Important benefits for women who quit smoking early

December 2012

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Important benefits for women who quit smoking early

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NEWS Science and health policy: Lost in translation

CONFERENCE

CABG superior to stents in diabetics with CAD

AFTER HOURS Monoclonal antibody aids statin-refractory patients

Malacca: A journey through time

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December 2012

Important benefits for women who quit smoking early Elvira Manzano

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moking nearly triples the risk of premature death in women and quitting the habit well before middle-age reduces this risk, according to the Million Women Study. In this prospective study, the largest in the history of studying the dangers of smoking, 12-year mortality rates among women who smoked throughout their adult years were almost three times higher than those of women who never smoked (rate ratio 2.97, 95% CI, 2.88-3.07). Even light smokers (those who smoked fewer than 10 cigarettes per day) had twice the mortality rate of never-smokers (rate ratio 1.98, 95% CI, 1.91-2.04). [Lancet 2012.DOI. org/10.1016/S0140-6736(12)61720-6] What was encouraging, however, was the positive effect that quitting seemed to have on women’s life span. Stopping the habit before age 40 avoided more than 90 percent of excess mortality from cigarettes. Quitting before age 30 avoided 97 percent of this added risk. “Smokers who stop before reaching middle-age will on average gain about an extra 10 years of life,” said study author Professor Sir Richard Peto, of the University of Oxford, Oxford, UK. “This does not, however, mean that it is safe to smoke until age 40 and then stop,” the authors warned. Decades later throughout life, women who smoked and stopped still have “1 to 2 times the mortality rate of never-smokers.” For those who continued to smoke past age 40, the risk is 10 times greater. The study enrolled 1.3 million women (age

50-65) in the UK followed for 12 years. At baseline, 20 percent were smokers, 28 percent were former smokers and 52 percent never smoked. By 2011, 66,000 had died. Compared with non-smokers, smokers lost at least 10 years of life and died from smoking-related diseases such as lung cancer, heart disease and stroke. While the absolute hazards of prolonged smoking are substantial, so are the benefits of quitting. “Even cessation at about 50 years of age avoids at least two-thirds of the continuing smoker’s excess mortality in later middle age,” the authors said. The benefits are, however, greater in those who quit earlier. In a linked comment, Dr. Rachel Huxley, from the University of Minnesota, Minneapolis, US, and Dr. Mark Woodward, from the University of Sydney, Australia, welcomed the findings. “Aside from its impressive sample size, the Million Women Study is distinct from previous large cohorts—and superior for assessment among women of the full hazards of prolonged smoking and the full benefits of long-term cessation because the participants were among the first generation of women in the UK in which smoking was widespread in early adult life, and although many continued smoking, many stopped before age 30 or 40 years.” The results emphasize the need for effective sex-specific and culturally-specific tobacco control policies that encourage adult smokers to quit and discourage children and young adults from starting smoking, they concluded.

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Multivitamins may protect against cancer Rajesh Kumar

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aily multivitamin use for more than a decade caused a modest but statistically significant 8 percent reduction in all cancers among men in a large randomized, doubleblind, placebo control trial. Researchers analyzed data from the Physicians’ Health Study II involving 14, 641 male US physicians aged 50 years or older, including 1,312 men with a history of cancer. The men were randomized in 1997 to receive either multivitamin supplements or placebo and were followed up through June 1, 2011. [JAMA 2012; DOI:10.1001/jama.2012.14641] The primary outcome was total cancer (excluding non-melanoma skin cancer), with prostate, colorectal, and other site-specific cancers among the secondary end points. During the trial, 2,669 cases of cancer were detected, including 1,373 cases of prostate cancer and 210 cases of colorectal cancer, with some men experiencing multiple events. Men taking a daily multivitamin had a statistically significant reduction in the incidence of total cancer compared with those taking placebo (17.0 and 18.3 events, respectively, per 1,000 person-years; hazard ratio [HR] 0.92; 95% CI, 0.86-0.998; P=0.04). The multivitamin group had a similar reduction in total epithelial cell cancer, but not in other site specific cancers such as colorectal, lung and bladder cancer. The men who had a history of cancer at baseline also saw a reduction in their total cancer risk but this was not any different from the case of healthier men. A 12 percent difference was seen in the risk of cancer mortality in multivitamin and placebo groups (4.9 and 5.6 events, respectively, per

1,000 person-years; HR 0.88; 95% CI, 0.77-1.01; P=0.07), but this was not statistically significant. Previous observational studies of long-term multivitamin use and cancer have been inconsistent and large-scale randomized trials testing single or small numbers of higher-dose individual vitamins and minerals for cancer have been negative or inconclusive. “Although the main reason to take multivitamins is to prevent nutritional deficiency, these data provide support for the potential use of multivitamin supplements in the prevention of cancer in middle-aged and older men,” said Dr. J. Michael Gaziano of Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusetts, US. Those with nutritional deficiencies would likely benefit more, since the current study cohort was of healthy physicians, said Gaziano. Also, total cancer rates in the trial were likely influenced by the increased surveillance for prostate-specific antigen (PSA) and subsequent diagnoses of prostate cancer during PHS II follow-up starting in the late 1990s, he added. Several individual vitamins and minerals contained in the multivitamin supplement used in the study have been ascribed chemopreventive roles, but it is difficult to definitively identify any single mechanism that may have reduced the cancer risk, said the researchers. A similar analysis of the PHS II cohort failed to find cardiovascular protective benefits of multivitamin supplementation. The rate of myocardial infarction, stroke, or cardiovascular death was no different between the multivitamin and placebo groups (HR 1.01, 95% CI 0.91 to 1.10) [Proceedings of the American Heart Association (AHA) 2012 Annual Meeting scientific sessions].

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Science and health policy: Lost in translation? Based on an excerpt from a lecture by Professor Peter Piot, director of the London School of Hygiene & Tropical Medicine, London, UK and co-discoverer of the Ebola virus, during a recent public health conference held in Singapore.

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ow are science, evidence and health policy related to each other, and what are the dynamics? Policymakers see the policy process differently from how the academy in general sees it. Policymakers work in a chaotic world exposed to a wide variety of influences and what comes out of academia can be a tiny issue for them. In contrast, scientific evidence is the major issue for us. One of the main actors in modern epidemiology, the late Emeritus Professor Geoffrey Rose, from the London School of Hygiene and Tropical Medicine, London, UK, said: “We know what is desirable, but the obstacles to its achievement are economic, industrial, and political.” I would say the opportunities to this achievement are economic, industrial and political. When it comes to evidence-informed policy, opinions vary by discipline. Economic analysis is extremely important, as well as foresight from family and community views. All these bring different kinds of evidence which all play a part in the cocktail of decision making. Foresight and strategic decision processes are also key elements in policy-making. In Finland, policy actors practice strategic alliance and sense-making before selection of priorities and implementation. These are as important as the results of randomized trials. How does this work for the big problems of our time? Every country in the world is confronted

with a tsunami of lifestyle-related diseases – an epidemic of non-communicable diseases such as heart disease and stroke, cancer and diabetes. With increasing longevity, ever more people are living with dementia and Alzheimer’s disease, most in low middle-income countries. The burden on society will be enormous, particularly as traditional family structures are changing and no longer taking care of the elderly. Climate change also has a huge impact on health. Extreme weather changes will lead to the emergence of food-borne and vectorborne diseases. Because of this, epidemics will never be far away. The world will continue to produce new viruses and emerging infections .While the cost on the health sector is fairly minimal, the economic cost and disruption will be significant. We should see beyond the health sector when we think about the impact of such diseases and what to do about it. This is the big problem of our time, for this region of the

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world in particular. With the exception of climate change, modification of behavioral risks is something we can do. There are effective and feasible interventions — tobacco control, salt, fat and alcohol reduction, weight control and physical activity — and yet, these are not happening. In the 7 years since the international public health policy commitment that is the Framework Convention on Tobacco Control (2005) took effect, only 5 percent of the global population is covered by it. Clearly, there are stronger factors at work than scientific evidence. The fight is never over. We have to continue to reinvent new approaches for tobacco control. In the UK, innovative approaches for salt reduction produced remarkable results, leading to a decline in the average salt consumption of 0.9 grams per person per day. This reduction is estimated to prevent more than 6,000 premature deaths and save £1.5 billion a year in health care costs. This is a major achievement and can be done in many countries. Throughout Eastern Europe, alcoholism is a major problem that the authorities seem unwilling to tackle. Another problem in this region is HIV infection and injection drug use. Denmark recently imposed a fat tax, the first in the world, on all obesogenic food — butter, full-fat milk, pizza. New York City’s latest action is to ban big soda. The health sector can-

not do it alone. It is only through this kind of regulation that we can hope to change people’s behavior and begin to turn the tide on noncommunicable diseases. Nevertheless, many of the effects of legislation on lifestyle changes and its impact on the economy are still unknown. We need more information. We should broaden our analysis way beyond the classic ways of analyzing health interventions. For political decisions at the highest level, we need to take a macroeconomic view as much as we need good technical information. Is science lost in translation? Yes and no. The robustness of our evidence is not that great. More research is needed. There are also paradoxes of science communication. We’ve seen papers and press releases claiming discoveries of new ‘cures’ for cancer all too frequently. We are partly to blame for over-selling our results. For decision makers, results issues and societal priorities are as important as scientific evidence. We can’t ignore that politics is extremely important. As scientists, we need to do a better job in terms of thinking through how to influence policy. This is also where a school of public health is essential. The role of the school of public health is to develop a science base, making sure that education and training programs are ‘in sync’ with society’s needs.

