Experts debate China s healthcare reforms

September 2012

Experts debate China’s healthcare reforms

FORUM

NEWS Weight training lowers type 2 diabetes risk in men

Healthcare in China: Finding the right balance

CONFERENCE

IN PRACTICE Recreational runners may strain heart too

Nerves can be a pressing problem

1,500 Academic Speakers 1,500 Academic Speakers 340 Sessions 340 Sessions 70 Special Topics 70 Special Topics Date: Date: Venue: Venue:

11-14 October 2012 11-14 October 2012 China National Convention Center (CNCC), China National Beijing, China Convention Center (CNCC), Beijing, China

Congress Language: English andLanguage: Mandarin Congress English and Mandarin

Organized by:

Organizing Committee of Asia Pacific Heart Congress (APHC) Organized by: Organizing Wall International Congress Organizing Committee Committee of of Great Asia Pacific Heart Congress (APHC)of Cardiology (GWICC) Organizing Committee of Great Wall International Congress of Cardiology (GWICC)

Congress Secretariat for Overseas Delegates:

Secretariat Office of GWICC & APHC (Shanghai Office) Congress Secretariat for Overseas Delegates: Tel: 86-21-6157 ext. 3861/3862/3864/3865 Secretariat Office3888 of GWICC & APHC (Shanghai Office) Fax: 86-21-6157 3899 Tel: 86-21-6157 3888 ext. 3861/3862/3864/3865 Email: [email protected] Fax: 86-21-6157 3899 Email: [email protected] Please visit www.heartcongress.org for further details

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delegates already 10,000 confirmed! delegates already confirmed!

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September 2012

Experts debate China’s healthcare reforms Elvira Manzano

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he inaugural Healthcare in China summit held in Beijing recently served as a platform for experts to debate China’s major health challenges, identify key issues that could derail implementation of its recent reforms, and formulate strategies to meet new targets. The forum brought together top government officials, policy makers, academics and experts within the country and from around the world. Mr. Lei Haichao, deputy director-general of the Beijing Health Bureau, said that although China has made significant headway towards system improvement (eg, the establishment of a nationwide health insurance system, a primary drug list and a centralized drug procurement system), some issues remain to be addressed including resource allocation. He said more than 85 percent of China’s health budget was spent on diagnosis and treatment, with very little allocated for disease prevention. Our services are still treatment-focused and the burden of healthcare on patients is still very heavy, especially on rural residents, he added. In recent years, the government has approved several health laws and initiated more projects that are set to benefit public hospitals. However, more investments have to be poured into insurance and equipment, Lei said.

China has implemented major reforms to its healthcare system in recent years, but resource allocation remains a major issue.

China’s healthcare system funding is a balance between public and private. No country has a purely public or purely private health system, and no country can provide solely public funding, said Lei. Like any country, China is trying to find a balance between the two forms. At the panel discussions convened during the conference, experts provided suggestions on how best to allocate resources, progress public hospital reforms, augment services and raise standards of care. Specific recommendations included removing physicians’ financial incentives to overprescribe drugs and tests, controlling investments and medical costs and refocusing efforts towards stemming the tide of chronic diseases which are responsible for a very high proportion (80 percent) of deaths in China.

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September 2012

Forum

Healthcare in China: Finding the right balance Based on an excerpt from a keynote address by Mr. Lei Haichao, deputy director-general, Beijing Health Bureau, during the Healthcare in China 2012 Economist Conference held recently in Beijing, China.

Elvira Manzano

O

ver that past 3 years, China has made commendable progress with respect to its healthcare reforms. Since 2009, the Chinese government has allocated more than RMB 1.5 trillion to improve the country’s healthcare system, with significant progress made in coverage of medical insurance and the establishment of a primary drug list and centralized drug procurement system. There remain deeply entrenched issues, however, particularly with the way in which resources are allocated. Our services are still very much treatment focused, with more than 85 percent of medical resources spent on diagnosis and treatment. Relatively little is spent on the prevention of diseases. Furthermore, the burden of healthcare on patients is still very heavy, especially on rural residents.

‘‘

With ongoing reforms,

we will see more financial resources allocated to hospitals, but personally

I don’t think it is enough yet Overall however, the Chinese government has been quite successful in implementing

China is looking to find the right balance between public and private funding of its healthcare system.

its recent healthcare reforms, playing a leading role in planning and showing high levels of commitment to building a better system. The government has already pushed through more than 10 new laws, as well as initiated many pilot projects. The results from these have been good and now they need to roll out to 10,000 public hospitals. Further areas that the government can do to improve Chinas’ healthcare system include the following: • Invest more in insurance and equipment. • Guarantee quality of service in all healthcare centers. • Provide better service when it comes to

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September 2012

Forum

public disclosure, so everyone knows the state of the market. • Better educate the general public in the prevention of diseases. While it is important for the government to maintain its role as the main provider of primary healthcare services, the private sector should also be involved in non-primary services. Indeed, the healthcare system needs to work closely together with the medical insurance system in order to help those with higher demands and who can afford more expensive and individualized services. The situation for hospitals throughout China has been that day-to-day hospital charges have not been financed by the government. In fact, hospital staff salaries have usually been covered by patients’ treatment fees. Hospitals have therefore faced the ongoing challenges

of how to pay their staff and cover their daily costs. With ongoing reforms, we will see more financial resources allocated to hospitals, but personally I don’t think it is enough yet. In the near future we will also see more government money and training going into generalist doctors and local facilities, with GPs and family doctors given more opportunities to train. In addition, in some places, people who go to local hospitals will be given more money back as an incentive to go to primary healthcare centers. We need to find the right balance between private and public. No country has a purely public or purely private system and no country can provide solely public funding. Like every country, China is trying to find its balance.

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September 2012

Indonesia Focus

Local events calendar

1st Current Update On Surgical Emergencies and Daily Cases Jakarta, 22-24 September 2012 Hotel Borobudur, Jakarta Sekr : Dept. Ilmu Bedah FKUI RSCM Gedung Staff lt. 4 Jl. Diponegoro No. 71, Jakarta Tel : 021-28711480 Fax : 021-3100050 Email : [email protected] Current Issue in Pediatric Nutrition and Metabolic Problem Jakarta, 22-23 September 2012 Hotel Millenium, Jakarta Website : http://ciprime2012. blogspot.com/ Email : ciprime2012@yahoo. com The 14th International Meeting on Respiratory Care Indonesia (Respina) 2012 Jakarta, 5-6 Oktober 2012 Hotel Shangri-la, Jakarta Sekr : Gedung Asma Lt.2, Jl. Persahabatan Raya No.1, Jakarta 13230 Tel : 021-47864646, 47864321 Fax : 021-47866543 Email : info.respina@yahoo. com, info.respina. [email protected] Website : www.respina.org 2012 ISICM End Year Symposium Makassar, 10-13 Oktober 2012 Sekr : Indonesian Society of Intensive Care Medicine (Perhimpunan Dokter Intensive Care Indonesia; PERDICI) Gedung Makmal Lt. 2 Komplek FKUI, Jl. Salemba Raya No.6 Tel : 021- 68599155/31909033 Fax : 021-31909033 Email : [email protected] Website : www.perdici.org

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

10th Asia and Oceania Thyroid Association Congress Bali, 24-27 Oktober 2012 Discovery Kartika Plaza Hotel, Bali Sekr : Divisi Endokrin, Fakultas Kedokteran Universitas Padjajaran Jl. Pasteur 38, Bandung 40161 Tel /Fax : 022-2033274 Email : [email protected] Website : www.aota2012.com KOPAPDI XV Medan Medan, 12-15 Desember 2012 JW Marriot International, Aryaduta, Grand Aston, Medan Sekr : Departemen Penyakit Dalam Fakultas Kedokteran Universitas Sumatera Utara /RS Umum Pusat H. Adam Malik Lt. III , Jl. Bungalau 17, Medan Tel/Fax : 061-4528075 Email : papdicabsumut@gmail. com, kopapdixv@pharma- pro.com Website : www.kopapdimedanxv. com

www.MIMS.com Smart Rx. Every Time.

