May 2012

www.medicaltribune.com

Dramatic blood sugar control with gastric surgery

INDONESIA FOCUS Bahaya konsumsi gula tambahan berlebih

IN PRACTICE Managing acute otitis media: Strategies for GPs

UROLOGY Odor may help signal UTI in children

NEWS Bergamot orange a natural supplement

May 2012

Dramatic blood sugar control with gastric surgery

Radha Chitale
astric surgery controlled blood sugar better than intensive medical therapy among obese type 2 diabetics, according to the STAMPEDE trial, the results of which were presented at the 61st Annual Scientific Sessions of the American College of Cardiology meeting in Chicago, Illinois, US. Patients who underwent Roux-en-Y gastric bypass surgery or sleeve gastrectomy achieved HbA1c control below 6 percent within a year in 42 percent (P=0.002) and 37 percent of cases (P=0.008), respectively, compared with 12 percent who received intensive medical therapy alone. [N Engl J Med 2012 Mar 26. Epub ahead of print] Despite improvements in pharmacotherapy, fewer than 50 percent of patients with moderate-to-severe type 2 diabetes actually achieve and maintain therapeutic thresholds, particularly for glycemic control, said researchers from the Cleveland Clinic in Ohio, US, Veterans Affairs Boston Healthcare System and Brigham and Womens Hospital in Boston, Massachusetts, US. Observational studies have suggested that bariatric or metabolic surgery can rapidly improve glycemic control... The trial randomized 150 obese patients (mean age 49 years, mean body mass index 36 kg/m2, mean HbA1c 9.2 percent) with uncontrolled type 2 diabetes to receive intensive medical therapy alone, medical therapy

The STAMPEDE trial showed that gastric surgery significantly lowered HbA1c levels compared with intensive medical therapy alone in obese patients with type 2 diabetes.

plus Roux-en-Y gastric bypass surgery or medical therapy plus sleeve gastrectomy. Intense medical therapy followed the guidelines of the American Diabetes Association and included lifestyle counselling, weight management, and drug therapy. Patients randomized to surgery experienced significantly more weight loss compared with those receiving medical therapy after 12 months (-29.5 kg gastric bypass, -25.1 kg sleeve gastrectomy, -5.4 kg medical therapy, P<0.001 for both) and lead author Dr. Philip Schauer, of the Cleveland Clinic, said this, more than anything else, was the likely driver for glycemic control. Mean HbA1c was 6.4 percent in the gastric bypass group (P<0.001), 6.6 percent in the sleeve gastrectomy group (P=0.003) and

May 2012 tute, Melbourne, VIC, Australia, and Dr. K. George M. M. Alberti, Kings College Hospital, London, England, said surgery would not be the universal panacea for obese patients with type 2 diabetes and pointed out that the study duration was only 1 year and that surgery has inherent hazards. [N Engl J Med 2012 Mar 26. Epub ahead of print] There is also the problem of remission versus cure, they said. Type 2 diabetes is often progressive, and worsening of glycemic control over time is likely in many patients. However, some years of improved glycemia may well result in less microvascular disease. Both the researchers and commenters called for further studies on the long-term clinical effects of gastric surgery.

7.5 percent among patients receiving medical therapy. Patients who underwent surgery also significantly reduced or halted use of glucose control and cardiovascular medications. Reductions in the use of diabetes medications occurred before achievement of maximal weight loss, which supports the concept that the mechanisms of improvement in diabetes involve physiologic effects in addition to weight loss... the researchers said. No deaths or life threatening complications occurred although four patients required a second surgery for complications. In an accompanying comment, Dr. Paul Zimmet, Baker IDI Heart and Diabetes Insti-