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December 2012

Indonesia Focus

Perayaan Hari Diabetes Sedunia Hardini Arivianti

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anggal 18 November 2012 lalu, Hari Diabetes Sedunia (‘World Diabetes Day’/WDD) 2012 diselenggarakan oleh Persatuan Diabetes Indonesia (PERSADIA) dan Institut Diabetes Indonesia (INDINA) bersama PT Novo Nordisk Indonesia dan didukung oleh Perkumpulan Endokrinologi Indonesia (PERKENI) dan Perhimpunan Edukator Diabetes Indonesia (PEDI). Kampanye WDD ini juga diprakarsai oleh ‘International Diabetes Federation’ (IDF). Acara WDD 2012 yang digelar di Jogjakarta ini dihadiri sekitar 600 penyandang diabetes dari beberapa kota lainnya, seperti Klaten, Solo, Lampung, dan sebagainya. Pertama kali WDD diperingati pada tahun 1991 oleh IDF dan WHO dalam menghadapi keprihatinan terhadap peningkatan ancaman kesehatan akibat diabetes dan WDD juga menjadi hari resmi PBB pada tahun 2007 dengan berlakunya Resolusi PBB 61/225. Hari Diabetes yang sebenarnya jatuh pada tanggal 14 November ini, merupakan hari kelahiran Frederick Banting yang bersama rekannya Charles Best yang berhasil menemukan hormon insulin tahun 1922. Kali ini, WDD di Indonesia bertemakan “Protect Our Future”. Logo WDD berupa lingkaran biru yang menandakan simbol global untuk diabetes yang diadopsi tahun 2007 untuk menandai diakuinya Resolusi PBB. Lingkaran tersebut melambangkan kehidupan dan kesehatan sedangkan warna biru mencerminkan warna langit yang menyatukan semua bangsa dan juga sebagai sesuai dengan warna bendera PBB.

Diabetes perlu perhatian khusus Jumlah penduduk dunia yang terkena diabetes mencapai angka 366 juta di tahun 2011 dan pada tahun 2012 ini, mengalami pe-ningkatan menjadi 371 juta dan separuhnya tidak sadar terkena diabetes. Hal ini diungkapkan oleh Prof. Dr. dr. Sidartawan Soegondo, SpPD-KEMD. Sepuluh negara dengan peyandang diabetes terbanyak adalah Cina, India, Amerika Serikat, Brazil, Rusia, Meksiko, Indoesia, Mesir, Jepang dan Pakistan. Diprediksi, Indonesia akan menduduki peringkat ke-7 dan dua propinsi yang menduduki prevalensi tertinggi (11,1%) adalah Maluku Utara dan Kalimantan Barat. Dari data dinyatakan sekitar 74% penyandang diabetes, tidak sadar/tahu dirinya terkena diabetes. “Itu sebabnya kita harus mencari yang termasuk 74% ini dengan cara membuat berbagai penyuluhan agar mereka datang dan sadar untuk memeriksakan dirinya,” tukas Ketua PB PERSADIA ini lebih lanjut. Tema yang diangkat WDD adalah lingkungan yang baik untuk semua, terutama lingkungan untuk anak dan remaja agar me-

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reka yang berisiko tinggi, tidak akan menderita diabetes kelak, mengingat selama ini gaya hidup membuat semuanya berisiko diabetes. Selain itu PBB juga telah sepakat agar diabetes ini harus benar-benar diperhatikan. ”Pengendalian diabetes perlu multisektor yang meliputi pemerintah, edukator, klinisi, dll.” IDF merekomendasikan pemeriksaan oportunistik mandiri dengan penggunaan kuesioner singkat untuk membantu tenaga kesehatan dalam mengidentifikasi orangorang yang berisiko lebih tinggi dan yang memerlukan pemeriksaan lebih lanjut. Kuesioner ini dapat digunakan untuk menilai faktor risiko dan dapat digunakan oleh individu, dan kuesioner ini berisikan data yang meliputi usia, lingkar pinggang, riwayat keluarga, riwayat penyakit kardiovaskular, dan sejarah kehamilan. Bukti ilmiah menunjukkan, berat badan ideal dan aktivitas fisik sedang dapat membantu mencegah perkembangan diabetes tipe 2. IDF merekomendasikan latihan fisik minimal 30 menit per hari yang telah terbukti

dapat mengurangi risiko diabetes tipe 2 sebesar 35-40%. Selanjutnya dr. Ida Ayu Kshanti, SpPDKEMD menjelaskan edukasi diabetes yang spesifik dibutuhkan untuk profesi kesehatan dan penyandang diabetes. ”Kendala utama untuk mendapatkan akses pendidikan adalah minimnya edukator yang berkualitas. Investasi program edukasi diabetes dan pencegahannya akan menghemat jangka panjang dengan didapatnya perbaikan kualitas hidup penyandang diabetes dan orang-orang yang berisiko terhadap penyakit ini,” tukas SekJen PEDI ini lebih lanjut. Perwakilan dari Kementerian Kesehatan Dr.Eko Rahajeng, SKM, M.Kes menjelaskan, semua desa di seluruh Indonesia melakukan gerakan poswindu (sekarang sudah ada sekitar 5000) dan diharapkan tahun depan dipercepat dan berharap dari berbagai sektor akan membantu mempercepat program poswindu ini. ”Poswindu merupakan pos penyakit tidak menular agar masyarakat sehat dapat melakukan pemeriksaan berkala seperti body fat analysis, konseling, dll.”

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25th Hospital Expo 2012, November 7-10, 2012, Jakarta

Upaya peningkatan akses dan mutu pelayanan kesehatan Hardini Arivianti

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asyarakat sehat, sejahtera dan mandiri merupakan tujuan yang akan dicapai dengan adanya jaminan kesehatan semesta (universal health coverage). Upaya ini termasuk langkah persiapan regulasi dan mencukupi jumlah tempat tidur di rumah sakit, tenaga kesehatan, pembiayaan, obat, alat kesehatan serta sarana penunjang lainnya. Hal ini dikemukakan oleh Menteri Kesehatan, dr. Nafsiah Mboi, SpA, MPH pada pembukaan ‘Hospital Expo’ 2012 awal November lalu. Kali ini, Hospex mengusung tema “Strategi Rumah Sakit Menghadapi Arus Kuat Perubahan sebagai Dampak akan Berlakunya UU SJSN dan Internasionalisasi Akreditasi”. Isu akreditasi internasional juga sangat relevan yang berfokuskan pada pembangunan kesehatan 2010-2014 yaitu dengan meningkatkan akses masyarakat pada pelayanan kesehatan yang bermutu termasuk pelayanan rumah sakit yang bermutu. “Hingga saat ini jumlah rumah sakit di Indonesia mencapai 2.068 dengan jumlah total tempat tidur sebanyak 229.612. Bila jumlah ini ditambah dengan tempat tidur di puskesmas perawatan dan klinik pratama, menjadi lebih dari 240 ribu, dan secara nasional, jumlah ini mencukupi.” Kesenjangan jumlah rumah sakit juga masih terjadi, misalnya rumah sakit terkonsentrasi di perkotaan sedangkan masih banyak daerah yang kekurangan tempat tidur, mis-

alnya daerah terpencil, perbatasan, atau kepulauan. “Pengembangan rumah sakit harus dibahas dengan pemerintah daerah (Pemda) agar memperhatikan tingkat kepadatan rumah sakit di wilayah yang akan dibangun dan Persatuan Rumah Sakit Indonesia (PERSI) di seluruh Indonesia perlu melakukan advokasi terhadap Pemda agar ke-timpangan-ketimpangan dan kesenjangan seperti itu tidak terjadi,” himbau Menteri Kesehatan ini. Dalam hal ini, PERSI sebagai mitra pemerintah, dihimbau untuk benar-benar melakukan advokasi sehingga pelayanan kesehatan terhadap masyarakat lebih merata dimanapun mereka berada. Kekurangan dan ketimpangan yang terjadi, diusahakan dipenuhi oleh pemerintah dengan meningkatkan kapasitas rumah sakit kelas 3 dan menambah jumlah puskesmas dengan tempat tidur, dan RS pratama (rumah sakit se-tingkat kelas D dengan sekitar 50 tempat tidur yang dilayani oleh dokter umum). Dalam rangka menyambut diberlakukannya SJSN, MenKes menjelaskan, yang harus diperkuat adalah primary health care sehingga pelayanan kesehatan lebih banyak berfokus pada usaha promotif, preventif dan kuratif ringan yang sedekat mungkin dengan tempat tinggal pasien. “Dalam menyongsong universal heatlh coverage dan meningkatkan mutu pelayanan rumah sakit, saya minta tidak ada rumah sakit atau dokter yang menolak pasien dalam kondisi darurat dengan alasan apapun.”

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Hingga kini dari 2.068 rumah sakit, baru 1.192 yang terakreditasi dan 5 rumah sakit terakreditasi internasional. Diharapkan PERSI mendorong anggotanya melakukan langkah-langkah yang diperlukan agar mendapatkan akreditasi dan pemerintah berusaha meningkatkan jumlah rumah sakit dengan akreditasi internasional. Di penghujung pidatonya, dr. Nafsiah

berharap agar PERSI juga memanfaatkan teknologi melalui internet untuk meningkatkan mutu pelayanan dan pemerataan pelayanan agar tidak ada satu pasien pun yang tidak mendapatkan pelayanan hanya karena daerahnya terpencil. Dengan teknologi ini juga dapat membantu memutuskan keterpencilan daerah mengingat Indonesia adalah negara kepulauan.

Penelitian dengue di Indonesia Hardini Arivianti

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ada tahun 2009-2011 terdapat sekitar 126.908 kasus DB dengan rerata kematian sekitar 1100 kasus dan Indonesia menempati posisi ke-2 kejadian tertinggi setelah Brazil. Bila dibandingkan tahun 2010, saat ini kasus secara nasional mengalami penurunan secara signifikan, namun tetap harus waspada mengenai adanya kemungkinan peningkatan kasus di tahun-tahun yang akan datang. Virus DB memiliki 4 serotipe, DEN 1, DEN 2, DEN 3, dan DEN 4 yang penyebarannya diperantarai oleh nyamuk Aedes agypti. Hingga saat ini belum ada obat spesifik dan vaksinasi merupakan salah satu alternatif yang potensial untuk memerangi DBD. Namun vaksin dengue yang teregistrasi juga belum tersedia dan masih dilakukan penelitian/uji klinis untuk mendapatkan vaksinasi yang optimal. Ada vaksin dengue yang dikembangkan dan diujicobakan dengan fase berbeda, ada yang baru masuk pra-klinis dan uji klinis. Yang sudah memasuki fase 2 dan fase 3 adalah CYP14 Sanofi Pasteur. Hal ini dikemukakan oleh Drs. Ondri Dwi Sampurno, Msi,