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September 2012

Indonesia Focus

Seputar donor ASI dan ibu dengan HIV Hardini Arivianti

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asil Survei Sosial Ekonomi Nasional (Susenas) tahun 2005-2010, cakupan pemberian ASI eksklusif pada bayi usia 0-6 bulan tidak ada peningkatan yang signifikan, dari 59,7% (2005) menjadi 61,5% (2010). Sedangkan cakupan untuk bayi usia 6 bulan meningkat dari 26,3% (2005) menjadi 33,6% (2010). Hal ini diungkapkan oleh Dr. Minarto, MPS beberapa waktu lalu dalam rangka merayakan ‘World Breastfeeding Week’ (Pekan ASI Sedunia) 2012 yang mengangkat tema global ‘Understanding the Past, Planning for the Future’. Banyak faktor yang dapat menyebabkan rendahnya cakupan ibu yang memberikan ASI eksklusif, antara lain ibu tidak yakin manfaat ASI dan ibu tidak mendapat cukup informasi tentang ASI yang benar, kondisi lingkungan yang mendukung ibu untuk menyusui, pemasaran susu formula yang belum tertib dan melibatkan petugas maupun institusi kesehatan serta belum meratanya dan memadainya keberadaan konselor di setiap wilayah. “Bila ibu tidak mungkin menyusui karena satu atau lain hal, pilihannya adalah de-ngan donor ASI,” tukas Dr. Minarto. Dalam Peraturan Pemerintah (PP) No. 33 tahun 2012 tentang pemberian ASI eksklusif mengatur tentang pemberian ASI eksklusif, pendonor ASI, pengaturan penggunaan susu formula dan produk bayi lainnya, pengaturan bantuan produsen atau distributor susu formula, sanksi administratif, serta tempat kerja dan sarana umum dalam mendukung program

ASI ekskslusif. Terkait pendonor ASI, dalam pasal 11 ayat 1 yang dimaksud dengan pendonor ASI adalah ibu yang menyumbangkan ASI kepada bayi yang bukan anaknya. Dalam pasal 6 menyatakan, setiap ibu yang melahirkan harus memberikan ASI eksklusif kepada bayi yang dilahirkannya. Pada PP tersebut, pendonor ASI dipertegas dalam pasal 11 ayat 1 dan 2 yaitu: (1) dalam hal ibu kandung tidak dapat memberikan ASI eksklusif bagi bayinya sebagaimana pasal 6, pemberian ASI eksklusif dapat dilakukan oleh pendonor ASI, (2) pemberian ASI eksklusif oleh pendonor ASI sebagaimana dimaksud pada ayat 1, dilakukan dengan syarat: permintaan ibu kandung atau keluarga bayi yang bersangkutan; identitas, agama dan alamat pendonor ASI diketahui oleh ibu kandung atau keluarga bayi penerima ASI; atas persetujuan pendonor ASI setelah mengetahui indentitas bayi yang diberi ASI; pendonor ASI dalam kondisi kesehatan yang baik dan tidak memiliki indikasi medis; dan ASI tidak diperjual belikan. (3) pemberian ASI sebagaimana dimaksud ayat 1 dan ayat 2 wajib dilaksanakan berdasarkan aspek sosial budaya, mutu dan keamanan ASI. (4) ketentuan lebih lanjut mengenai pemberian ASI eksklusif dari pendonor ASI sebagaimana dimaksud ayat 1, ayat 2 dan ayat 3 diatur dengan Peraturan Menteri. Sebagai tindak lanjut PP No. 33 tahun 2012 tersebut, Kemenkes melalui Dirjen Bina Gizi dan KIA sedang menyusun PERMENKES yang mengatur tata cara penyediaan fasilitas khusus menyusui, penggunaan susu formula bayi dan produk bayi lainnya atas indikasi media, pemberian ASI eksklusif dari pendonor ASI dan sanksi terkait pasal dalam PP No.

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September 2012

Indonesia Focus

33 tahun 2012. “Dalam rangka mencegah penularan HIV AIDS antar ibu dan anak, dapat dilakukan dengan cara: memberikan ASI eksklusif selama pengobatan dengan ARV; ASI bisa didapatkan dari pendonor ASI; dan bila ibu dan donor ASI tidak memungkinkan, baru dipertimbangkan pemberian susu formula,” lanjut Direktur Bina Gizi Kementerian Kesehatan RI ini. Survei nasional Pada tahun 2010-2011, Ikatan Dokter Anak Indonesia melakukan beberapa survei nasional. salah satunya insidensi ASI eksklusif. Pada usia 0-3 bulan sebesar 43% dan 0-6 bulan mencapai 27%. “Sebagian besar masyarakat telah mendengar adanya terminologi ASI eksklusif. Di pulau Jawa, Bali, Kalimantan dan Sumatera cukup tinggi mencapai 78%,” jelas dr. Elizabeth Yohmi, SpA, IBCLC. ASI merupakan makanan terbaik bagi bayi namun sayangnya ASI juga dapat menularkan berbagai virus. Menurut CDC, beberapa virus yang terdeteksi dalam ASI antara lain HIV-1, hepatitis D, CMV (1:1000), West Nile,dan human T-cell lymphotropic tipe I dan II. Transmisi HIV perlu diperhatikan saat di kandungan, persalinan dan menyusui. Menurut WHO, transmisi melalui laktasi sebesar 5-20%. Analisis Ghent (2002) menunjukkan tingkat penularan meningkat semakin lama bayi itu disusui. Hingga 2 tahun meningkat hingga 16%. Menurut meta-analisis 2004 menunjukkan transmisi kumulatif sebesar 9,3% pada usia 18 bulan. Bila ibu hamil dengan HIV + tidak diobati atau tidak mendapatkan ARV dan menyusui selama 2 tahun maka

dapat melipatgandakan risiko bayi terinfeksi menjadi 40%. “Saat hamil, ibu (HIV +) sudah dapat menularkan sebesar 5-10%. Proses persalinan karena faktor ketidaktahuan ibu, persalinan biasa meningkatkan penularan hingga 1015%. Bila tidak menyusui, peluang anak tertular menjadi 15-25%. Kalau diberikan ASI selama 6 bulan, meningkat sedikit 20-35% dan bila menyusui lebih lama lagi, meningkat 3045%,” tukasnya lebih lanjut. Mengenai situasi HIV dan AIDS di Indonesia (sesuai laporan triwulan Departemen Kesehatan hingga Maret 2009) di 33 propinsi (2000-2009), berdasarkan jenis kelamin, 74,5% ( laki-laki) dan 25% (perempuan). Lebih dari 50% kasus AIDS terjadi pada kisaran usia produktif, 15-29 tahun. Rekomendasi pemberian makan bayi sesuai guideline dari WHO tahun 2010 dinyatakan ibu mengonsumsi ARV dari minggu ke-28 kehamilan hingga 1 minggu setelah persalinan, atau untuk jumlah waktu yang tidak ditentukan jika ibu memakai ARV untuk kesehatan mereka sendiri; rejimen panjang ARV selama masa menyusui baik untuk ibu dan/atau bayi; ASI eksklusif 6 bulan; menyapih bertahap; makanan tambahan setelah 6 bulan; dan tetap merekomendasikan terus menyusui dan makan campur (makanan pendamping) dengan mengonsumsi ARV. Cara mengurangi infeksi melalui ASI donor, dr. Rosalina D Roeslani, SpA (K) menjelaskan, skrining oleh dokter, penyimpanan ASI dalam pendingin (< -20 derajat) yang dapat mematikan atau me-non aktif-kan CMV dan HTLV, serta pasteurisasi (mematikan CMV dan HIV).

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10 September 2012 Indonesia Focus Jakarta Internal Medicine in Daily Practice PAPDI, 1-2 September 2012, Jakarta

Menilai kandung kemih hiperaktif Hardini Arivianti

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urrent Management of Overactive Bladder (OAB) menjadi salah satu topik pada ‘Jakarta Internal Medicine in Daily Practice’ (JIM DACE) PAPDI, 1-2 September 2012 lalu. “Menurut beberapa literatur, OAB diartikan sebagai kandung kemih hiperaktif,” jelas dr. Edy Rizal Wahyudi, SpPD, K-Ger, FINASIM saat membahas ‘How to Optimize OAB Management: Focus on Elderly Problem’. Pada keadaan normal, frekuensi berkemih kurang dari 8 kali/24 jam dan tidak pernah terbangun malam hari karena urgensi berkemih serta ada fase menahan saat kandung kemih dalam keadaan penuh. Pada OAB, frekuensi berkemih lebih dari 8 kali/24 jam, disertai nokturia, dan tidak bisa menahan berkemih. Dibandingkan dengan penyakit kronik lainnya, prevalensi OAB ini tidak sedikit. Di Amerika Serikat, OAB berada di atas diabetes dan osteoporosis. Namun banyak juga kasus OAB yang tidak terdeteksi. “Penelitian menyimpulkan, kejadian OAB akan meningkat seiring dengan pertambahan usia,” tukas dr. Edy. Di Amerika Serikat insidensi pada usia di atas 40 tahun mencapai 11-12 %. Dari sebuah survei pada Klinik Geriatri RSCM yang menilai frekuensi berkemih pada 169 lansia menunjukkan 14,5% (pria) dan 17,9% (wanita). Sedangkan banyaknya berkemih > 2x di malam hari menunjukkan 30,2% (pria) dan 31,2% (wanita). Secara terperinci hasil survei di RSCM dan sentra pelayanan geriatri di beberapa kota di Indonesia (Jakarta, Padang, Bandung, dan Semarang), dapat

dilihat pada tabel berikut: Beberapa propinsi di Indonesia, lanjut dr. Edy, memiliki populasi usia lanjut yang besar dibandingkan dengan balita dan hal ini berkaitan dengan peningkatan usia harapan hidup yang nantinya dikaitkan lagi dengan berbagai masalah kesehatan di usia lanjut Klinik Geriatri RSCM