May 2012

Electronic skin patches for health monitoring

Radha Chitale

ltra thin electronic skin patches that wirelessly relay health information could free patients who need to be monitored from inpatient care. The technology can be used to monitor brain, heart or muscle activity in a completely noninvasive way, while a patient is at home, said Dr. John Rogers, a professor of materials science and chemistry at the University of Illinois at Urbana-Champaign, who developed the device. These new materials for electronics can intimately integrate with the human body. The electrical components of the patches are designed to withstand water, sweat and movement. Rogers and colleagues accomplished this by preparing the same silicone used in rigid electronic wafers, in thin membranes cut into a web-like mesh and integrated with silicone rubbers that are laminated to the skin like a temporary tattoo. The findings were presented during the annual meeting of the American Chemical Society, held recently in San Diego, California, US. The patchs sensor functions allow it to measure a variety of electronic metrics

including, muscle contractions, heartbeat, brain functions, temperature and hydration. Hydration looks like a very interesting [application] for us, Rogers said. Measuring skin hydration has applications in cosmetics and athletics but Rogers pointed out that certain heart conditions can be spotted based on the bodys fluid retention. The device should also be particularly useful for patients who require monitoring by electroencephalograms, electrocardiograms and electromyograms. But the patch could be used for more than skin surface applications. Rogers said they could be integrated with advanced surgical devices to feedback information, on the surface of balloon catheters, for example, to add a diagnostic function. In addition to sensory reception, the patch can also provide electrical stimuli, Rogers said, which may be useful for physical rehabilitation. The electronic skin patch can stay on the skin for about 1 week, but beyond 2 weeks the surface layer of skin cells is naturally sloughed off. Rogers said they would need to think about accommodating this exfoliation process in situations of long-term monitoring.

May 2012

Forum

Biobanks: Research dream or ethical nightmare?

Professor Alastair V. Campbell, Director of the Centre for Biomedical Ethics at the National University of Singapore, discussed the research potential of large-scale human health databases during the Asia-Pacific Research Ethics Conference, held recently in Singapore.

iobanks, large epidemiological cohorts, including past and present populations, that are associated with extensive samples of DNA and other biological materials, linked to health data, offer a rich source of information for public health research. Data capture health episodes affecting participants as they occur and are often followed up for decades. However, the possibility of information abuse or use for commercial gain is high. Creating and maintaining biobanks raises a number of major ethical questions that should be dealt with as we strive to define and defend the biocommons. Opportunities for research Biobanks warrant unusual consideration. The data they contain offer a broad range of possible research opportunities, mined from a broad range of future health information that will be captured. This is large-scale data, with many participants, making it somewhat impersonal. In addition, a range of researchers will have access to the data for a very long time. The major features that make a biobank enterprise different from a piece of research are the need for general consent, appropriate stewardship, and justified trust. Therefore, special measures are required for biobanks, rather than holding them to the

same standards of research protocol as other data sets. The UK Biobank is the worlds largest resource of genetic health and lifestyle data. It includes over 500,000 participants aged 4069 and has the unique advantage of gaining data from the comprehensive British National Health Service. This biobank took about 10 years of lead time in order to clarify the governance and ethical framework, in addition to public consultations. People would get a letter inviting them for an assessment at a clinic. A major part of the visit was spent explaining what they were giving consent to. Participants in the UK Biobank consented to access to medical records for the remainder of their lives and after their death, without feedback on the results of their testing, other

May 2012

Forum
This kind of data consolidation lends itself to growing into virtual biobanks. Virtual biobanks are gaining popularity as researchers push to share and use population information across regions. The issue of access is important in the face of pressure to link data sets internationally but it is complicated because there is no consistency in governance across international biobanks. Ethicists could discuss whether it is right to trust international entities with biobank data without international consistency. Security measures are important to have in place to prevent inappropriate access. Stewards must address who has access to the biobank data, to what extent access to other records is controlled and how easy it is to hack into the resource. Safeguards to prevent abuse One solution could be for a virtual biobanks to link registries with safeguards to prevent identification. A person would be assigned a serial number and the serial number is linked to the health data as a way to store data without compromising the safety of the subject. The link would be stored with an independent trusted third party and without their cooperation, no one can link the health information back to the original subject. Whatever the problems with broad consent, presumed consent is not sufficient. Biobanks are more than just a collection of tissue or data. Researchers have to see these as public property for the common good, uninfluenced by commercial or nationalist interests. The prospect for large-scale data sharing for health not profit could lead to greater information and more justice in healthcare.