Apt, perwakilan dari Kementerian Kesehatan pada acara peresmian Kemitraan Sanofi Pasteur dan Lembaga Eijkman dalam Penelitian Dengue di Indonesia beberapa waktu lalu. “Pengembangan vaksin dengue yang dapat memberikan respon antibodi netralisasi terhadap ke-4 serotipe masih menjadi tantangan, karena Indonesia memiliki serotipe dan genotip yang berbeda dengan negara lain. Itu sebabnya perlu strategi pengembangan vaksin yang berasal dari strain universal dengan menggunakan berbagai teknologi vaksin agar mendapatkan vaksin dengue yang optimal.” Kementerian Kesehatan, Kementerian Riset dan Teknologi, beberapa perguruan tinggi nasional dan industri nasional mendirikan konsorsium penelitian vaksin DB untuk mensinergikan sumber daya dan efisiensi penatalaksanaan penelitian. “Penelitian yang dilakukan oleh konsorsium tidak duplikasi dengan yang dilakukan Sanofi Pasteur karena pengembangan teknologi vaksinnya berbeda,” tukas Drs. Ondri lebih lanjut. Guna mendukung pemerintah dalam penelitian dengue di Indonesia, Sanofi Pasteur (divisi vaksin Sanofi) bermitra dengan Lembaga Eijk-

10 December 2012 Indonesia Focus man. “Sanofi Pasteur bertujuan mengembangkan vaksin DB yang aman dan efektif, dan dapat diakses dengan mudah terutama di negara-negara dengan prevalensi DB tinggi.” tukas JeanLouis Grunwald, Vice President Asia Pasific-Japan, Sanofi Pasteur. Kemitraan ini akan mencakup program peningkatan kapasitas bagi peneliti yang terpilih dari Lembaga Eijkman melalui dukungan ‘Global Clinical Immunology Research and Development Center’ di Amerika Serikat dengan mempelajari secara spesifik teknik ‘Plaque Reduction Neutralization Test’ (PNRT) guna memonitor respons imunitas anak-anak yang telah mendapatkan vaksinasi dengue. Penelitian epidemiologi “Dengue masih merupakan tantangan bagi kesehatan masyarakat secara global dan hingga tahun 2003, kasus tertinggi dilaporkan di Thailand, sedangkan 2004 kasus tertinggi ditemukan di Indonesia,” papar Prof. Dr. dr. Sri Rezeki S Hadinegoro, SpA(K). Pada tahun 2006, sekitar 57% semua kasus dilaporkan dari Indonesia. Dalam periode 1968-2008, ledakan dengue di Indonesia terjadi pada tahun 1988, 1998 dan 2007. Program Kontrol DB terdiri dari beberapa hal yang meliputi surveilans epidemiologi, kontrol vektor, manajemen kasus, melakukan kampanye, jaringan intersektor, partisipasi komunitas dan pelatihan secara rutin. Sebagai indikator, target morbiditas nasional kasus DB/100.000 populasi pada 2011 adalah <20, namun realisasinya mencapai 58,55 pada tahun 2008. Target mortalitas <1%, dan realisasinya mencapai 0,86 (tahun 2008). Hingga kini vaksin DB masih belum tersedia, papar Prof. Sri, karena banyak sekali tantangannya seperti uji coba tidak bisa dilakukan pada hewan, memiliki 4 serotipe virus, dan membutuhkan data studi efikasi vaksinasi un-

tuk menunjukkan daya proteksi pada manusia. “Penelitian di Indonesia membandingkan berapa jumlah anak yang terkena DB setelah divaksinasi dengan anak yang tidak mendapatkan vaksin.” Selanjutnya Prof. Sri memaparkan studi efikasi vaksin DB tetravalent fase 3 yang dilakukan pada anak sehat berusia 2-14 tahun di Indonesia, Thailand, Vietnam, Filipina, dan Malaysia. Jumlah subyek pada studi CYP14 yang dilakukan secara acak dan multinasional ini adalah 10.278, dimulai dari Juni 2011 dan dilakukan follow up jangka panjang yaitu 3 tahun setelah dosis ke-3 (2015). Dosis vaksin yang diberikan 0,5 ml CYD vs plasebo dan jangka pemberian 6 bulan (0, 6, dan 12 bulan). Di Indonesia melibatkan 3 kota besar yaitu Jakarta, Bandung dan Bali. Jakarta diwakili oleh 5 puskesmas yang mewakili 5 wilayah DKI Jakarta, Bali berpusat di 1 tempat yaitu RS Sanglah, sedangkan Bandung melibatkan 3 puskesmas. Jumlah subyek secara keseluruhan mencapai 10 ribu (dari 5 negara),1870 subyek dari Indonesia dan pada perjalanannya 20 subyek mengalami drop out dikarenakan beberapa hal, misalnya pindah rumah, dll. Subyek kebanyakan berusia sekolah dasar. Dosis pertama diberikan pada periode JuniAgustus 2011 dan dosis ke-3 diberikan pada 10 September 2012 lalu. Bila subyek mengalami demam tinggi lebih dari 2 hari, dilakukan pemeriksaan laboratorium. Surveilans secara aktif juga dilakukan setahun setelah imunisasi, dan bekerjasama dengan sekolah, petugas puskesmas dan orang tua.”Penelitian ini diharapkan dapat bermanfaat dan dapat membantu menurunkan angka kematian di Indonesia.” Genetik virus dengue di Indonesia Ada 3 faktor yang mempengaruhi DN, yaitu host, virus, dan vektor. Faktor host, dipengaruhi

11 December 2012 Indonesia Focus oleh status imunitas, etnis, genetik, jenis kelamin dan status gizi. Faktor yang mempengaruhi virus antara lain genotip, struktur antigen, dll. Sedangkan vektor dipengaruhi oleh perubahan iklim dan resistensi terhadap insektisida. Hal ini diungkapkan oleh Dr. Tedjo Sasmono pada acara yang sama. Dikatakan genotip terkait dengan penyebaran geografis dan dikaitkan dengan tingkat keparahan penyakit. Berdasarkan penelitian tipe Asian dan American yang pernah dilakukan di Amerika Selatan, tipe Asian akan menimbulkan penyakit yang lebih parah. ”Namun perdebatan mengenai hal ini masih berlangsung hingga kini.” Indonesia merupakan negara kepulauan yang memiliki keanekaragaman etnis, dll. Kini human migration lebih mudah sehingga penyakit juga meluas karena tidak adanya lagi isolasi geografis dan perbatasan sehingga keragaman tersebut juga berpengaruh menjadi patogen. ”Kami di lembaga Eijkman, melakukan penelitian epidemiologi molekuler, pemetaan virus, kekebalan virus, deteksi virus dengue pada nyamuk, dll, untuk mengetahui jenis-jenis serotipe dan genotip virus disini,” tukasnya. Semua serotipe ada di Indonesia, dan dulu didominasi oleh DEN 2 namun sekarang mengarah ke DEN 1. Genotip DEN di Indonesia meliputi DEN 1 (genotip I dan IV), DEN 2 (Cosmopolitan), DEN

3 (genotip I dan IV) dan DEN 4 (genotip II). Setiap serotipe DEN memiliki banyak genotip. Goncalves dkk (2002) memaparkan serotip DENV1 memiliki 4 genotip (genotip I-V). DENV2 memiliki genotip Asian I, Asian II, Cosmopolitan, Asian/American, American (Twiddy dkk, 2002). Sedangkan DENV3 memiliki genotip I-IV (Lanciotti dkk, 1994) dan serotipe DENV4 memiliki genotip I-II. ”Pada tahun-tahun lalu, di Indonesia didominasi oleh genotip 4 namun akhir-akhir ini didominasi oleh genotip I. Jadi ada pergeseran strain-strain virus yang masuk, bukan strain baru namun strain lama yang masuk ke negara kita.” Kawasan Asia Tenggara bagian Selatan (Indonesia, Singapura, Malaysia) muncul genotip baru yang mungkin disebabkan oleh perubahan asam amino dan sekuen protein A pada genotip 1 DEN 1 mengalami sedikit mutasi. DEN 1 lebih banyak terdapat di Indonesia menggantikan genotip 4. ”Kita melakukan kultur dan mengukur kecepatan tumbuh dan ternyata hasil kultur menunjukkan genotip 1 lebih cepat tumbuh dibandingkan genotip 4,” tukas Dr. Tedjo. Genotip 1 secara perlahan menggantikan genotip 4. Namun dari segi klinis belum tahu korelasi genotip 1 dan keparahan penyakit dan peran klinisi disini sangat berarti guna berbagi data.

Susu berkalsium tinggi dan pelepasan mineral tulang Hardini Arivianti

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enanda pembaharuan tulang (bone marker turn over) dapat dilakukan pada osteob-

las dan osteoklas, dua sel yang berperan pada pembentukan dan penyerapan tulang. Fungsi osteoblas dapat diukur dengan menggunakan alkalin fosfatase (AP), osteokalsin, dan P1NP,

12 December 2012 Indonesia Focus sedangkan fungsi osteoklas diukur dengan hidroksiprolin (OHP), crossed type collagen (Ntelopeptida, C-telopeptida/CTX, deoksipiridinolina), hidroksilisin glikosida, dan tratrate resistant acid phospatase. “Bila hasil CTX tinggi berarti pelepasan kalsium tulang ke dalam darah rendah, jadi CTX berbanding terbalik dengan pelepasan mineral tulang,” ungkap Dr. dr. Fiastuti Witjaksono, SpGK beberapa waktu lalu. Kruger dkk (2006) melakukan penelitian ‘Effect of Calcium Fortified Milk Supplementation With or Without Vitamin K on Biochemical Markers of Bone Turn Over in Premenopausal Women’ pada 82 wanita usia pra menopause (20-35 tahun) selama 16 minggu. Penelitian tersamar ganda ini dibagi menjadi 3 kelompok. Kelompok 1 mendapatkan 2 porsi susu berkalsium tinggi/hari dengan jumlah kalsium tambahan 1000 mg dan vitamin K 80 µg/hari. Kepada kelompok 2 diberikan 2 porsi susu berkalsium tinggi/hari dengan jumlah kalsium tambahan 1000 mg, tanpa vitamin K, sedangkan kelompok 3, tidak mendapatkan susu. Pengukuran osteokalsin total, prokolage, CTX dilakukan pada minggu ke-2, 12 dan 16. Hasil studi ini menunjukkan pada 2 kelompok yang mendapatkan 2 porsi susu berkalsium tinggi terjadi penurunan berbagai ukuran penanda yang dilakukan. Hal ini menandakan susu berkalsium tinggi menurunkan pelepasan/penghancuran kalsium tulang pada wanita usia pra menopause. Berikutnya penelitian Kruger dkk (2009) “The Effect of a Fortified Milk Drink on Vitamin D Status and Bone Turn Over in Post Menopausal Women from South East Asia” yang dilakukan selama 16 minggu pada 60 wanita (Indonesia) dan 60 wanita (Filipina) yang berusia diatas 50 tahun yang diacak menjadi 2 kelompok. Kelompok pertama mendapatkan 2 porsi susu tinggi kalsium 1200 mg yang difortifikasi dengan vitamin D (9,6 µg), magnesium (96 mg)