Beberapa sentra layanan geriatri di beberapa kota di Indonesia

OAB

23,9%

24,4%;

Inkontinensia stress

37,0%

22,9%

Berkemih > 8x/hari

42,6%

42,6%

Nokturia

79,3%

67,3%

yang dikenal dengan istilah 14 I, diantaranya inkontinensia. Karakteristik usia lanjut antara lain adanya penurunan fungsi organ, multipatologis, dan polifarmasi yang nantinya akan berperan penting saat dilakukannya pengobatan OAB. Insidensi OAB yang begitu banyak masih belum mencakup semua kasus karena selalu ada hambatan saat melaporkan kasus, misalnya inkontinensia dianggap wajar, pasien/ keluarga merasa malu, dan pasien mencoba mengobati sendiri. ‘Sekitar 2/3 pasien, memerlukan waktu dua tahun sebelum memutuskan ke dokter dan bila sudah ke dokter, tidak semuanya dinilai sebagai OAB,” jelasnya lebih lanjut. Diagnosis OAB ditegakkan berdasarkan beberapa faktor, antara lain riwayat pasien, gejala, pemeriksaan fisik, dan urinalisa. Pengobatan berupa perubahan perilaku, farma-

11 September 2012 Indonesia Focus kologi dan kombinasi keduanya. Pengobatan disesuaikan dengan lingkungan, ekspekstansi, gaya hidup, dan usia. Terapi standar OAB adalah antimuskarinik yang dapat menimbulkan efek samping berupa mulut kering, konstipasi dan penglihatan kabur. Antimuskarinik “Ada 5 subtipe reseptor muskarinik yaitu M1-M5 dan yang memperantarai kontraksi detrusor adalah M2 dan M3,” tukas Prof. Dr. dr. Armen Muchtar, DAF, DCP, SpFK (K). Reseptor terbanyak pada kandung kemih adalah M2 lalu diikuti M3 dan hambatan

langsung pada M3 merupakan mekanisme kerja antimuskarinik untuk pengobatan OAB. Oleh karena itu antimuskarinik selektif yang menghambat M3 (darifenacin, solifenacin, solifenacin) lebih disukai dibandingkan dengan yang non-selektif (propiverine, tolterodine, trospium). Akan tetapi hambatan terhadap antimuskarinik pada semua reseptor muskarinik yang tersebar di berbagai organ lain berpotensi menimbulkan efek sam-ping diantaranya mulut kering karena M3 merupakan reseptor yang memperantarai sekresi saliva.

Penelitian bakteri pada pakaian Hardini Arivianti

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ola hidup higienis pada rumah tangga dapat mencegah terjadinya infeksi atau penyakit, hal ini dipromosikan oleh ‘International Scientific Forum on Home Hygiene’ (IFH). Penelitian yang dilakukannya di beberapa negara, seperti Kanada, Jepang, Amerika dan lainnya menyimpulkan, bakteri dapat hidup pada pakaian dan peralatan rumah tangga berbahan kain, seperti alas tempat tidur, handuk, sarung bantal, dll. Definisi ‘home hygiene’ menurut IFH adalah segala aktivitas di rumah yang bertujuan untuk mencegah penyebaran penyebaran penyakit infeksi, yang meliputi kebersihan makanan, pemakaian air, pembuangan limbah, healthcare at home (misalnya ada orang sakit di rumah), kebersihan individu (mencuci tangan dan pakaian), dan kebersihan umum (mencuci pakaian).

Menurut salah satu ahli mikrobiologi lingkungan dari IFH, Ryan Gene Gaia Sinclair, PhD, MPH, memaparkan bila pakaian dan peralatan rumah tangga (handuk, seprai, sarung bantal, dan peralatan berbahan kain lainnya) tidak terjaga kebersihannya ditemukan bakteri S Aureus, E coli, K pseudomonas dan pseudomonas. “Penyebaran bakteri tersebut bervariasi, misalnya S aureus dapat menempel pada dinding mesin cuci yang terbawa pakaian kotor dan berpotensi menyebar ke pakaian lain, terutama yang lembab dan basah,” lanjutnya. Studi yang dilakukan Ojima dkk (2002) pada 86 rumah di Jepang mengevaluasi kontaminasi yang berasal dari dapur dan handuk, serta handuk di kamar mandi. Hasil isolasi menunjukkan koliform 0-8% (60% towel counter), E coli 0-2,5%, P aeruginosa 0% (6,2% dari towel counter) dan S aureus 2,6-7,4%. Pada saat yang sama, Dr. dr. Hindra Irawan

12 September 2012 Indonesia Focus Satari, SpA(K) mengutip studi Cotner S dkk (2010) yang meneliti perbedaan pertumbuhan bakteri pada kain natural dan artifisial. Hasilnya menunjukkan serat polyester dan acrylic ‘mengikat’ mikroorganisme gram negatif dan gram positif hingga 80%, sedangkan serat katun ’mengikat’ kurang dari 10%. Bakteri lebih banyak pada kain berbahan dasar sintetis dibandingkan dengan kain yang dibuat dari bahan dasar selulosa. Pada kain berbahan dasar selulosa menjadi tempat kolonisasi bakteri-bakteri yang normal ada pada keringat manusia, misalnya kelompok propionibacteria, corynebacteria, staphylococcus dan streptococcus. Pada kain sintetis menjadi tempat kolonisasi oleh bakteri yang tidak ditemukan dalam keringat manusia. Studi lain yang dilakukan Neely (2000) menilai length of survival beragam bakteri gram negatif pada kain dan plastik yang digunakan di rumah sakit. Tujuh bahan diuji yaitu katun (baju), handuk, kain campuran (katun 60%/40% polyester) pada jas laboratotium, polyester, dan poliuretan (penutup keyboard). Pada 102 mikroorganisme/swatch, bakteri itu bertahan lama kurang

dari satu jam hingga 8 hari. pada 10(4)-10(5) bakteri/swatch, bakteri dapat bertahan dari 2 jam hingga lebih dari 60 hari. Peran tekstil sebagai rantai penyebab infeksi juga diteliti oleh Dirk Hofer (‘Arab Medical Hygiene’, 2011). Tekstil berperan penting dalam rantai penularan infeksi akibat mikroorganisme patogen, misalnya bakteri, jamur, dan virus yang ditemukan pada kain dan peralatan lain berbahan kain. Itu sebabnya terutama institusi pelayanan kesehatan seperti rumah sakit, memerlukan perhatian ekstra pada kain-kain dan cara mencucinya sebagai bagian dari pencegahan infeksi. Dari studi yang dilakukan oleh IFH, mencuci dengan menggunakan bahan deterjen saja ternyata tidak cukup untuk menghilangkan kuman atau bakteri yang menempel pada pakaian dan peralatan rumah tangga lainnya yang berbahan dasar kain. Proses mencuci menjadi sangat penting, kebersihan secara estetis bukan lagi menjadi tujuan akhir mencuci, namun mencuci harus menjadi salah satu cara guna mendapatkan pakaian yang bersih secara higienis dalam arti bebas bakteri yang dapat menimbulkan penyakit.

14 September 2012 News

COPD patients benefit from antibiotic prophylaxis Alexandra Kirsten

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atients suffering from chronic obstructive pulmonary disease (COPD) may benefit from a regular intake of antibiotics to prevent acute exacerbations, according to new research. A meta-analysis of two clinical trials involving 1,251 patients with COPD showed that patients taking a daily regimen of azithromycin for 1 year had a significantly reduced frequency of COPD exacerbations compared with those receiving placebo. [N Engl J Med 2012;367:3407] While there was no significant difference between groups in terms of overall mortality, the study did show that azithromycin intake also prolonged time to first acute exacerbation and significantly improved patients’ quality of life.