than minor initial tests for basic things like blood pressure levels. Consent for use of participant data is rescindable but not conditional. That is, you cannot specify what type of research you are willing to allow your tissues to be used for. The big brother scenario The nightmare scenario would be that big brother is watching. How can we be sure such databases wont be used in ways other than what the participant signed up for? If, for example, stored genetic information could be accessed by court order in a society where authorities increasingly want access to citizens? In addition, if the commercial dominates, the whole purpose of the collection is in danger. This is where ethics in governance comes in. If the ethics governing body believes the participants trust was abused, they say so, acting as proxy for the people involved. The governance of the UK Biobank is independent, and they alone guard the ethics and governance framework. They advise on revisions, monitor the UK Biobank and report their findings publicly and provide general advice.

Creating and maintaining

biobanks raises a number of

major ethical questions that should be dealt with as we strive to define and defend the biocommons Biobanks can be built from the ground up, as the UK Biobank was, but they can also be created by linking existing collections of tissue and registry information.

May 2012

Indonesia Focus
The 9th Congress Of Indonesian Society of Endocrinology Manado, 57 Juli 2012 Hotel Grand Kawanua Convention Centre, Manado Sekr : Bagian Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia/ RSUP Nasional Dr. Cipto Mangunkusumo Jalan Salemba 6, Jakarta 10430 Telp : 021-3100075, 3907703 Fax : 021-3928658, 3928659 Email : endo_id@indo.net.id Website : www.perkeni.net 7th Symposium on Nutri Indonesia in conjunction with 1st International Symposium on Nutrition (From Evidence to Practice) Jakarta, 5-8 Juli 2012 Hotel Acacia, Jakarta Sekr : Pacto Convex Ltd Lagoon Tower, Level B1, The Sultan Hotel Jl. Jend. Gatot Subroto, Jakarta 10270 Tel : 021-5705800 Fax : 021-5705798 Email : secretariat@ nutriindonesia.org Website : www.nutriindonesia.org PIN X PB PAPDI (Emergency in Internal Medicine) Balikpapan, 29 Juni1 Juli 2012 Hotel Gran Senyiur, Balikpapan Sekr : Gedung ICB Bumiputera, Ground Floor 2B, Jl. Probolinggo No.18 , Gondangdia, Menteng, Jakarta 10350 Tel : 021-2300818 Fax : 021-2300755/2300588 Email : pin9pbpapdi@gmail. com ; pin9pbpapdi@ yahoo.co.id; pb_papdi@ indo.net.id KOGI 2012 (Congress Obstetry & Gynecology) 30 Juni 4 Juli 2012, Bali Nusa Dua Convention Centre Sekr : Pogi Jakarta Tel : 021-3143684 Fax : 021-3910135 Email : pogi@indo.net.id 54th Anniversary PAPDI JAYA Preset: Jakarta Internal Medicine in Daily Practice 31 Agustus 2 September 2012, Jakarta Hotel Borobudur, Jakarta Sekr : Gedung ICB Bumiputera Lt.1, Jl. Probolinggo 18, Gondangdia, Menteng, Jakarta 10350 Tel : 021-2301267 Fax : 021-2301267 Email : papdijaya@gmail.com, jim_dace@yahoo.com The 14th International Meeting on Respiratory Care Insonesia (Respina) 2012 5 - 6 Oktober 2012, Jakarta 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. indonesia@gmail.com Website : www.respina.org