dan zink (2,4 mg). Kelompok 2 mendapatkan 2 porsi minuman yang berbahan dasar beras (powder milk rice-based). Kepadatan tulang diukur dengan hormon penanda PTH dan CTX. Penelitian menunjukkan hasil terdapat penurunan PTH dan CTX pada minggu ke 2, 8 dan 16 pada kelompok perlakuan dibandingkan dengan kelompok kontrol. Pada kelompok 1 kadar CTX menurun sebesar 34% setelah 2 minggu mengonsumsi susu. Penelitian Kruger pertama dilakukan oleh Massey University, Fonterra Brands Ltd dan St. Thomas Hospital (Inggris) dan penelitian yang kedua juga dilakukan oleh Massey University dan Fonterra Brands Ltd beserta Departemen Obstetri dan Ginekologi FKUI/RSCM. Dari penelitian didapat fakta sebagai berikut: rerata asupan kalsium sebesar 218,7 mg/ hari (Indonesia) dan 372 mg/hari (Filipina). Status vitamin D, diperkirakan > 70% wanita Indonesia mengalami kekurangan vitamin D (< 50nmol/L) sedangkan dengan wanita Filipina sebanyak 20%. Kedua penelitian diatas, papar dr. Fiastuti, menunjukkan konsumsi susu tinggi kalsium dan vitamin D selama 2 minggu secara signifikan dapat mengurangi kerusakan tulang. Sesuai data Puslitbang Gizi Departemen Kesehatan (2005), 2 dari 5 orang Indonesia berisiko terkena osteoporosis. Pada usia 50 tahun, risiko osteoporosis dijumpai pada 1 diantara 3 wanita dan 1 diantara 5 laki-laki. Pada usia 60-70 tahun didapat risiko osteoporosis > 30% wanita dan usia > 80 tahun didapat 70% wanita . “Konsumsi susu di Indonesia hanya 235 mg atau 9-11 liter/tahun,” tukasnya. Saat ini Departemen Gizi FKUI bekerjasama dengan Fonterra Brands Indonesia sedang melakukan riset serupa guna menilai manfaat susu tinggi kalsium pada pria dan wanita kelompok usia 35-45 tahun dan 46-55 tahun.

13 December 2012 Indonesia Focus

SEANUTS, temuan terbaru gizi anak Indonesia Hardini Arivianti

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onferensi Nasional ‘South East Asia Nutrition Survey’ (SEANUTS) yang berlangsung 14 November 2012 lalu bertujuan untuk menyajikan hasil studi SEANUTS di Indonesia. Studi ini merupakan inisiatif Royal FrieslandCampina, induk perusahaan Frisian Flag Indonesia yang mencakup empat negara di wilayah Asia Tenggara yaitu Malaysia (3.542 anak), Thailand (3.119 anak) dan Vietnam (2.872 anak). Dengan jumlah subyek penelitian terbesar, di Indonesia bersama PERSAGI sebagai tim melakukan pengumpulan data dan analisa pada 7.211 anak berusia 6 bulan hingga 12 tahun yang dilakukan Januari-Desember 2011 di 48 kabupaten/kota di Indonesia. Selaku Direktur Nutrisi Masyarakat, Kementerian Kesehatan Republik Indonesia, Dr. Minarto menyampaikan, peme-rintah memiliki program Gerakan 1.000 Hari Pertama Awal Kehidupan atau hingga anak berusia 2 tahun, yang bertujuan untuk mencapai target MDG tahun 2015. Hasil SEANUTS ini bersifat komprehensif dan melengkapi data nasional yang dimiliki pemerintah Indonesia diantaranya Riset Kesehatan Dasar (Riskesdas), Survei Sosial Ekonomi Sosial (Susenas) dan sumber penelitian lainnya. SEANUTS menunjukkan pencapaian program pemerintah meningkatkan status vitamin A pada anak melalui program pembagian kapsul vitamin A dosis tinggi 2 kali setahun kepada anak balita dan peningkatan status yodium melalui yodinisasi

garam terbukti efektif. Namun hasil SEANUTS juga menunjukkan masih ada beberapa indikator gizi yang harus diperhatikan diantaranya adalah status vitamin D pada anak, stunting (tubuh pendek), underweight (kurang gizi termasuk gizi buruk), dan anemia, serta hasilnya dapat menjadi landasan dalam pengembangan program yang lebih tepat sasaran dalam me-ngatasi masalah gizi anak Indonesia. Hasil temuan Berdasarkan SEANUTS, tingkat defisiensi vitamin A anak usia 24-59 bulan adalah 0,6%, sedangkan pada anak usia 5-12 tahun adalah 0,7%. Risiko defisiensi ini (kadar serum retinol 20-29 mcg/dL) pada usia 24-59 bulan sebesar 8,2% dan 6,9% pada usia 5-12 tahun. Pada yodium, ditemukan fakta, ekskresi yodium kategori defisien (<100 mcg/L) adalah 11,5%, dan 14,9% pada ekskresi yodium kategori >200 mcg/L. Aktivitas juga diukur pada studi ini, dengan cara menghitung jumlah langkah yang dilakukan selama 2 hari. Hasilnya menun-

14 December 2012 Indonesia Focus jukkan perbedaan signifikan aktivitas fisik antara laki-laki dan perempuan, anak lakilaki lebih aktif. Anak laki-laki yang tinggal di pedesaan lebih aktif dibandingkan di perkotaan sedangkan anak perempuan di perkotaan lebih aktif daripada anak laki-laki. Fakta baru lainnya juga dipaparkan oleh Dr. Minarto. Sekitar 1,1% anak-anak di pedesaan mengalami kondisi wasting berat, dan sekitar 6,9%nya mengalami kondisi wasting. Kondisi stunting dibedakan stunting berat dan stunting. Stunting berat ditemukan lebih banyak pada balita laki-laki daripada perempuan dengan perbedaan sekitar 2,2%. Pada usia 5-12 tahun, terjadi lebih banyak pada anak laki-laki dengan perbedaan sekitar 1%. Sedangkan kondisi stunting ditemukan pada balita perempuan dengan perbedaan 0,2%. Pada usia 5-12 tahun juga sama (lebih banyak pada anak perempuan) yang bila diban-dingkan anak laki-laki memiliki perbedaan 1,1%. Selanjutnya Dr. Sandjaja selaku Ketua Tim Peneliti SEANUTS Indonesia menambahkan, SEANUTS memberikan gambaran yang lebih komprehensif terkait dengan status gizi makro dan mikro anak serta meneliti karakteristik rumah tangga, karakteristik anak, konsumsi dan pola makanan seharihari, status gizi, pola pertumbuhan, status biokimia, kualitas tulang, aktivitas fisik, perkembangan kognitif dan psikomotorik

di seluruh Indonesia. “Kondisi kekurangan zat gizi mikro terutama vitamin A, anemia, dan yodium, sudah jauh menurun dibandingkan dengan hasil Riskesdas 2010, namun masih ada masalah lain yang belum terselesaikan, yakni jumlah anak pendek yang masih mencapai 34%, berbeda sedikit dengan Riskesdas 2010 (35%). Sementara itu gizi kurang masih 6,9%.” Teknik pengambilan data Penelitian dilakukan se-suai dengan standar penelitian ‘World Health Organization’. Desain metode penelitian adalah studi potong lintang (cross sectional study) berupa kuesioner, antropometri dan biokimia. Dengan kuesioner, data yang didapat adalah sosial ekonomi (data perumahan dan sanitasi lingkungan), dan kesehatan dan konsumsi (aktivitas dan ritual konsumsi selama 24 jam, pola kebiasaan makan, menyusui dan pemeriksaan klinis). Untuk memperoleh data biokimia pada studi ini meliputi antropometri (usia, berat badan, tinggi badan, tinggi duduk, lingkar lengan atas, lapisan lemak tubuh, lebar tungkai, pergelangan tangan, siku); kognitif dan motorik (aktivitas 24 jam, raven test, WISC test, Denver test, bailey test), dan biokimia (serum vitamin A, serum vitamin D, hemoglobin, feritin, hs-CRP, AGP, EIU, densitas tulang dengan USG, omnisence, DEXA).

15 December 2012 Indonesia Focus The 1st Indonesia-France Seminar in Medicine and Public Health, November 3-4 2012, Jakarta