‘‘

This approach has

the potential to eliminate one-third of the severe exacerbations each year among patients with COPD “This approach has the potential to eliminate one-third of the severe exacerbations each year among patients with COPD,” said lead author Dr. Richard Wenzel, Virginia Commonwealth University, Richmond, Virginia, US, and colleagues. “A patient who continues to have frequent acute exacerbations despite guidelines-based treatment is a potential candidate for prophy-

A meta-analysis has shown that a daily course of azithromycin for a year significantly cut rate of COPD exacerbations.

lactic use of azithromycin.” Nevertheless, they cautioned, a patient should have had at least two episodes of acute exacerbation in the previous year to be considered for such therapy, both to provide a baseline against which to assess clinical response and to limit overuse of azithromycin. This protocol may not be suitable for every patient, said Wenzel. Some may suffer adverse consequences with year-long use of azithromycin, such as hearing loss, antibiotic resistance and heart rhythm disturbances. According to the WHO, approximately 64 million people suffer from COPD, the fourth leading cause of death worldwide. Acute exacerbations of COPD contribute markedly to the condition’s morbidity and mortality. On average, patients experience one to two exacerbations annually, and the rate generally increases as the disease progresses. Every episode is potentially life-threatening and can lead to additional lung function decline.


Involving patients reduces unnecessary antibiotic Rx Rajesh Kumar

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shared decision-making program for GPs led to greater patient involvement in the treatment process and fewer prescriptions for antibiotics to treat acute respiratory infections, a Canadian study has shown. The reduction in antibiotic prescriptions did not have a negative effect on patient outcomes 2 weeks after the GP consultation, said the researchers. [CMAJ 2012; DOI:10.1503/ cmaj.120568] They randomized nine family practice teaching units in six regions of Quebec, Canada into two study arms: DECISION+2 and control. GPs in the DECISION+2 practices were offered a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making, while those in the control group were asked to provide usual care. The primary outcome was the proportion of patients who decided to use antibiotics immediately after the consultation. Outcomes among 181 patients who consulted 77 GPs in five family practice teaching units in the DECISION+2 group were then compared with 178 patients who consulted 72 GPs in four family practice teaching units in the control

Unnecessary antibiotic prescriptions may be reduced when patients are more involved in the decision-making process.

group. The proportion of patients who decided to use antibiotics after consultation was 52.2 percent in the control group and 27.2 percent in the DECISION+2 group (absolute difference 25.0 percent, adjusted relative risk 0.48, 95% CI 0.34–0.68). DECISION+2 was associated with patients taking a more active role in decision-making (P≤0.001) and patient outcomes 2 weeks after consultation were similar in both groups. Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections. But the authors suggested that physician training in a shared decisionmaking process, with greater patient involvement, can make a huge difference.


Single dose of iron improves quality of life in iron-deficient women Malvinderjit Kaur Dhillon

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omen with iron deficiency but are not anemic no longer have to suffer from fatigue and impaired quality of life as a study shows one dose of ferric carboxymaltose (FCM) replenishes iron stores and reduces fatigue symptoms. “Iron deficiency is very prevalent in up to a third of young western women. It is well documented that iron deficiency leads to fatigue. Fatigue leads to impairment of cognitive function, quality of life and physical performance,” said Dr. Michael Hedenus, of Sundsvall Hospital, Sweden, at the 17th Congress of the European Hematology Association. [Arch Intern Med 1993;153:2759-65, J Gen Intern Med 1992;7:276-86, Blood 2011;118:3222-7, Haematologica 2012;97(1):193] “Almost 300 young women who were fatigued and non-anemic were recruited from four European countries and were blindly randomized to receive either 1 g of FCM or 250 mL of saline. The patients had to be fatigued according to the instrumental Piper Fatigue Scale (PFS) [score ≤5]. Several exclusion criteria included patients were not allowed to suffer from major depression or any other active diseases,” said Hedenus. Percentage of patients with improved PFS total score (≥ 1 point reduction) was measured at 7, 28 and 56 days after treatment and it was found that the fatigue score improved significantly more often in FCM-treated patients compared to the placebo group (65.3 percent

A single dose of iron may also reduce fatigue in iron-deficient women.

versus 52.7 percent, P=0.03). Twice as many women in the FCM group also achieved a 50 percent reduction in their fatigue (33 percent versus 18 percent, P≤0.01). [Abstract P0405] Hedenus also noted that a difference in the median fatigue score was observed in just 7 days after treatment initiation. In addition to the total fatigue score, all sub-scores as well as mental quality of life and self-rated computerized visual analog scale (VAS) scores of alertness, contentment and calmness improved in the FCM-treated women. Almost all women in the FCM-treated group successfully replenished their iron stores and the entire group had hemoglobin levels ≥ 12 g/dL on day 56. “A single dose of FCM rapidly reduces fatigue within a week and was found in this study to be well tolerated. Our message is to assess iron status in non-anemic women with fatigue and consider them for treatment of iron deficiency,” he concluded.


Synthetic protein may keep flu at bay Malvinderjit Kaur Dhillon

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synthetic protein, EP67, has been found very effective in kick-starting the innate immune system and help fight influenza within just 2 hours of being administered, a recent animal study has shown. Prior to this study, EP67 had been mainly used as an adjuvant for vaccines, something added to the vaccine to help activate the immune response. “The flu virus is very sneaky and actively keeps the immune system from detecting it for a few days until you are getting symptoms,” said Dr. Joy Phillips, lead author of the study at the University of Nebraska Medical Center, US. Phillips, alongside with her colleague Dr. Sam Sanderson, decided to investigate the potential of EP67 to work on its own. “Our research showed that by introducing EP67 into the body within 24 hours of exposure to the flu virus caused the immune system to react almost immediately to the threat, well before your body normally would,” she said. [PLoS ONE 2012 doi:10.1371/journal. pone.0040303] According to Phillips, EP67 functions the same, regardless of the influenza strain, as it works on the immune system itself and not on the virus. This is in contrast with the influenza vaccine, which has to perfectly match the currently circulating strain. In this study, testing was done primarily in mice by infecting them with influenza virus. Researchers found that mice given a dose of EP67 within 24 hours of infection did not get sick or were not as sick as those that

were not treated with EP67. In mice, being infected with influenza translates to weight loss, which is how the level of illness was measured. Typically, mice lose approximately 20 percent of their weight when they are infected with influenza. However, mice treated with EP67 were found to only lose an average of 6 percent. More importantly, the mice that were treated a day after being infected with a lethal dose of influenza did not die, Phillips said. “When you find out you’ve been exposed to the flu, the only treatments available now target the virus directly but they are not reliable and often the virus develops a resistance against them,” Phillips said. “EP67 could potentially be a therapeutic that someone would take when they know they’ve been exposed that would help the body fight off the virus before you get sick.” Philips added that while the study focused on influenza, EP67 could potentially work on other respiratory diseases and fungal infections, and could have huge potential for emergency therapeutics. She also said it could be used in the event of a new strain of disease, before the actual pathogen has been identified, much like the SARS outbreak or the 2009 H1N1 influenza pandemic. Future research plans include examining the effect EP67 has in the presence of a number of other pathogens, and to investigate how EP67 functions within different cells in the body.


Calcium supplements linked to MI, kidney stones Yen Yen Yip

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he safety of calcium supplements has come under further scrutiny as recent reports suggest they may be linked with higher risks of myocardial infarction (MI) and kidney stones. “Calcium supplements have been widely embraced by doctors and the public on the grounds that they are a natural and therefore safe way of preventing osteoporotic fractures,” wrote Professor Ian Reid and Dr. Mark Bolland from the Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand, in an editorial in a recent issue of Heart journal. [Heart 2012;98:895-896] The editorial accompanied a study linking calcium supplements to an increased risk of heart attacks. [Heart 2012;98:920-925] The European Prospectiv Investigation into Cancer and Nutrition (EPIC) study, led by researchers based in Heidelberg, Germany, assessed calcium intake through the diet and supplements of close to 24,000 subjects for about 11 years. The results showed that subjects who took calcium supplements regularly were 86 percent more likely to have a heart attack than those who did not take any supplements. “Calcium supplements, which might raise MI risk, should be taken with caution,” concluded lead author Dr. Kuanrong Li from the Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany, and colleagues. The study also evaluated subjects whose

Calcium supplementation appears less safe when compared with normal dietary intake of calcium.

calcium intake came from dietary sources. Those who took a moderate amount of calcium through their diet (820 mg per day), instead of supplementation, were about 30 percent less likely to suffer a heart attack compared with those who took less dietary calcium (513 mg per day). Interestingly, those who included more than 1,100 mg of calcium in their daily diet did not observe a lowered risk of heart attack.

