress failure of pulmonary capillaries, fluid-electrolyte imbalances, and increased permeability pulmonary edema. However, the most likely cause is increased pulmonary wedge pressure, whereby pressure within pulmonary artery force out fluid into the interstitium. “While pulmonary edema can be a negative consequence of marathon running, regular exercise can also keep you fit and healthy. We do not yet know the impact of this finding on long-term health of runners,” concluded Zavorsky.

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40

October 2012

Conference Coverage

Flight hypoxia assessment inappropriate for pediatrics Dr. Yves St. James Aquino

B

ritish Thoracic Society (BTS) recommendations on hypoxic flight assessment are not appropriate for pediatric patients, according to a study by UK researchers. The study involved 107 children age 0.1 to 19.2 years who were referred for a variety of conditions including muscular dystrophy, cystic fibrosis, severe asthma, long-term ventilation, long-term oxygen therapy and sleep breathing disorders. The BTS recommendations aim to enhance safety for passengers with lung problems who are travelling by air, reducing the number of in-flight emergencies due to respiratory disease. The BTS established upper and lower thresholds for “no inflight oxygen required” at percutaneous oxygen saturation (SpO2) >95 percent or “in-flight oxygen needed” at SpO2 <92 percent. The study was a retrospective audit of patients referred to a pediatric respiratory function laboratory. The hypoxic challenge test as described by Gong et al suggests the maximum cabin altitude of 2,438 meters (8,000 feet) can be simulated at sea level with a gas mixture containing 15 percent oxygen in nitrogen [Am Rev Respir Dis 1984;130:980–6]. According to the researchers, the test protocol used 100 percent nitrogen to dilute the contents of a body plethysmograph to a fraction of inspired oxygen (FiO2) of 15 percent, before assessing the SpO2 profile

for 20 minutes. Based on the BTS criteria, failure in the hypoxic challenge constituted a mean SpO2 of less than 90 percent when breathing FiO2 15 percent. Hypoxic challenge testing is the pre-flight test of choice for patients with hypercapnia, according to BTS [Thorax 2002;57:289–304]. Results showed that out of the 107 children, of which 58 percent were female, 83 percent (N=89) had a baseline SpO2 of greater than 95 percent in FiO2 21 percent. In addition, 29 percent of the patients were noted to be hypoxic in FiO2 15 percent. The study noted that if BTS criteria were to be applied in this pediatric sample, 17 percent (N=18) would be referred and only 10 percent (N=11) would be detected with hypoxia at mean SpO2 of <90 percent in FiO2 15 percent. However, if all referrals regardless of the BTS criteria will be assessed, 35 percent would be detected to have hypoxia. For mean SpO2 desaturation to <85 percent, use of BTS criteria would result in detection of 6.5 percent of cases versus all referral detection of 15 percent. Based on the results, the BTS recommendations for referral for hypoxic flight assessment are not appropriate for pediatrics, according to the study. It added that using sea level SpO2 <95 percent as a cutoff for referring patients will result in detection of fewer patients who desaturate in hypoxic conditions. Researchers concluded that children with respiratory disease should be considered for a hypoxic challenge test irrespective of sea-level SpO2 percent.

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Personal Perspectives

‘‘

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

‘‘

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

‘‘

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

‘‘

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

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October 2012

Calendar

October 23rd Great Wall International Congress of Cardiology (GW-ICC) – Asia Pacific Heart Congress (APHC) 2012 11/10/2012 to 14/10/2012 Location: Beijing, China Info: Secretariat Office of GW-ICC & APHC (Shanghai Office) Tel: (86) 21-6157 3888 Extn: 3861/62/64/65 Fax: (86) 21-6157 3899 Email: [email protected] Website: www.heartcongress.org

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

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

November 012 Scientific Sessions of the American 2 Heart Association 3/11/2012 to 7/11/2012 Location: Los Angeles, California, US Info: American Heart Association Tel: (1) 214 570 5935 Email: [email protected] Website: www.scientificsessions.org

8th International Symposium on Respiratory Diseases & ATS in China Forum 2012 9/11/2012 to 11/11/2012 Location: Shanghai, China Info: UBM Medica Shanghai Ltd. Tel: (86) 21-6157 3888 Extn: 3861/62/64/65 Fax: (86) 21-6157 3899 Email: [email protected] Website: www.isrd.org

3rd Annual Meeting of the American 6 Association for the Study of Liver Diseases 9/11/2012 to 13/11/2012 Location: Boston, Massachusetts, US Info: American Association for the Study of Liver Diseases Tel: (1) 703 299 9766 Website: www.aasld.org

Upcoming National Diagnostic Imaging Symposium 2/12/2012 to 6/12/2012 Location: Orlando, Florida, US Info: World Class CME Tel: (980) 819 5095 Email: [email protected] Website: www.cvent.com/events/national-diagnosticimaging-symposium-2012/event-summaryd9ca77152935404ebf0404a0898e13e9.aspx

Asian Pacific Digestive Week 2012 5/12/2012 to 8/12/2012 Location: Bangkok, Thailand Tel: (66) 2 748 7881 ext. 111 Fax: (66) 2 748 7880 E-mail: [email protected] Website: www.apdw2012.org

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

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October 2012

Calendar

54th American Society of Hematology Annual Meeting 8/12/2012 to 11/12/2012 Location: Georgia, Atlanta, US Info: American Society of Hematology Tel: (1) 202 776 0544 Fax: (1) 202 776 0545 Website: www.hematology.org