Rabies dan penanganannya Hardini Arivianti

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abies pada manusia (human rabies) masih merupakan masalah kesehatan masyarakat yang perlu perhatian besar. Berdasarkan estimasi WHO, kematian akibat rabies mencapai 40.000-70.000 kasus per tahun di seluruh dunia. Sebagian besar kematian terjadi di negara-negara berkembang seperti Afrika, India, dan Asia Tenggara. Hal tersebut dipaparkan oleh Prof. Dr. dr. Ketut Tuti Parwati Merati, SpPD-KPTI, pada ‘The 1 st Indonesia-France Seminar in Medicine and Public Health’ yang berlangsung tanggal 3-4 November 2012 lalu. Risiko terinfeksi tergantung pada tingkat keparahan luka gigitan, bagian yang tergigit yang dikaitkan dengan jalur saraf dan jarak ke otak, serta kadar dan jenis virusnya. Gejala-gejala awal hampir mirip dengan infeksi virus sistemik lainnya, seperti demam, sakit kepala, dan merasa tidak enak badan. Mungkin disertai dengan parestesia pada bgian yang terpapar virus (tergigit), diikuti dengan gejala disfungsi serebral, ansietas, konfusi, agitasi, delirium, perilaku abnormal, halusinasi dan insomnia misalnya pada furious (ensefalitis) rabies. Gejala lain yang menyertai adalah disfungsi otonom berupa hipersalivasi, berkeringat, piloereksi, dan priapisme (pria). Manifestasi lainnya berupa hidrofobia (50-90% pasien). Periode akut penyakit ini biasanya berakhir setelah hari ke-10. Setelah gejala klinis muncul, penyakit hampir dikatakan fatal dan penatalaksanaannya berupa terapi suportif. Rabies memiliki 2 bentuk klinis, pertama

adalah ensefalitis (hebat) pada 80% pasien dan ke-2 adalah paralisis pada 20% pasien. Bila penyakit semakin progresif, pasien akan mengalami koma. “Teknik PCR dan pemeriksaan antibodi monoklonal dapat memastikan jenis virus yang berbeda yang dikaitkan dengan jenis hewan dan geografis,” tukas dr. Tuti. Pemberian vaksinasi Rabies merupakan penyakit yang hampir 100% dapat dicegah asal dilakukan 3 langkah yaitu pencucian luka, vaksinasi lengkap dan serum antirabies. Hal ini dikemukakan oleh Prof. Dr. drh. IGN Ngurah Marhadika. Dari total kasus di Bali yang dialami oleh manusia, rerata usia 36,6 tahun, sebagian besar laki-laki dan berasal dari daerah pedesaan. Hampir semuanya memiliki riwayat pernah digigit anjing dan hanya 5,8% yang lukanya dirawat dan menerima vaksin antirabies setelah tergigit. namun tidak ada yang mendapatkan rabies immunoglobuline (RIG). Dari saat tergigit hingga menimbukan gejala-gejala, memerlukan waktu kira-kira 110,4 hari. Pada saat dibawa ke rumah sakit sekitar 21,6% pasien menunjukkan manifestasi paralisis, sedangkan lainnya menunjukkan gejala rabies berat lainnya. Tingkat fatalitas kasus 100%. Bila diberikan vaksin pada hari ke-0, atau sebelum menunjukkan tanda-tandanya rabies, bisa selamat. Pemberian suntikan secara intramuskular sebenarnya hampir sama dengan intradermal, namun intradermal memerlukan dosis yang lebih sedikit sehingga persediaan dapat lebih panjang dan efek

16 December 2012 Indonesia Focus samping lebih minimal. “Keduanya memberikan proteksi yang sama, namun pertimbangannya biaya dan persediaan vaksin.” Inkubasi virus tergantung pada banyak faktor yaitu tempat gigitan, kedalaman luka, jenis virus dan patogenitasnya. Kebanyakan masa inkubasi kurang lebih 3 bulan atau 1012 hari bila gigitan terjadi di leher dan gejala kadang bahkan timbul 3-6 tahun kemudian. Risiko tertular rabies tanpa pemberian ‘Post Exposure Prophylaxis’ (PEP) sebesar 15,2% dan setelah PEP menjadi 4,17%. Selanjutnya Kepala Laboratorium Biomedik dan Biologi Molekuler Hewan pada Fakultas Kedokteran Hewan (FKH) Uni-

versitas Udayana ini, menjelaskan bahwa rabies menjadi masalah kesehatan masyarakat yang cukup besar di Bali. Kematian pada manusia yang cukup tinggi akibat rabies di Bali ini, disebabkan oleh beberapa faktor, antara lain kurangnya pengetahuan masyarakat akan risiko terkena rabies, manajemen luka yang buruk (setelah digigit anjing), dan terbatasnya ketersediaan RIG. Untuk mencegah terjadinya kasus rabies pada manusia, perlu meningkatkan kesadaran masyarakat mengenai manajemen luka gigitan anjing, meningkatkan ketersediaan ARV dan RIG, dan melakukan kampanye vaksinasi anjing.

18 December 2012 Indonesia Focus Local events calendar

KOPAPDI XV Medan Medan, 12-15 Desember 2012 JW Marriot International, Aryaduta, Grand Aston, Medan Sekr : DepartemenPenyakit Dalam Fakultas Kedokteran Universitas Sumatera Utara /Rumah Sakit 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 The 6th National Symposium of Aesthetic Medicine and Cosmetic Surgery Jakarta, 15-16 December 2012 Hotel Grand Sahid Jaya, Jakarta Sekr : Jl. Semolowaru Elok I/11-12A, Surabaya Tel : 031-34339288 Fax : 031-3957929 Email : perbeki.jtm@gmail. com The 1st ISICM National Clinical Case Conference On Intensive and Critical Care Medicine & Exhibition Makassar, 19-20 Januari 2013 Swiss-Belinn Panakkukang, Makassar Sekr : Indonesian Society of Intensive Care Medicine (PERDICI), Gedung Makmal Lt.2, Komplek FKUI, Jl. Salemba Raya No.6, Jakarta Pusat Tel : 021-685991557 Fax : 021-31909033 Email : [email protected] Website : www.perdici.org

PIPKRA : Towards Respiratory Healthy for the Future Jakarta, 7-10 Februari 2013 Hotel Borobudur, Jakarta Sekr : Poliklinik Paru Lt.2 RS Persahabatan, Jl. Persahabatan Raya No.1 Rawamangun, Jakarta Tel : 021-70726355, 4893536 Fax : 021-4705684 Email : [email protected] 3rd Asian Society for Neuroanesthesia and Critical Care (ASNACC) Bali, 20-23 Februari 2013 Hotel Sanur Paradise Plaza, Bali Sekr : Departemen Anestesi, Fakultas Kedokteram Universitas Padjajdaran/ RS Dr. Hasan Sadikin Bandung, Jl. Pasteur No.38, Bandung Tel : 022-2038285, 2034853 ext 3221 Fax : 022-2038306 InaSH Jakarta, 22-24 Februari 2013 Hotel Ritz Carlton, Jakarta Sekr : PERKI House Building, 2nd Floor, Jl. Danau Toba No. 139A-C, Bendungan Hilir, Jakarta Pusat Tel : 021-5734978 Fax : 021-5734978 Email : [email protected] Email : www. Inash.or.id karta 22- 24 Februari 2012

Kursus Penyegar & Penambah Ilmu Kedokteran FKUI 2013 (KPPIK) Jakarta, 2-3 Maret 2013 Hotel Ritz Carlton, Jakarta Sekr : CME-CPD FKUI, Salemba Raya No.6, Jakarta 10430 Tel : 021-3106737 Fax : 021-3106443 Email : [email protected] Website : http://cme.fk.ui.ac.id KONAS 1 Psikiatri ‘ Excellent Psychiatry’ Yogyakarta, 8-10 Maret 2013 Hotel Inna Garuda Yogyakarta Sekr : Bagian Psikiatri Fakultas Kedokteran Universitas Gadjah Mada / RSUD Dr. Sardjito. Jl. Kesehatan No.1 Sekip Utara, Yogyakarta Tel : 0274- 587333 Fax : 0274 553112 Email : [email protected] Website : www.pdskjiclp.wordpress. com National Symposium & Workshop of Anti Aging Medicine (NASWAAM) Bali, 22-24 Maret 2013 Hotel Sanur Beach Bali Sekr : Center for Studi of Anti Aging Medicine, Medical Faculty Udayana University, Denpasar, Bali Tel : 022 4262063 Fax : 022 4262065 Email : [email protected]

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19

December 2012

Conference Coverage

American Heart Association Scientific Sessions 2012, 3-7 November, Los Angeles, California, US

CABG superior to stents in diabetics with CAD Rajesh Kumar

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oronary artery bypass graft (CABG) surgery was found to be superior to percutaneous coronary intervention (PCI) using drug-eluting stents in diabetic patients with multi-vessel coronary artery disease in a large international trial. The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial enrolled 1,900 adults with diabetes and blockage of multiple coronary arteries (but not the left main artery which usually requires immediate CABG) from 18 countries between 2005 and 2010. [N Engl J Med 2012; DOI: 10.1056/NEJMoa1211585] At 140 clinical centers, teams of specialists in neurology, heart disease, diabetes, and general medicine screened potential participants to ensure that they were eligible for both CABG and PCI. Those who were selected for the trial were randomly assigned to receive either of the two interventions and followed up for at least 2 years. At a cumulative 5-year follow-up, the CABG group had a lower combined rate of strokes, heart attacks and deaths (18.7 percent vs. 26.6 percent, respectively; P=0.005). Strokes, which are a well-known risk of bypass surgery, occurred slightly more often in the CABG group than in the PCI group (5.2 percent vs. 2.4 percent, respectively; P=0.03). The benefit of CABG was driven by differences in rates of both myocardial infarction

(13.9 percent in PCI vs. 6.0 percent in CABG; P<0.001) and death from any cause (16.3 in PCI group vs. 10.9 in CABG; P=0.049). This survival advantage over PCI was consistent regardless of race, gender, number of blocked vessels, or disease severity. During the trial, participants received standard medical care for all major cardiovascular risk factors such as high LDL cholesterol, high blood pressure, and high blood sugar. They were counseled about lifestyle choices such as smoking cessation, diet, and regular exercise. Also, as recommended by international guidelines for patients who receive drug-eluting stents, the PCI group also received anticlotting therapies. Abciximab was administered intravenously during the procedure, and clopidogrel was given orally for at least 12 months after the procedure, accompanied by aspirin for those who could tolerate it. “The advantages of CABG over PCI were striking in this trial and could change treatment recommendations for thousands of individuals with diabetes and heart disease,” said principal investigator Dr. Valentin Fuster of Mount Sinai School of Medicine in New York City, New York, US. But the results of the trial apply to only the type of patients enrolled in the trial, said Dr. David Williams of Brigham and Women’s Hospital in Boston, Massachusetts, US, while commenting on their clinical implications. It is well established that there are patients with multi-vessel disease for whom CABG offers no benefit in terms of death or MI over

20

December 2012

Conference Coverage

PCI. FREEDOM, which was limited to patients with diabetes, represents a different type of patient, he said. “PCI is especially effective in relieving angina. So far, we know little of angina relief in FREEDOM…..therefore, presence of diabetes should strongly influence our decisions in managing patients with multi-vessel coro-

nary artery disease,” concluded Williams. Dr. Alice Jacobs of the Boston University Medical Center said whether the continual evolution of the new drug eluting stents technology will diminish the advantage of CABG was unclear, but appeared less likely if CABG protects the myocardium against the new disease.