‘‘

Taking [calcium] in one or two daily [doses] is not natural

In contrast to past research, the EPIC study did not show an association between higher calcium intake and reduced CV and stroke risk, or overall CV mortality. The safety of calcium supplements has come into question, said Reid and Bolland. “It is now becoming clear that taking this

19 September 2012 News micronutrient in one or two daily [doses] is not natural, in that it does not reproduce the same metabolic effects as calcium in food. “We should return to seeing calcium as an important component of a balanced diet, and not as a low cost panacea to the universal problem of postmenopausal bone loss.” In a separate study, high doses of calcium and vitamin D supplements were shown to cause higher rates of hypercalciuria and hypercalcemia in 163 postmenopausal women with vitamin D insufficiency. The study, presented at the 2012 Annual Meeting of The Endocrine Society in Houston, US, randomized the women to vitamin D doses ranging from 400 IU to 4,800 IU per day, and calcium from 1,200 mg to 1,400 mg daily, over a year. Blood and urinary calcium

levels were measured at baseline and every 3 months during the year-long study period. The investigators found that about one in three subjects (33 percent) experienced hypercalciuria, defined as urinary calcium levels greater than 300 mg in a 24-hour urine calcium test. Hypercalcemia was also identified in about one in 10 subjects (10 percent). Given that both events are known to contribute to the risk of kidney stones, lead study investigator Professor Christopher Gallagher, director of the Bone Metabolism Unit at Creighton University Medical Center, Nebraska, US, has suggested that clinicians should monitor the blood and urine calcium levels of patients who take calcium and vitamin D supplements on a longterm basis.


Vitamin E may help reduce liver cancer risk Radha Chitale

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arge amounts of dietary or supplementary vitamin E may help reduce the risk of liver cancer in women, according to a large prospective, populationbased study of Chinese adults. “We found a clear, inverse dose-response relation between... vitamin E intake and liver cancer risk, an association that was independent of supplement use and that appeared to be slightly stronger among participants who reported no liver disease or family history of liver cancer,” said researchers from Vanderbilt Epidemiology Center in Nashville, Tennessee, US, and the Shanghai Cancer Institute in Shanghai, China. Previous epidemiological studies have proved inconclusive about the effects of vitamin E on various cancers but there is evidence that vitamin E improves liver function in people with viral hepatitis. Case controlled studies of dietary vitamin E are few. The study included 132,837 people from the Shanghai Women’s Health Study (19972000) and the Shanghai Men’s Health Study (2002-2006). [J Natl Cancer Inst 2012 Jul 17 Epub ahead of print] Participants were interviewed about their dietary habits and vitamin supplement consumption and evaluated using food frequency questionnaires, plus follow-up interviews. Not including the first 2 follow-up years, the analysis showed that 118 women and 149 men developed liver cancer an average 10.9 and 5.5 years, respectively. People who consumed greater amounts of dietary vitamin E had a lower risk of de-

Supplemental vitamin E intake was inversely correlated with liver cancer risk in adult Chinese women.

veloping liver cancer compared with those who consumed less vitamin E (P Trend = 0.01). Supplemental vitamin E was similarly inversely associated with a lower risk of liver cancer. The results were consistent for both men and women with and without self-reported liver disease or a family history of liver cancer but were only statistically significant for women. Liver cancer is the third most common cause of cancer deaths worldwide and has a poor survival rate – about 15 percent over 5 years. The majority of liver cancer cases occur in developing countries and over half occur in China. Other studies have suggested that vitamin E is an antioxidant that prevents DNA damage, enhances DNA repair, prevents lipid peroxidation, inhibits carcinogens and boosts the immune system. A high concentration of dietary vitamins

21 September 2012 News and minerals may reduce inflammation and prevent infection, both of which can contribute to liver cancer, particularly in the presence of chronic hepatitis B or C virus, but this is so far unstudied. Hepatitis B is a known risk factor for liver cancer. Contrary to vitamin E, the study showed that vitamin C supplements and multivitamins were associated with a higher risk of liver cancer in adults with self-reported

liver disease or family history of liver cancer, and highest in male smokers. However, dietary vitamin C and other vitamins were unrelated to the risk of liver cancer. The researchers noted this result may be due to reverse causation as people with a history of cancer are more likely to take vitamin supplements, but that further studies on the effect of vitamin supplements on liver cancer are warranted.


Vitamin B12 may boost Hep C treatment response Elvira Manzano

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upplementation with vitamin B12 may help increase the effectiveness of antiviral treatment administered to patients with chronic hepatitis C virus (HCV) infection. This was the key finding of an open-label pilot study conducted in Italy. Patients treated with vitamin B12 plus standard therapy (pegylated interferon-alfa and ribavirin) had better sustained viral response (SVR) rates – undetectable serum HCV RNA 6 months after treatment – than those treated with standard therapy alone (72 percent vs. 38 percent, P=0.001). SVR rates were also significantly higher in genotype 1 carriers and patients with high viral loads at baseline (41 percent and 38 percent, respectively). [Gut 2012; Epub ahead of print] “Overall, adding vitamin B12 to standard therapy strengthened the rate of SVR by 34 percent,” said study author Professor Gerardo Nardone, from the Department of Clinical and Experimental Medicine, Gastroenterology Unit, University of Naples, Naples, Italy. SVR is an indicator of long-term remission and currently the best marker of successful therapy for HCV infection. While there is some support for detection of viral response 3 months after treatment, the 6-month posttherapy identification time-point remains the gold standard for treatment success. Vitamin B12 has been shown to inhibit HCV replication in vitro. In the study by Nardone and colleagues, adding vitamin B12 to standard treatment further increased viral response. A total of 94 patients with chronic, untreated HCV infection were randomized to standard therapy with or without vitamin

B12 5,000µg monthly for 6 to 12 months. After one month, response did not differ between the two groups. However, patients on vitamin B12 had significantly greater responses at all other time points, particularly 6 months after completion of treatment. Six patients receiving standard care and five receiving vitamin B12 plus standard therapy discontinued treatment because of adverse events. Multivariate analysis demonstrated that only vitamin B12 supplementation (overall response [OR]=6.9; P=0.002) and genotype 2 or 3 (OR=9; P=0.001) were independently associated with SVR. HCV genotypes 2 and 3 are easier to treat than genotype 1. Patients with genotypes 2 and 3 may have to be treated for 6 months, with higher response rates of 70 to 80 percent in most studies, whereas genotype 1 carriers have to be treated for up to 12 months, with only 40 to 50 percent response rates. The addition of vitamin B12 to current standard therapy offers a safe and inexpensive option for difficult-to-treat patients and those with high baseline viral load, Nardone said. “This strategy would be useful in countries where, owing to limited economic means, the new generation antiviral therapies cannot be given in routine practice.” Commenting on the study, Associate Prof. Tan Chee Kiat, senior consultant, Department of Gastroenterology and Hepatology, Singapore General Hospital said the study, being small and preliminary, has to be validated by other studies. “We will need the result to be validated by other independent studies as the study is just a pilot study and was open-label rather than double-blind.”


No effect of maternal antibodies on Hep A vaccination in infants Alexandra Kirsten

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accination against the hepatitis A virus (HAV) in children 2 years of age and younger remains effective for at least 10 years and is not affected by maternal anti-HAV antibody transfer. These were the results of a recently published study by epidemiologists from the Centers for Disease Control and Prevention in Atlanta, Georgia, US. “Persistence of seropositivity conferred by hepatitis A vaccine administered to children under 2 years of age is unknown and passively transferred maternal antibodies to hepatitis A virus may lower the infant’s immune response to the vaccine”, the researchers explained. The trial is the first to examine the effectiveness of a two-dose inactivated hepatitis A vaccine in children younger than 2 years of age over a 10-year period. Study author Dr. Umid Sharapov and colleagues enrolled 197 infants and young children who were healthy at 6 months of age. The children were divided into three groups to receive a two-dose hepatitis A vaccine: group 1-infants 6 to 12 months; group 2-toddlers between 12 and 18 months; and group 3-toddlers 15 to 21 months of age. Each group was randomized by maternal anti-HAV status. HAV antibody levels were measured at 1 and 6 months, and additional follow-up took place at 3, 5, 7 and 10 years after the second dose of the vaccine. At 1 month after the second dose of the vaccine, children in all groups showed signs of seroprotection (>10 mIU/mL) from the Hepatitis A virus. After 10 years of follow-up, most children retained anti-HAV protection. In the first

A study in the US showed persistence of seropositivity for at least 10 years after hep A vaccination of infants less than 2.

group, 7 percent and 11 percent of children born to anti-HAV–negative and anti-HAV– positive mothers, did not retain HAV protection from vaccination, respectively. Overall, 4 percent of group 3 children born to anti-HAV negative mothers lost HAV protection. [Hepatology 2012; DOI: 10.1002/hep.25687] “Our study demonstrates that seropositivity to hepatitis A persists for at least ten years after primary vaccination with two-dose inactivated HAV vaccine when administered to children at ages 12 months and older, regardless of their mothers’ anti-HAV status,” concluded Sharapov. Additionally he pointed out that a future booster dose may be necessary to maintain protection against HAV. The study group will continue to follow-up participants into their teens to monitor benefits of the initial immunization.