17th Congress of the Asian Pacific Society of Respirology 14/12/2012 to 16/12/2012 Location: Hong Kong Info: UBM Medica Pacific Limited Tel: (852) 2155 8557 Fax: (852) 2559 6910 E-mail: [email protected] Website: www.apsr2012.org

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

28th Congress of the Asia-Pacific Academy of Ophthalmology 17/1/2013 to 20/1/2013 Location: Hyderabad, India Info: APAO Secretariat Tel: (852) 3943 5827 Fax: (852) 2715 9490 Email: [email protected] Website: www.apaoindia2013.org

Asian Pacific Society of Cardiology 2013 Congress 21/2/2013 to 24/2/2013 Location: Pattaya, Thailand Info: Kenes Asia (Thailand Office) Tel: (66) 2 748-7881 Fax: (66) 2 748-7880 Email: [email protected] Website: http://www2.kenes.com/apsc2013/pages/home. aspx

44

October 2012

After Hours

Radha Chitale

W

hen they first went up, the enormous splayed towers encased in geometric scaffolding, what would become “supertrees,” standing bare behind the Marina Bay Sands hotel in Singapore recalled a factory more than a home for flora and fauna. But my recent visit to the National Parks Board’s ambitious Gardens by the Bay show the area has transformed from a wasteland of construction into a unique botanical park well on its way to becoming an iconic example of sustainability in urban landscaping. The over S$1 billion project covers 101 hectares of reclaimed land and includes lakes, sky walks, cultural gardens and two biomes that house 220,000 plant varieties from around the world. The supertrees are clustered in several spots around the park and are vertical

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October 2012

After Hours

gardens between 25 and 50 meters high. Their scaffolding holds ferns, flowering climbers and bromeliads that will eventually grow to cover the entire structure. The towers also function to cool the biomes, are air exhaust receptacles and are fitted with photovoltaic cells that harvest solar energy to light up the supertrees at night. The horticultural attractions of the Gardens are in the domed glass biomes. Walking into the Cloud Forest biome, one goes from sea level to 1,800 meters above and the sharp temperature drop is a welcome change from the heat outside. The waterfall at the entryway cascades down a mini mountain top covered in pitcher plants and other flowers and shrubs that thrive in cool, moist conditions. I may have mistakenly expected a wilderness of scented flowers from the Flower Dome, but the manicured central flower field is colourful enough and made a pretty picture for one couple dressed up for wedding photos, seated on matching forest thrones in a bed of gerber daisies, complete with a small gazebo in the background. The Flower Dome also features garden plants from a variety of regions such as baobab trees from Africa, wine palms from South America and olive groves from the Mediterranean. Both biomes end with educational exhibits detailing the carbon cycle, different energy sources, the science of polar ice caps, and threats to plants from urbanization and climate change. The Gardens manage to incorporate a lot of educational information across the park. Plaques studded among the portion of the Gardens that are free to the public describe the varieties of plants, what their uses are, how sustainable elements have been incorporated into the building and a smorgasbord of trivia. The plants in the biomes, by contrast, are not obviously labelled, probably to indicate that one should rent the self-guided audio tour. Beyond well-developed biomes, the Gardens are still a project in progress, with clear spots yet to be filled with plants, evidenced by patches of exposed black soil and empty wiring and trellises for plants to take over. Although the National Parks Board’s vision of a “City in a Garden” germinated the Gardens by the Bay, the vista of Singapore’s central business district looms over the park creating a sense that this is still a garden – a very large garden – in a city. But that is a question of semantics. At its most basic, the Gardens by the Bay put more plants in an urban space, and that is a good thing.

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October 2012

After Hours

Medicinal Plants Several plants in the Gardens by the Bay have medicinal properties. These plants are located all over the park and are selected because they have strong cultural connections to the garden they are in or they are native to the climate. Lemon Gum (Corymbia citriodora)

Australia Garden, Flower Dome - R  elieves arthritic pain, alleviates nasal congestion, antiseptic properties Tree Aloe (Aloe barberae)

South African Garden, Flower Dome - Antimicrobial properties, soothes skin, anti-inflammatory Monkey Puzzle Tree (Araucaria araucana)

South American Garden, Flower Dome - P  roduces a resin used to treat ulcers and sores Olive Tree (Olea Europaea)

Olive Grove, Mediterranean Garden, Flower Dome - M  etabolism inducer, reduced LDL cholesterol, blood pressure, and blood sugar levels Lavender (Lavandula dentate)

Mediterranean Garden, Flower Dome - R  educes insomnia, alopecia, anxiety, stress-related disorders, post-operative pain Tongkat Ali (Eurycoma longifolia)

Malay Heritage Garden

- Increases testosterone production, anti-malarial and anti-microbial properties Curry Tree (Murraya koenigii)

Indian Heritage Garden

- Anti-diabetic, anti-oxidant, anti-inflammatory, hepatoprotective Camphor (Cinnamomum camphora)

Indian Heritage Garden

- Anasthetic, anti-microbial Weeping willow (Salix babylonica)

Chinese Heritage Garden

- Antirheumatic, astringent, source of salicylic acid Mulberry (Morus alba)

Chinese Heritage Garden - Antimicrobial, antioxidant, hypolipidemic

47

October 2012

Humor

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

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

“If you the worst happens, canon I “Do have to go on and keephow yourgross lawn mower?” about the whole thing is?”

“What your husband is experiencing, it’s what we call rigor mortis, making it difficult for him to relax!”

“I said I was sorry!”

“Sure, some of my patients became very sick after the operation, and others have died, but none of them seriously!”

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