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LATEST TREATMENT OPTIONS FOR DIABETES MIMS Video Series features 5-minute interviews with leading experts. In this Series, find out what these medical experts have to say about latest updates in the treatment of diabetes: Professor Juliana Chan talks about advances in diabetes management and the recent controversy on insulin therapy and cancer risk. Professor Ronald Ma discusses the unmet needs in diabetes management. Dr Anthony Wierzbicki shares his perspective on lipid management for diabetes patients.

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December 2012

Conference Coverage

American Heart Association Scientific Sessions 2012, 3-7 November, Los Angeles, California, US

Aspirin a good option for patients following first-time DVT/PE Elvira Manzano

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spirin therapy did not significantly reduce the rate of repeat venous thromboembolism (VTE) in the ASPIRE* trial but significantly reduced major vascular events, with improved net clinical benefit. In the study, which involved 822 adult patients who had a first episode of unprovoked deep vein thrombosis or pulmonary embolism, the annual rate of VTE recurrence (the primary outcome) was not significantly different in patients randomized to aspirin (100 mg/ day) or placebo (4.8 percent vs. 6.5 percent; HR 0.74, 95 % CI 0.52–1.05; P=0.09). Aspirin however reduced the secondary composite outcome of major vascular events (VTE, MI, stroke and death) by 34 percent without increasing bleeding. [NEJM 2012.DOI:10.1056/ NEJMoa 1210384] Patients had completed initial anticoagulation therapy before switching to aspirin for a mean of 37 months. With fewer patients recruited than originally planned, ASPIRE alone was not powered to show a significant reduction in the primary outcome. However, when combined with the results of the WARFASA** study, which was prospectively planned, “a clear effect is evident,” said lead author Dr. Timothy Brighton, from the Prince of Wales Hospital in Sydney, Australia. The WARFASA study, which involved 402 patients, showed that aspirin was able to re-

duce the rate of VTE recurrence by 42 percent as compared with placebo (P=0.02). Patients had baseline characteristics similar to those in the ASPIRE trial, making a meta-analysis possible. The pooled results from the two trials showed a 32 percent reduction in VTE recurrence rates P=0.007) and a 34 percent reduction in the rate of major vascular events P=0.002) with aspirin. “There’s consistent evidence now that aspirin provide a net benefit with no real cost in terms of side effects or bleeding,” Brighton said. “For the greater number of patients who are not able to take anticoagulants, aspirin is a good choice in the long term.” ASPIRE co-investigator Dr. John Simes, from the University of Sydney in Sydney, Australia, said they are not advocating that patients should stop anticoagulant therapy early as a result of these findings. “But in patients who are going to stop anyway, aspirin provides a moderately effective treatment compared with not having anything. We believe this is a cheap and relatively safe therapy that should be considered to prevent further venous thromboembolic events. Not only is it of benefit, it is also cost saving.” In an accompanying editorial, Dr. Theodore Warkentin, from McMaster University in Ontario, Canada however advises clinicians to treat patients with effective anticoagulation for at least 3 months before considering aspirin to avoid the high risk of early recurrence. “Aspirin is inexpensive, does not

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December 2012

Conference Coverage

require monitoring (in contrast to warfarin), and does not accumulate in patients with renal insufficiency (in contrast to dabigatran and rivaroxaban). Treatment for unprovoked VTE consists of warfarin, followed by heparin or the newer anticoagulants for 3–12 months. However,

many patients do not get treatment for longer than 3 to 6 months despite recommendation to prolong therapy. *ASPIRE: Aspirin to Prevent Recurrent Venous Thromboembolism **WARFASA: Warfarin and Aspirin study

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December 2012

Conference Coverage

Omega-3 fatty acids come up short in afib Elvira Manzano

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hort-term supplementation with omega-3 fatty acids prior to cardiac surgery appears to have no benefits in terms of preventing arrhythmias, according to new research. In the largest trial of fish oil in surgery ever conducted (OPERA*), administration of omega-3 polyunsaturated fatty acids (n3-PUFAs) 2 to 5 days prior to surgery and until hospital discharge did not reduce the risk of postoperative atrial fibrillation (AF). There was no difference in the incidence of postoperative AF of >30-second duration – the primary endpoint – between the treatment and placebo groups (30 percent vs. 30.7 percent, respectively; P=0.74). Results were similar for a number of secondary endpoints – postoperative AF that was sustained, symptomatic or treated, major adverse cardiovascular events, 30-day and 1-year mortality and bleeding – among different patient subgroups. [JAMA 2012; DOI:10.1001/jama.2012.28733] “Omega-3 fatty acids may not be powerful enough to be effective in preventing arrhythmias,” said study author Dr. Roberto Marchioli, from Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy. OPERA involved 1,516 patients scheduled for cardiac surgery in 28 centers in the US, Italy and Argentina randomized to a perioperative loading dose of placebo or n-3 PUFAs 8 to 10g, followed by 2 g/day postoperatively until hospital discharge. While previous small trials of perioperative fish oil on postoperative AF showed mixed effects, OPERA provides no evidence that n-3 PUFAs have anti-ar-

Two trials failed to show that fish oil prevented arrhythmias.

rhythmic actions. The findings were backed by another trial (FORWARD**) presented at the same meeting which showed that 1 g/day of fish oil did not prevent recurrences in patients with previous AF (HR 1.28, P=0.17). [Circ Cardiovasc Qual Outcomes 2012; DOI:CIROUTCOMES.112.966168). “Every time we’ve had a trial with omega3s, we’ve come up short,” said Dr. Peter Wilson, from the Emory University in Atlanta, Georgia, US. “It’s very discouraging for the omega story.” Amiodarone and b-blockers have been tested for postoperative AF, but these drugs only partly reduced the risk. The effects of cardiac surgery on atrial remodelling may be too immense to be countered by most drugs, including n-3PUFAs, said OPERA lead author Dr. Dariush Mozaffarian, from the Brigham and Women’s Hospital in Boston, Massachusetts, US. “Postoperative AF remains an intractable and enigmatic complication of surgery. More investigations are needed to allow novel targeted preventive and therapeutic interventions,” he concluded. *OPERA: Omega-3 Fatty Acids for Prevention of Postoperative AF **FORWARD: Fish Oil Research with Omega-3 for Atrial Fibrillation Recurrence Delay

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December 2012

Conference Coverage

American Heart Association Scientific Sessions 2012, 3-7 November, Los Angeles, California, US

Monoclonal antibody aids statin-refractory patients Radha Chitale

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atients with high cholesterol who cannot tolerate statins can turn to a new drug to help them control their lowdensity lipoprotein (LDL) levels, according to findings from a phase II study. In the randomized controlled GAUSS* trial, which included a total of 630 adult patients with high cholesterol who had failed statin therapy at least once, those randomized to receive a high 420 mg dose of AMG 145, a monoclonal antibody that helps clear LDL cholesterol from the blood, had significantly lower LDL levels after 12 weeks compared with those given standard ezetimibe statin monotherapy (-51 percent vs. -15 percent; P<0.001). [JAMA 2012;1-10. DOI:10.1001/ jama.2012.25790] Combined 420 mg AMG 145 plus ezetimibe therapy reduced LDL even more, by 63 percent over the 12-week trial period (P<0.001 vs. ezetimibe monotherapy). AMG 145 alone at 280 mg and 350 mg were less effective than the higher dose or combined therapies and resulted in 41 percent and 43 percent reductions in LDL from baseline, respectively. Goal LDL levels for healthy people is <130 mg/dL. High-risk patients should aim for LDL <100 mg/dL and further control should yield LDL <70 mg/dL in patients at very high risk of heart disease. Ninety-percent of patients achieved LDL <100 mg/dL on AMG 145 plus ezetimibe as

AMG 145 delivered robust results in the GAUSS trial.

did 61 percent of patients on 420 mg of AMG 145 monotherapy, compared with 7 percent of those on ezetimibe monotherapy by week 12. No patients on ezetimibe monotherapy achieved the more aggressive goal LDL <70 mg/dL at week 12 while 62 percent of patients on AMG 145 plus ezetimibe and 29 percent of patients on 420 mg AMG 145 did. “Improvements were observed in other lipid and lipoprotein parameters,” said lead researcher Dr. Evan Stein, of the Metabolic and Atherosclerosis Research Center in Cincinnati, Ohio, US. AMG 145 was associated with musclerelated side effects in 5 percent of recipients, with myalgia being the most common type (3 percent). Dr. Peter Wilson, of Emory University in Atlanta, Georgia, US, said this phase II trial showed that the AMG 145 drug class demonstrated efficacy and a good amount of safety, but that more information on the long-term safety profile and immune effects in studies

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Conference Coverage

that lasted beyond 12 weeks would be useful. “These data are very exciting and may offer a new paradigm for LDL cholesterol reduction. The next step will be a large-scale, longterm cardiovascular outcomes trial,” said Dr.

Marc Sabatine, of Brigham and Women’s Hospital in Boston, Massachusetts, US. *GAUSS: Goal Achievement after Utilizing an Anti-PCSK9 Antibody in Statin-Intolerant Subjects

Chelation trial dredges up unexpected controversy Radha Chitale

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ong-term chelation therapy had modest cardiovascular benefits in patients who had previously experienced a heart attack, according to the results of a US trial. In the 4-year Trial to Assess Chelation Therapy (TACT) involving 1,708 post-myocardial infarction (MI) patients, 26 percent of those randomized to infusions of chelation therapy experienced subsequent cardiovascular events, including MI, stroke and coronary revascularization, compared with 30 percent of placebo recipients (HR 0.82, 95% CI 0.69 to 0.99, P=0.035). “[This chelation regimen] showed some evidence of a potentially important treatment signal in post-MI patients already on evidence-based therapy,” said lead researcher Dr. Gervasio Lamas, of Mount Sinai Medical Center in Miami Beach, Florida, US. “Our findings are unexpected and additional research is needed to confirm or refute our results and explore possible mechanisms of therapy.” The trial, supported by the US National Center for Complementary and Alternative Medicine and the US National Heart, Lung and Blood Institute, was meant to pin down the effects of chelation therapy, which in-

Chelation therapy was associated with modest long-term CV benefits in post-MI patients.

volves using disodium ethylenediaminetetraacetic acid (EDTA) to remove heavy metals such as lead and iron from the body, on cardiovascular health.