Testosterone therapy linked to weight loss in men Rajesh Kumar

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ong-term testosterone therapy may reduce weight, waist circumference and body mass index (BMI) in hypogonadal men who are overweight or obese, according to research presented at the Endo 2012 conference held recently in Houston, Texas, US. The open-label, prospective registry study included 255 men (mean age 60.6 years) with testosterone levels between 1.7 and 3.5 ng/mL who were given parenteral testosterone undecanoate 1,000 mg every 12 weeks for up to 5 years. Their mean body weight significantly decreased from 106.22 kg at baseline to 90.07 kg after 5 years (P≤0.0001). Mean waist circumference also significantly declined from 107.24 cm at baseline to 98.46 cm after 5 years (P≤0.0001), while mean BMI declined from 33.93 to 29.17 (P≤0.0001). The benefit was progressive over the follow-up period, said the researchers. Mean weight loss after 1 year was 4.12 percent, after 2 years 7.47 percent, after 3 years 9.01 percent, after 4 years, 11.26 percent and after 5 years 13.21 percent. At baseline, 96 percent of men had a waist circumference of ≥94 cm. This proportion decreased to 71 percent after 5 years. “It is clear that long-term testosterone treatment in hypogonadal men makes them lose weight,” said study author Professor Farid Saad of the Gulf Medical University, Ajman, UAE and head of Global Medical Affairs (Andrology) at Bayer Pharma. Adverse events and adverse drug reactions (ADRs) occurred in 12 percent and 6 percent of patients, respectively. The most

common ADRs were increase in hematocrit, increase in prostate specific antigen (PSA), and injection site pain (all <1 percent). No case of prostate cancer was observed. Another study has confirmed similar benefits of testosterone therapy. The IPASS* study spanning 23 countries in Europe, Asia, Latin America, and Australia, analyzed 1,438 (mean age 49.2 years) hypogonadal men who were overweight and were given a total of 6,333 injections of long-acting-intramuscular testosterone undecanoate over 9 to 12 months. [J Sex Med 2012; DOI: 10.1111/j.17436109.2012.02853.x] While their scores of mental and psychosexual functions (libido, vigor, overall mood, and ability to concentrate) improved markedly, mean waist circumference decreased from 100 cm to 96 cm. Blood pressure and lipid parameters were also favorably altered in a significant manner, said the researchers. After four injection intervals, the percentage of patients with ‘low’ or ‘very low’ levels of sexual desire/libido decreased from 64 percent at baseline to 10 percent; moderate, severe, or extremely severe erectile dysfunction decreased from 67 percent to 19 percent. At the last observation, 89 percent of patients were ‘satisfied’ or ‘very satisfied’ with therapy. “Keeping testosterone levels normal has clear health benefits for the male, other than sexual,” concluded Professor Peter Lim, urologist at the Gleneagles Medical Centre and head of the Society for Men’s Health Singapore. *IPASS: International, multicenter, Post-Authorization Surveillance Study on long-acting-intramuscular testosterone undecanoate


Shift work increases CV risk Elvira Manzano

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eople working overnight shifts or any odd-shifts outside of regular 9am to 5pm working hours are at increased risk of heart attack and stroke, a meta-analysis has found. The analysis showed that shift workers were 23 percent more likely to experience a heart attack, 24 percent more likely to have coronary events, and 5 percent more likely to have a stroke compared with people working day shifts. The risks remained consistent despite adjustment for factors such as study quality, socioeconomic status and unhealthy behaviors, including smoking. Interestingly, shift work was not associated with increased rates of death from any cause. [BMJ 2012;345:e4800] “Our findings suggest that people who do shift work should be vigilant about risk factor modification,” said lead study author Dr. Daniel G. Hackam, assistant professor at the Department of Epidemiology and Biostatistics at University of Western Ontario in London, Ontario, Canada. “Shift workers should be educated about cardiovascular symptoms to forestall the earliest clinical manifestation of the disease.” Hackam and colleagues reviewed 34 previous studies linking shift work to vascular events or mortality. Shift work was defined as night shifts, rotating or split shifts, on-call or casual shifts or any non-daytime schedules. The analysis involved over 2 million workers. Overall, there were 17,359 incidents of

coronary events, 6,598 heart attacks and 1,854 strokes. One in 14 heart attacks and 1 in 40 strokes were directly related to shift work. The increased risk for heart attack and stroke may be related to disruption in the body’s circadian rhythm and impairment in sleep quality, said the authors. “Even a single overnight shift is enough to increase blood pressure and impair variability of heart rate.” Those who worked night shifts had the highest risk for coronary events at 41 percent. Shift workers were also more likely to smoke, eat unhealthy foods and have no time to exercise. “They should be aware of the health risks that go with their work patterns. They should go to their doctors and have their blood pressure, cholesterol, waist circumference and blood glucose routinely checked,” Hackam said. He also recommends that employers institute health screening programs in the work place, give employees time to sleep and rationalize shift scheduling systems. “Modification and rationalization of shift schedules may yield dividends in terms of healthier and more productive workers.” The study is the largest synthesis of shift work and vascular risk reported thus far. Despite several limitations of the study, including heterogeneity in the outcome of coronary events, “we have identified an epidemiological association between shift work and vascular events… which may have implications for public policy and occupational medicine,” the authors concluded.


Weight training lowers type 2 diabetes risk in men Alexandra Kirsten

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en who do regular weight training may be able to reduce their risk of type 2 diabetes (T2D), according to the findings of a new study by researchers based in the US and Denmark. “Until now, previous studies have reported that aerobic exercise is of major importance for type 2 diabetes prevention,” said lead author Mr. Anders Grøntved, visiting researcher in the department of nutrition at Harvard School of Public Health, Boston, Massachusetts, US. This is the first trial to examine the role of weight training in the prevention of T2D. In their study, data from a prospective cohort study involving 32,002 men enrolled into the Health Professionals Follow-up Study conducted in the US from 1990 to 2008 were analyzed. Participants recorded how much time they spent each week on weight training and aerobic exercise (including jogging, running, cycling and swimming) on questionnaires they filled out every 2 years. During 18 years of follow-up, 2,278 new cases of T2D were documented. [Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3138] What the researchers found was a doseresponse relationship between an increasing amount of time spent on weight training and lower risk of T2D (P=0.001 for the trend). To examine the association of weight training with the risk of T2D and to assess the influence of combining weight training with

Men who engaged in both aerobic and weight training for more than 150 minutes per week had the greatest reduction in T2D risk.

aerobic exercise, the men were categorized according to how much weight training they did per week: up to 59 minutes, between 60 and 149 minutes, and 150 minutes or more. Depending on the training amount, they reduced their T2D risk by 12 percent, 25 percent and 34 percent, respectively, compared with no weight training. Men who engaged in aerobic exercise and weight training for at least 150 minutes per week had the greatest risk reduction of 59 percent. “This study provides clear evidence that weight training has beneficial effects on diabetes risk over and above aerobic exercise, which are likely to be mediated through increased muscle mass and improved insulin sensitivity,” the researchers stated. The authors added however that further research is needed to confirm the results of the study as well as to analyze whether the findings can be generalized to women. Furthermore, the effect of duration, type and intensity of weight training on T2D risk should be examined in greater detail.

27 September 2012 Conference Coverage ASEAN Federation of Cardiology Congress, 13-15 July, Singapore

Recreational runners may strain heart too Rajesh Kumar

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igh levels of endurance exercise in recreational runners may result in transient but significant ventricular stunning, release of cardiac biomarkers and acute kidney injury, according to a Singapore study. Previous studies involving elite long distance runners have linked high-level endurance exercise with elevated cardiac biomarkers, right ventricular dysfunction as well as a decrease in glomerular filtration rate. However, it has been suggested that such findings may not apply to the majority of recreational runners participating in moderate endurance events. In the present pilot study, the researchers recruited 10 healthy subjects (mean age 36.5 years) to complete a 21km treadmill run. Before and after the run, echocardiograms and peripheral blood samples were taken from the participants to confirm the hypothesis that changes in cardiac biomarkers may reflect RV dysfunction after moderate endurance activity. Highly sensitive troponin T (hsTnT), Nterminal pro brain natriuretic peptide (NTProBNP) and the novel renal biomarker neutrophil gelatinase-associated lipocalin (NGAL) were analysed prior to, within 1 hour of run completion, and 24 hours after the run. The hsTnT in five out of 10 subjects ranged from 15 to 33 pg/mL within 1 hour post-exercise, which was above the 99th percentile (14 pg/mL) of the upper reference limit. These

A pilot study conducted in Singapore showed that recreational runners can strain their hearts or damage their kidneys while performing heavy amounts of endurance exercise.

fell below the cut-off in all but one subject at 24 hours. NTProBNP levels were below the established cut-off value for detection of heart failure. There was no direct correlation between changes in strain and hsTnT or NTProBNP. While the findings support the concept of cardio-renal coupling in endurance exercise, the researchers acknowledge that the number of subjects in this study is small, and validation with a larger study is required. “Whether these individuals are more prone to chronic myocardial and/or kidney injury is unknown. The findings warrant further investigation in larger populations of recreational runners and the general population should not be unnecessarily alarmed at this point,” said study researcher Dr. Yeo Tee Joo of the cardiac department at National University Heart Centre, Singapore. Yeo said that physicians should reassure any of their patients who are recreational runners that the benefits of regular exercise far outweigh any potential risks.

28 September 2012 Conference Coverage In a healthy person with no history of cardiovascular disease, he said some key points they need to be reminded of, are: • Always keep well hydrated. • Slow down or stop if there are any unusual symptoms including: chest pain/uneasiness, giddiness and/or palpitations. • Avoid strenuous activity when unwell (eg,

during fever or flu). • Engage in exercise in a progressive manner. “[The latter] is in particular for ‘weekend warriors’ who lead a sedentary lifestyle and feel compelled to over-strain once or twice a week rather than exercise regularly at a manageable intensity, more frequently,” said Yeo.

Measure BP on both arms Rajesh Kumar

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hysicians are being reminded to take routine blood pressure (BP) measurements from both arms of their patients following research that showed a difference of just 10 mmHg in inter-arm systolic BP is closely linked to peripheral artery disease, especially in non-obese and nonhypertensive patients. “We as physicians neglect to evaluate BP from both arms. It’s a simple procedure which can reveal so much information on other vascular diseases and correlation with surrogate marker such as ankle brachial index (ABI),” said author Dr. Erwin Mulia of the department of cardiology and vascular medicine, faculty of medicine at Universitas Indonesia, Jakarta, Indonesia. The cross-sectional study evaluated 80 patients who followed elective coronary angiography from March to May 2011. The mean difference in inter-arm systolic BP was 34.6 mmHg and mean ABI was 1.3 (0.7-1.8). A difference of 10 mmHg in systolic BP was found in 85 percent of subjects. The correlation between inter-arm BP difference and ABI in coronary artery disease patients was 0.337 (P=0.001). In non-overweight/ obese and non-hypertensive patients, the correlation was 0.450 (P=0.001) and 0.501 (P=0.043), respectively.

“Some also say that [inter-arm difference in systolic BP] has correlation with severity of coronary stenosis, though my previous research didn’t show its correlation with Gensini score,” said Mulia. In primary care services or in rural areas where availability of diagnostic tools is limited, Mulia said such a simple procedure could prevent delays in the diagnosis of vascular diseases. He pointed out that the textbook of cardiovascular medicine Braunwald’s Heart Disease recommends blood pressure measurement on both arms, while earlier research had linked a difference of just 15 mm Hg or more in inter-arm SBP to the risk of vascular disease or death. An earlier meta-analysis concluded that “a difference in systolic BP of 10 mm Hg or more…between arms might help to identify patients who need further vascular assessment [while] a difference of 15 mmHg or more could be a useful indicator of risk of vascular disease and death.” [Lancet 2012; 379:905-914] Therefore, a patient with an inter-arm sytstolic BP difference of 10 mmHg would benefit from further investigation for vascular disease and ought to be targeted with aggressive management of their cardiovascular risk factors, said Mulia.

Please visit www.isrd.org for further details

Chinese Alliance Against Lung Cancer (CAALC)

Nearly 100 Academic Speakers, 15 Sessions and 6 Special Topics English Sessions Highlights：

ISRD 2012 The very first joint scientific sessions with the American Thoracic Society

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

30 September 2012 Atrial Fibrillation

Anti-arrhythmics offer superior survival rates for older AF patients Elvira Manzano

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nti-arrhythmic agents may improve survival in older patients with atrial fibrillation (AF) compared with rate control drugs, a large population-based study has found. In the study, which involved 26,130 patients aged ≥66 years who had a primary or secondary hospitalization for AF, mortality rates were steadily lower in those receiving rhythm control therapy (24 percent) after 5 years (ratio [HR] 0.89; 95% CI 0.81 to 0.96) vs. rate control drugs. At 8 years, the HR for patients on rhythm control drugs further went down to 0.77 (95% CI 0.62 to 0.95). [Arch Intern Med 2012;172:997-1004] “With increasing follow-up time, mortality among patients treated with rhythm controlled drugs gradually decreased relative to those treated with rate control drugs, reaching a 23 percent reduction after 8 years,” said study author Dr. Louise Pilote, from McGill University and the Royal Victoria Hospital in Montreal, Quebec, Canada. “Rhythm control therapy seems to be superior in the longterm.” Patients were followed for a mean of 3.1 years and for a maximum of 9 years. While there was a small increase in mortality associated with rhythm control therapy in the first 6 months of treatment (HR 1.07), a survival benefit was seen in the same group of patients over time. “The risk reduction associated with rhythm control was more pronounced in patients who maintained initial treatment over longer periods of time, suggesting that the use of rhythm control therapy may be beneficial for AF patients in whom antiarrhythmic drugs are ef-

fective and well-tolerated,” Pilote said. “Before we decide on giving rate control therapy to a patient, we should see if [the patient] can be on the current rhythm control therapies and if he can tolerate it. [We should] make an added effort in those who are good candidates for rhythm control.” However, experts cautioned that given the limitations of such population-based studies, the findings should not change the current approach to managing AF. In an accompanying editorial, Dr. Thomas A. Dewland and Dr. Gregory M. Marcus, from the University of California, San Francisco, US, said the choice of a rhythm control vs. a rate control strategy for AF is particularly prone to confounding by indication, as rhythm control is preferentially offered to younger patients with fewer medical co-morbidities. “Although the findings are provocative, they are insufficient to recommend a universal rhythm control strategy for all patients with AF,” they said. However, they also noted that “no clinical trial has definitively shown that maintenance of sinus rhythm is inferior to rate control, and expert consensus recommends a rhythm control strategy for individuals with arrhythmiaattributable symptoms.” Shorter duration studies previously conducted such as the RACE (Rate Control Versus Electrical Cardioversion) and the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trials provided evidence that the rate control strategy was preferred for older patients without AF-related symptoms. Dewland and Marcus said the current study challenges the wisdom of this approach.


Targeted cardiac ablation highly effective in treating AF Radha Chitale

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argeted cardiac ablation was twice as successful at treating atrial fibrillation (AF) as standard catheter ablation, according to the results of the CONFIRM* trial. The trial is the first to demonstrate that AF is sustained by small areas of abnormal electrical activity – electrical rotors and focal impulses – that can be targeted for ablation to achieve long-lasting AF improvement. “Human AF rotors and focal impulses were fewer in number, longer lived, and more conserved in this study than suggested,” said researchers from the University of California at Los Angeles, University of California at San Diego and Indiana University in the US. The prevalent hypothesis is that AF persists due to “meandering electrical waves,” which cardiologists treat by catheter ablation around the pulmonary veins. However, AF can return in a third or more treated patients, even after multiple procedures. “That alters our conceptual framework for human AF, and enabled FIRM [focal impulse and rotor modulation] ablation to be practical and effective.” The trial included 107 patients with AF who received standard catheter ablation (N=71) or FIRM-guided ablation followed by standard ablation (N=36). [J Am Coll Cardiol 2012 Jul 13. Epub ahead of print] FIRM-guided patients were ablated based on a personalized computational map that showed precisely where to destroy the source tissue. Each of the FIRM intervention patients had about two sources of localized rotors or focal impulses. AF terminated or slowed in 86 percent of

FIRM-guided patients compared with 20 percent of FIRM-blinded patients (P<0.001). FIRM ablation at the source stopped AF in a median 2.5 minutes. After 2 years (median 273 days) after one procedure, 82.4 percent of FIRM-guided patients were AF-free compared to 44.9 percent of FIRM-blinded patients (P<0.001) based on implanted electrocardiograph monitoring. Both FIRM-guided and standard catheter ablation procedures took similar amounts of time and adverse events were similar between groups. The researchers reported that FIRM ablation at target points stopped AF in a median time of 2.5 minutes, indicating the mechanistic role of rotors and focal sources in sustaining AF. “Patients in whom FIRM ablation slowed rather than terminated AF had sources that could not be eliminated, for safety considerations or protocol imposed time limits… and may have had residual sources in unmapped regions,” the researchers said. AF is the most common form of arrhythmia in the world and significantly increases the risk of stroke as well as being associated with cardiac issues. One-year success for ablation therapy without pharmacotherapy is up to 60 percent with one procedure and up to 70 percent for three or more. “FIRM-guided therapy presents an opportunity to improve ablation outcomes while avoiding more extensive strategies that may result in serious sequelae,” the researchers said. *CONFIRM: Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation