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December 2012

Conference Coverage

Since it was developed in the 1950s, chelation therapy has only been FDA-approved for treating lead poisoning. But consistent off-label use to treat a variety of diseases, including cardiovascular disease, kept controversy over chelation therapy simmering. “Some have suggested [chelation] is valuable, effective and safe; others have suggested it’s likely unsafe, certainly ineffective and should be abandoned,” said Dr. Paul Armstrong, of the University of Alberta in Edmonton, Canada, during a discussion of the trial results. A quality-of-life sub-study showed no difference in functional status, mental well-being or any other metric with chelation therapy compared with placebo over 2 years of follow up, which makes it even more unlikely to become a mainstream therapy down the road. “The [sub-study results] don’t actually support or provide additional support for these clinical results, which we weren’t very sure about in the first place,” said Dr. Mark Hlatky, of Stanford University in Stanford, California, US. The double-blind factorial trial randomized heart patients, median age 65 years, to 40 infusions of chelation solution (included EDTA, 7 grams ascorbic acid, B-vitamins, electrolytes, anaesthetic, and heparin) or placebo infusions. The trial ran from 2002 to 2011 in the US and Canada and patients were followed for a median of 4 years. Patients were between overweight or obese, about one-third were

diabetic, and all were on either beta-blocker, statin, ACE inhibitor, ARB or antiplatelet therapy. Seventeen-percent of patients withdrew consent during the trial period. The primary endpoint was a composite of death, MI, stroke, coronary revascularization and hospitalization for angina. Coronary revascularization occurred most frequently, 287 events out of 483 total composite events. Nearly one-third of diabetic patients (31 percent) experienced events. Two unexpected serious adverse events occurred in each study arm, with one death in each arm, “possibly or definitely related to study therapy,” Lamas said. He also noted that despite the modest statistical significance of cardiovascular benefit with chelation, the upper confidence interval was 0.99. The mechanism of action is still not well understood. Of note, the researchers saw no improvements in angina among chelated patients. Relief of angina pectoris was one of the driving factors in the initial use of chelation for heart disease. However, Mark said that improved management of angina could have kept patients asymptomatic at follow-up, particularly when the incidence of angina was low at baseline. “Intriguing as the results are, they are unexpected and should not be interpreted as an indication to adopt chelation into clinical practice,” said Dr. Elliott Antman, of the Harvard Medical School in Boston, Massachusetts, US.

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December 2012

In Practice

Treatment options for fecal incontinence

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polyps/cancer, proctitis, perianal fistula-inano and anal fissures. Patients with FI should have colonic assessment with colonoscopy. After excluding conditions mimicking FI, the patient should undergo anorectal physiology testing with anorectal manometry, anal electromyography, pudendal nerve terminal motor latency test (PNTML) and endoanal ultrasound. These tests help to define the anatomy and physiologic state of the anal sphincter to guide treatment.2-3

Diagnosis Common factors associated with FI are traumatic childbirth, previous anal surgery (especially anal dilatation), advanced age, obesity or neurological conditions such as multiple sclerosis, diabetic neuropathy, stroke or Parkinson’s disease. In all these cases, conditions that cause excessive mucoid discharge from the anus that mimic FI should be excluded first. These include colorectal

Practice guidelines Most practice guidelines recommend taking a detailed history of a patient’s bowel habits, especially number of incontinent episodes, getting the patient to complete a weekly bowel diary of number of bowel movements and accidents, obstetric history with emphasis on number of deliveries, mode of deliveries, use of forceps, episiotomies and medical history, especially use of drugs that may cause diarrhea as well as drugs that reduce anal sphincter tone such as anti-hypertensive drugs. Clinical examination needs to be done for perianal conditions such as hemorrhoids, anal fissures and warts. Physicians should also look for other signs of FI such as patulous anus and perianal excoriation and pruritis ani. Change any drugs that may have caused FI, if medically possible, and avoid medications that may cause diarrhea. Try treating with anti-diarrheal medication first (such as diphenoxylate/atropine or low-dose loperamide) and refer to a specialist in FI management (colorectal surgeon) for further assessment if there is no improvement.

Dr. Lim Jit Fong Colorectal Surgeon and Director, Pelvic Floor Disorders Fortis Colorectal Hospital, Singapore

ecal incontinence (FI) is defined as involuntary loss of solid, liquid or gas from the anus. While no data is available on its prevalence in Asia, many population-based studies elsewhere put the figure between 5 to 15 percent, with higher prevalence among the elderly.1 While not lifethreatening, FI causes significant physical and emotional trauma and can be disabling. Its causes are usually multi-factorial. The condition can be broadly classified into urge or passive FI with many patients having a mixed pattern. In a case of urge FI, the patient complains of difficulty delaying a bowel movement but does not stain the underwear at rest. For passive FI, the patient may not have difficulty delaying the bowel movement but may stain the underwear in sleep or after strenuous activity (eg, after a long walk or after work).

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In Practice

Treatment Treatment includes lifestyle and behavioral modifications, oral and topical medications, anorectal biofeedback, injectable implants, anal sphincter and pelvic floor repair, sacral neuromodulation (SNM), anal sphincter replacement techniques, dynamic stimulated gracilopasty (DG), artificial bowel sphincter (ABS) implant, antegrade continence enema (ACE) surgery and permanent colostomy. The aim of treatment is to restore the patient’s continence and quality of life. All patients are taught simple behavioral modifications to cope with the FI episodes. Some have dietary triggers which worsen their condition and these need to be identified. While undergoing treatment, it is important to treat the secondary symptoms such as perianal excoriation with topical agents. The topical creams used should be silicone based (to act as barrier against fecal content on skin) and contain zinc oxide (to aid healing of inflamed skin) and these are found in many commercially available diaper rash creams. Patients are also taught anorectal biofeedback, which combines counseling and lifestyle modification along with pelvic floor exercises to strengthen the anal and pelvic floor muscles. Injectable implants are useful for those with passive FI but their effect rarely lasts beyond a year. These injections can be repeated. Anal sphincters that are torn may be repaired surgically with concurrent repair of the pelvic floor muscle. Those with severely damaged anal sphincters may be suitable for sphincter replacement operations but these are technically complex and carry significant risks of infection. Patients with neuropathic FI are best treated with SNM which is easy to perform and

has very high chance of success. The risks are low and the procedure is well accepted by patients. This treatment is also suitable for patients with mixed pattern FI, which form the majority of cases with FI. ACE and colostomy are considered last options because they are not well accepted by patients. The patient needs to have regular clearing of their bowel and care of the colostomy bag in an elderly patient can be difficult. There is also a significant limitation to patient’s activities with ACE or colostomy. Disease management tools Different forms of treatment have different risks, success and recurrence rates. These need to be explained to the patient when planning the optimal option for the patient. Non-surgical managements are extremely low risk and necessary even if the patient requires surgery. The success rate of anorectal biofeedback depends on how motivated the patient is, but almost all patients who are able to follow the program will improve their bowel control to varying degrees. The majority of patients with milder FI will only require this option. Injectable implants started with autologous fat but current versions involve silicone4 (PTQTM), carbon beads (DurasphereTM), porcine collagen (PermacolTM) or synthetic resin (Gatekeeper TM). Most injectable implants have reported success rates based on improved continence severity scores but few report success rates in percentages of patients improved. The treatment is simple to perform but carries a small risk of infection and secondary fistula-in-ano formation if not performed properly. Anal sphincter and pelvic floor repair (anal sphincteroplasty and levatorplasty) are aimed at correcting structurally torn

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In Practice

striated muscles of the levator ani and external anal sphincter. The reported success rate after repair is 50 to 86 percent but this deteriorates with time to between 11 and 50 percent for studies with follow-up beyond 5 years.5 DG and ABS are technically complex procedures. They also carry significant risk of complications. DG is associated with 55 to 71 percent rate of success in patients achieving > 50 percent improvement in incontinent episodes but the risk of serious wound complications may be as high as 30 percent. There is also a 20 percent risk of pain either in the anus or donor limb which may require explantation of the stimulator.6 ABS involves the implantation of a silicone expandable cuff in then perineum surrounding the anus with a reservoir in the pre-peritoneal space anterior to the bladder. The reported infection rate of the implant is as high as 33 percent which almost always required a second surgery to remove the implant.7 SNM as the latest advancement SNM is carried out in two phases, the peripheral nerve evaluation (PNE) and permanent implant phases (Medtronic Interstim II). At the PNE stage, a straight electrode is inserted percutaneously and connected to an external battery. This procedure is done as a day surgery procedure and there is minimal discomfort as no incisions are made.8 The patient then wears the electrode for 2 to 4 weeks to determine whether there is any improvement in fecal incontinent episodes. Patients with >50 percent improvement in continence are then offered a permanent implant. The permanent implant is similar to the PNE stage except a 5cm incision is needed to insert the pulse generator and is similar to

cardiac pacemaker implantation. With careful selection of patients, more than 80 percent of patients who undergo PNE successfully undergo permanent implantation. Newer treatment options that are being explored include an implantable magnetic ring around the anus (FENIXTM) and injectable pudendal nerve stimulator, but it is too early to know where these new devices place in the treatment algorithm of FI. Currently, SNM is the first option of surgical treatment for patients with FI in most leading centers in Europe, UK, US and Australia.

Conclusion FI is a debilitating condition which is under-reported and often misrepresented as a normal part of aging. It is treatable and many patients can achieve good bowel control with medical management and anorectal biofeedback alone. Fewer than 20 percent will require some form of surgery. SNM and injectable implants are the most promising surgical inter-

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ventions as they carry very low risk of complications with good success rates. In some patients, more than one type of treatment may be necessary in order to achieve optimal results. References: 1. Macmillan AK, Merrie AEH, Marshall RJ, Parry BR. The prevalence of faecal incontinence in community dwelling adults: a systematic review. Dis Colon & Rectum. 2004 (47):1341-49. 2. Jorge JMN, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993, 36:77–97. 3. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC. Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43(1):9-16. 4. Tjandra JJ, Lim JF, Hiscock R, Rajendra P. In-

jectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective. Dis Colon Rectum. 2004; 47(12): 2138-46. 5. Brown SR, Nelson RL. Surgery for faecal incontinence in adults. Cochrane Database Syst Rev 2007(2):CD001757. 6. Chapman AE, Geerdes B, Hewett P, Young J, Eyers T, Kiroff G, Maddern GJ. Systematic review of dynamic graciloplasty in the treatment of faecal incontinence. Br J Surg 2002; 89(2):138-53. 7. Wong WD, Congliosi SM, Spencer MP, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum 2002; 45(9):1139-53. 8. Tjandra JJ, Lim JF, Matzel K. Sacral nerve stimulation: an emerging treatment for faecal incontinence. ANZ J Surg. 2004; 74(12):1098106. Review.