Anticoagulant safety protocols working well in Europe Rajesh Kumar

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hysicians should be reassured that safety indicators in place for anticoagulation therapy in patients with atrial fibrillation (AF) are working well, a large European study suggests. For patients on warfarin, the International Normalized Ratio (INR) should typically be between 2.0 and 3.0 (in healthy people, it is about 1.0). However there have been no large scale studies to establish the danger INR level in patients with AF. The prospective European Action on Anticoagulation (EAA) study has now confirmed INR >5.0 as the safety indicator, which is consistent to that currently outlined by the UK National Health Service improvement document. [J Clin Pathol 2012;65:452-456] The EAA study researchers monitored the INR of 5,839 patients using their blood tests, which were independently assessed. Any clinical events, such as bleeding or thrombosis, were also monitored and matched to the patient’s INR reading. At least 13 percent who had at least one INR >5.0 had a bleeding or thrombotic event. The incidence was significantly higher than for the 6.2 percent of patients who had a clinical event but did not develop an INR >5.0 (95% CI 1.41 to 2.04; P≤0.001). Of patients starting oral anticoagulation who had a bleeding episode (minor, major or fatal), 9.5 percent had at least one INR >5.0. This was significantly higher than the 4.6 percent in patients who did not develop INR >5.0 (95% CI 1.32 to 2.04; P≤0.001). In the first 2 months of treatment, bleeding occurred in 11.0 percent of patients who had

Safety indicators used in the UK for anticoagulant therapy with warfarin have been correct, according to a study.

at least one INR >5.0. This was significantly higher than the bleeding rate of 5.0 percent in patients who did not develop an INR >5.0 (P≤0.001). “This study demonstrates through significant patient results that the ‘safety indicators’ (as listed in the UK document) are correct. This is a really important finding for the hundreds of thousands of patients who suffer from AF and for the medical staff who treat them,” said EAA project leader Professor Leon Poller of the EAA central facility at the faculty of life sciences, University of Manchester, Manchester, UK Warfarin is a commonly used anticoagulant all over the world and all countries have their own safety protocols around its use. But the findings on the UK protocols should influence practice. Medical professionals everywhere, including Asia, should be aware of them and apply them to make the treatment of AF safer, said Poller.

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34 September 2012 Calendar September Medical Fair Asia — 9th International Exhibition on Hospital, Diagnostic, Pharmaceutical, Medical and Rehabilitation Equipment Supplies 12/9/2012 to 14/9/2012 Location: Singapore Info: Messe Düsseldorf Asia Tel: (65) 6332 9626 Email: [email protected] Website: www.medicalfair-asia.com

Hospital Management Asia 2012 13/9/2012 to 14/9/2012 Location: Hanoi, Vietnam Info: Ms. Sheila Pepito Tel: (632) 846 8339 Email: [email protected] Website: hospitalmanagementasia.com

London College of Clinical Hypnosis (LCCH-Asia) Certificate in Clinical Hypnosis 22/9/2012 to 23/9/2012 Location: University of Malaya, Kuala Lumpur, Malaysia Info: LCCH Secretariat Tel: (60) 3-7960 6439 / 7960 6449 Email: [email protected] Website: www.hypnosis-malaysia.com

October 48th Annual Meeting of the European Association for the Study of Diabetes 1/10/2012 to 5/10/2012 Location: Berlin, Germany Info: EASD Secretariat Email: [email protected] Website: www.easd2012.com

15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012) 3/10/2012 to 6/10/2012 Location: Florence, Italy Tel: (41) 22 908 0488 Fax: (41) 22 732 2850 Email: [email protected] Website: www.kenes.com/esid

8th World Stroke Congress 10/10/2012 to 13/10/2012 Location: Brasilia, Brazil Info: World Stroke Organization Tel: (41) 22 908 0488 Email: [email protected] Website: www1.kenes.com/wsc

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

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

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

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

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

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

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

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

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

36 September 2012 In Practice

Nerves can be a pressing problem Adjunct Associate Professor Hee Hwan Tak M.B.B.S. (Singapore), F.R.C.S. (Glasgow)

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Singaporean patient who had undergone a kidney transplant complained of unsteadiness in 2009 and developed a tendency to fall. The kidney specialist was concerned enough to admit him for an MRI scan of the spine to see if there was anything compressing the nerves of his spinal column, which could cause such symptoms. The scan revealed significant compression of the nerves in the neck. We all know that the spinal column houses, protects and nourishes our nerves. Control of all our major body systems and organs is via our nervous systems, which are akin to electrical wires branching out from a central grid. The nerves in the neck belong to the upper motor nerves, which are more critical. Injury or damage to these nerves will result in greater damage and consequences than lower motor nerves. There was little chance that this patient’s compressed nerves would get better by themselves. I advised him to undergo spinal surgery to free the compressed nerves and, at the same time, undergo a fusion of the affected level of the spine. Fusion as the first surgical option Fusion involves linking the affected segments, or vertebrae, of the spine, by stimulating bone growth between the segments and by attaching them with rods, screws

and plates. This stops further movement between the segments and prevents them from compressing the nerves. The patient was not keen and said that some form of transplant surgery might be made available to him should his nerves deteriorate further. I told him that nerve and stem-cell transplant was still in the animal experiment stage and the only option at the time was to release the nerves from further compression before his condition worsened. By making more room for the nerves in such cases, we hope that there will be more blood supply bringing nutrients to the nerves. The eventual result may be gradual recovery of the function of the nerves. When patients see a spine specialist regarding a spine problem, their main concerns usually are: whether their condition is serious, whether they will be paralysed and whether surgery is needed now or in the future. Ruling out the “red flags” Our medical undergraduates have been taught to rule out “red-flags” or serious spinal conditions, which may be life- or limbthreatening. Examples of such red-flag conditions include cancer, infections, unstable fractures of the spine and compression of the upper motor nerves. These symptoms include weakness of the arms or legs, fever, urinary incontinence and loss of appetite or weight. Fortunately, most complaints of neck and back pain are due to muscular strain, poor posture and wear and tear of the spine. The vertebrae in the spine are cushioned and separated by spongy intervertebral discs, which are each made of a fibrous out-

37 September 2012 In Practice er shell containing a gel-like material. When the spine degenerates, the shells of the intervertebral discs can weaken and tear. When this happens, the inner material bulges out and compresses the spinal nerves. Chemicals called prostaglandins are also released from the discs. These can result in intermittent attacks of pain, punctuated with good symptom-free days. When the nerves within the spinal column are pinched, the pain may radiate or spread to the extremities. The patient may complain of numbness, tingling or weakness of the affected extremities. The good thing is that most of these symptoms are resolved in most patients, usually after two to three months of simple treatment measures such as anti-inflammatory medication, back or neck exercises and lifestyle modification. As they feel better, patients often ask if the extent of their nerve compression has been reduced. A patient gets better not because the degree of nerve compression has lessened but because the chemical irritation of the nerves has become less acute. Anti-inflammatory medication inhibits the effects of the chemicals that leak from the damaged intervertebral discs. However, about 10 to 15 per cent of patients do not feel significantly better after two to three months. It usually means that their nerves are unable to cope with the compression around them. This is when the possibility of surgery is discussed. In general, the aim of all types of spinal

surgery is the same, regardless of the condition of the spine – decompression or freeing of the nerves. Sometimes, the segment of the spine may be potentially unstable or painful and may need to be stabilized to some degree. Treatment options abound About 10 to 20 years ago, fusion of the segment was the only option. Nowadays, we have the luxury of more treatment methods at our disposal. These include disc replacement, which means replacing the damaged intervertebral disc with an artificial one made of metal and plastic; and dynamic stabilization, which involves implanting a metal device to reinforce the damaged part of the spine. Determining whether to stabilize or not and the type of stabilization to be used is often a joint decision by the spine specialist and the patient. We take into account the age, lifestyle, job demands and expectations of the patient in the decision-making process. Progress has been made in the treatment that he wanted, although it remains experimental. In October 2010, the world’s first clinical trial using human embryonic stem cells to treat spinal cord injuries began. The aim is to convert stem cells into cells similar to our nerve cells. Only time will tell if this method will improve the outcome for patients. Scientific research may not always produce the results that we want. But there is no going back in our quest for improvement in the treatment of spinal conditions.

About the Author: Adjunct Associate Professor Hee Hwan Tak, a specialist in spinal disorders and deformities, is the medical director of the Centre for Spine and Scoliosis Surgery, Singapore Medical Group, and a lecturer at Singapore’s National University of Singapore Yong Loo Lin School of Medicine.

38 September 2012 Humor

“I’ve been Dr. Lamont’s patient for over 12 years and I’ve never seen his face!”

“Lucy, I think we should “Go ahead and take those, I’m curious get a divorce!” to see what they will do to you!”

“What’s halitosis?”

“Do you know what gets me? You put on a white coat and right away everyone thinks you are a doctor!”

“Do you have to go on and on about how gross the whole thing is?”

“It was just a joke!”

“Glad you could make it!”

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