33 December 2012 Calendar December 1st Asia-Pacific Glaucoma Congress  (APGC 2012) 7/12/2012 to 9/12/2012 Location: Bali, Indonesia Info: Kenes Asia (Singapore) Tel: (65) 6292 4710 Fax: (65) 6292 4721 E-mail: [email protected] Website: apgc2012.org/

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

Molecular Medicine Conference 2012 (MMC2012) 19/12/2012 to 22/12/2012 Location: Bangkok, Thailand Info: Drs Thawornchai Limjindaporn or Ornnuthchar Poungpair Tel. (66) 2419 2754 to 57 E-mail: [email protected] Website: www.mmc2012.org

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

Emergency Medicine 2013 23/1/2013 to 24/1/2013 Location: London, UK Info: MA Healthcare Conferences (London) Tel: (44) 20 7501 6762 Fax: (44) 20 7978 8319 Email: [email protected] Website: www.mahealthcareevents.co.uk/

4th International Conference on Legal Medicine, Medical Negligence and Litigation in Medical Practice (IAMLE-2013) 25/1/2013 to 27/1/2013 Location: Thiruvananthapuram, Kerala, India Info: Prof. R.K.Sharma, Chairman - IAMLE 2013 Tel: (91)11 4158 6401/402 Email: [email protected], [email protected] Website: www.iamleconf.in

February Food Allergy and Anaphylaxis Meeting (FAAM) 2013

January

7/2/2013 to 9/2/2013 Location: Nice, France Info: EAACI FAAM 2013 Secretariat Tel: (33) 1 7039 3554 Fax: (33) 1 5385 8283 Email: [email protected] Website: www.eaaci-faam.org/

16th Bangkok International Symposium on HIV Medicine

International Meeting on Emerging Diseases and Surveillance (IMED 2013)

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

15/2/2013 to 18/2/2013 Location: Vienna, Austria Info: International Society for Infectious Diseases Tel: (617) 277 0551 Fax: (617) 278 9113 Email: [email protected] Website: www.isid.org/imed/Index.shtml

34 December 2012 Calendar 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: www2.kenes.com/apsc2013/pages/home.aspx

March 23rd Conference of the Asia Pacific Association for the Study of the Liver 7/3/2013 to 10/3/2013 Location: Singapore Info: Gastroenterological Society of Singapore, The Asian Pacific Association for the Study of the Liver Tel: (65) 6292 4710 Fax: (65) 6292 4721 Email: [email protected] Website: www.apaslconference.org

62nd American College of Cardiology (ACC) Annual Scientific Session 9/3/2013 to 11/3/2013 Location: San Francisco, California, US Info: American College of Cardiology Foundation Tel: (415) 800 699 5113 Email: [email protected] Website: www.accscientificsession.org/Pages/home.aspx

4th Biennial Congress of the Asian-Pacific Hepato-Pancreato-Biliary Association 27/3/2013 to 30/3/2013 Location: Shanghai, China Info: Asian Pacific Hepato-Pancreato-Biliary Association Tel: (86) 21 350 30066 Fax: (86) 21 655 62400 Email: [email protected] Website: www.aphpba2013shanghai.org

35

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After Hours

tanding atop St Paul’s Hill, facing the sea, you just need to close your eyes and get whisked away by the gentle breeze to a time not very long ago when Malacca was a bustling port with ships, sailors and traders from the far corners of the world. Nestled strategically between the Indian Ocean and the South China Sea, protected from winds, earthquakes and volcanoes, it is little wonder why Malacca was an international trading port. It is precisely because of Malacca’s status as an international harbor that so many pow-

ers tried to conquer it. Today, as one strolls through the streets of Malacca town, it is easy to spot the various influences of the colonists who came and went over the centuries. Of course, it helps that there are little plaques inserted into the walls, signs and fences to indicate when the structures were built and what they served as. At the foot of St Paul’s Hill, you can see A’ Famosa, the landmark fort that was built by the Portuguese. Also a remnant of those times is the chapel on St Paul’s Hill. In Malacca’s town square, the Stadthuys, easily distinguishable by its red walls, sits beside Christ

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Church, also built by the Dutch. In the town square, tourists mill around, snapping pictures of the red buildings as colorful trishaws wait for passengers. At the riverbank, one cannot ignore the large ship that appears to have docked there. The Malacca Maritime Museum is a replica of the Flora de La mar, a Portuguese trading vessel that sank off the coast of Malacca while en route to Portugal with loot plundered from Malacca. Inside, visitors can get a peek into the trading history of Malacca, from the time of the Sultanate and through the years of Portuguese, Dutch and British dominance. Malacca has turned some of its historic buildings into museums housing precious relics of its past. The Stadthuys, once a Dutch administrative building, now houses historical artifacts, guiding visitors through the history of Malacca from its humble beginnings to its height of glory as a trading destination and onwards through the years of colonization by the European powers.

Everything in Malacca is within walking distance. From the A’Famosa to the Stadthuys, it is just a few minutes’ walk. In between are many attractions for tourists to feast their eyes on. And right by the town square is the famed Jonker Street. Jonker Street is a delight for anyone who loves antiquities or just finds joy looking at curios. One of the shops is a cobbler’s, who still makes shoes worn by the ancient Chinese women with bound feet and authentic Nyonya beaded slippers. While wandering about these streets, you may also be ‘accosted’ by the wonderful smells of nyonya cuisine wafting from the little coffeeshops. The beauty and charm of Malacca must be experienced first-hand. Just a 2-hour drive from Kuala Lumpur, it’s the perfect place for a weekend getaway. With good food and a rich culture, one leaves Malacca feeling sated in both body and mind, already longing for another round of ayam pongteh and chicken rice balls.

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We take in the sights of Berlin without burning fossil fuel and having to fight aggressive drivers. Fans of train rides or trains in general … this is where we get on! Leonard Yap writes.

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etting around Berlin is quite a breeze if you can embrace the complexities of the different modes of transport. If you are a train nut or you like Thomas the Tank engine like I do, or you want to see the world without leaving a huge carbon footprint, you have come to the right place. There are officially five types of public transport: the subway known as the U-Bahn; the urban rail network known as the S-Bahn; the bus; the tram; and a ferry service which takes you away from Berlin to more rustic and rural areas. In essence, if the trains do not cover your destination, the bus, tram or ferry will take you where you need to go. The best way to experience Berlin is by taking the S-Bahn or the bus. The S-Bahn is a particularly good option because the tracks are elevated and cut through some of the best parts of the city. Take the S-Bahn line 5 or 7 to Berlin’s green lung, the Tiergarten, the zoo (Zoologischer Garten) and the Olympiastadion, built for the 1936 Summer Olympics and home of football club Hertha Berlin. Looking out the window, you watch as the train glides past wide boulevards, quirky architecture and Berliners shopping at farmers markets. One of the great sights is the ‘graffiti’ on buildings. There are a great number of works of

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After Hours

art painted on buildings along the train line. Some train stations are actually destinations themselves. The Hauptbahnhof (main train station) is a 6-storey glass behemoth – you will gawk and jaw drop at its cathedral glass ceiling. Some 11,000 pieces of glass cover this huge transit center. Be prepared to be lost in it as there are 12 or more platforms just on the top level of the station. To add to the confusion, it shares platforms with regional trains and the high-speed intercity express. If getting lost causes you distress, you can get some shopping therapy at the multitude of shops in the station. When the train is no longer doing the trick, take the bus, in particular number 100 from Zoologischer Garten, for a tour of the main attractions. It is a real bargain because it takes you pass the Brandenburger Tor (Brandenburg Gate), the German parliament known as the Reichstag/Bundestag, and various museums – and you don’t have to pay the price of a tour, which can be hefty. You can get to virtually anywhere in Berlin affordably via public transport. Avoid getting behind the wheel if you want to avoid crazy Berliners in ultra-fast German machines of mass destruction, high fuel prices and a levy on driving in parts of the city. The true benefit of public transport, apart from not burning fossil fuels and saving your heart from getting a coronary, is the opportunity to see the whole gamut of Berliners, which is as diverse as the United Nations. If lost, do not be afraid to ask for directions. Germans

may seem a bit reserved, but if you ask nicely and follow the unfailing formula of ‘guten tag’ (hello) or entschuldigung (excuse me), followed by sprechen sie englisch, Berliners are quite happy to put you back on your way. Berlin in context Berlin shares the trappings of most big cities, the predictable bad drivers, incessant smoking and drinking in public spaces, and an overly complex public transportation system. That being said, it still retains a charm that eludes many modern cities. For one it has an enormous amount of open spaces, green areas, parks, playgrounds and walking paths that straddle the river Spree, which courses through the heart of the city. Berlin has a very complex modern history: Hitler’s fascists taking over, going to war and bombed flat in World War 2, split in half by a wall (physical and ideological) during the Cold War and the falling of that wall in 1989, and, finally, the Berlin of today, growing with scars, warts and all to be a very international city. Geographically located in northeastern Germany, Berlin is approximately 60 km west of the Polish border, in an area of low-lying marshy woodlands. It is part of the vast Northern European Plain, which stretches from northern France to western Russia. The Spree flows through Berlin and empties into the river Havel. The Havel flows through a chain of lakes, the largest of which are the Tegeler See and Großer Wannsee.

39

December 2012

Humor

“I think we should operate immediately!”

“So, whenever you get up after sleep, you feel dizzy for half an hour, then you’re alright. I suggest you wait for half an hour before getting up!”

“Of course it’s second hand!”

“Remember what the doctor said, your brown to not“Itosent worry about the suit outcome thethe cleaners. It will of operation. Youmatch won’tthe be mahogany perfectly!” able to seecasket the difference!”

“Your lab tests came back, and we don’t know what’s wrong with you. We suspect that it’s something to do with your health!”

“Sorry, I can’t reveal the details of the operation. It’s an old secret family recipe!”

“You are saying there is “I sent your brown to nothing wrong withsuit me? the cleaners. match the Well, thenIt Iwill suppose casket perfectly!” I’llmahogany have to find another doctor!”

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