L events calendar ocal

The 3rd Asia Oceanian Conference of Physical and Rehabilitation Medicine Bali, 21-24 Mei 2012 Hotel Discovery Kartika Plaza, Bali Sekr : Jl. Cakalang Raya No. 28 A, Rawamangun, Jakarta Timur Tel / Fax : 021-47866390 Email : aocprm2012bali@ pharma-pro.com Website : www.aocprm2012.org Perhimpunan Respirologi Indonesia (Pertemuan Ilmiah Respirasi 3 Makassar) Makassar, 25-27 Mei 2012 Hotel Grand Clarion Makassar Sekr : Division of Respirology and Clinical Respiratory Disease, Department of internal medicine, Department of pulmonology & respirastory medicine, Faculty of medicine, University of Hasanudin, 2nd Fl, Infection Center Bldg, RS dr. Wahidin Sudirohusodo, Jl. Perintis Kemerdekaan km.11, Tamalanrea, Makassar 902145 Tel / Fax : 0411-582002 Email : konasperpari makasaar@gmail.com KONAS PDPI XIII Surabaya, 4-7 Juli 2012 Shangri-la Surabaya Sekr : Bagian / SMF Ilmu Penyakit Paru, RSUD Dr. Soetomo Surabaya Jl. Mayjen Prof. Dr. Moestopo No. 6-8 Surabaya 60286 Telp/Fax : 031 - 5036047 Email : konaspdpixiii surabaya@yahoo.co.id Website : http://www. konaspdpi2012.com

May 2012

Indonesia Focus

Bahaya konsumsi gula tambahan berlebih

Hardini Arivianti
enurut WHO, masalah obesitas sudah mendunia dan akan bertambah bila tidak ada upaya untuk mengatasinya. Diperkirakan tahun 2015, lebih dari sepertiga penduduk dunia (2,3 miliar) akan mengalami obesitas. Riskesdas (2007 dan 2010), kejadian obesitas di Indonesia pada anak balita selama 3 tahun terakhir meningkat, dari 12,2% menjadi 14%. Tahun 2020 diperkirakan berbagai penyakit akibat pola diet yang salah tersebut, akan menyebabkan hampir dari semua kematian di dunia, yaitu jantung iskemik (71%), stroke (75%), diabetes (70%) di negara berkembang. Yang perlu menjadi perhatian adalah secara global sekitar 60% penyakit-penyakit tersebut akan terjadi di negara berkembang yang nantinya akan meningkatkan beban anggaran kesehatan bagi pemerintah. Itu sebabnya WHO merekomendasikan agar konsumsi gula tambahan tidak melebihi 10% dari total energi (dibatasi sebanyak 5-8 sendok teh per hari) terutama pada anak-anak

Gula tambahan
Gula tambahan merupakan gula, baik jenis alami (fruktosa) maupun buatan (sirop gula jagung), yang ditambahkan ke dalam proses pembuatan makanan atau minuman. Proses tersebut biasa dilakukan guna menguatkan rasa. Pada Maret lalu, IDI meluncurkan kampanye Bahaya Gula Tambahan untuk mengantisipasi tingginya konsumsi gula (terutama pada anak-anak) dan berpotensi menyebabkan ledakan obesitas dan diabetes melitus dini. Kampanye ini menghadirkan beberapa pem-

bicara yaitu Prof. Dr. dr. Razak Thaha, MSc, Prof Dr Sidartawan Sugondho SpPD-KEMD, dan dr. Aman B Pulungan, SpA(K). Sebagai moderator adalah dr Slamet Budiarto, SH, MHKes (Sekjen PB IDI) Menurut Prof.Razak, Indonesia saat ini tengah mengalami transisi epidemiologi gizi. Indonesia mulai memasuki pola epidemiologi gizi ke-4 yaitu berkembangnya penyakit tidak menular (Non-communicable Disease/NCD), yang penyebabnya antara lain meningkatnya asupan lemak, gula, dan makanan olahan. Biasanya dalam rangka catch up berat badan, maka pada anak kurang gizi dilakukan pemberian makanan tambahan yang terlalu cepat. Akibatnya, saat dewasa akan berisiko menderita penyakit kronik. Penambahan berat badan yang cepat pada anak kurang gizi akan meningkatkan risiko penyakit kronis saat dewasa. Anak-anak dengan pertumbuhan awal terganggu kemudian diintervensi sehingga mencapai penambahan berat badan dengan cepat cenderung memiliki penyakit tekanan darah tinggi, diabetes, penyakit kardiovaskular dan sindrom metabolik. Gula merupakan makanan kedua terbanyak yang dikonsumsi (65,2%) setelah perasa makanan (77,8%). Konsumsi lemak justru tidak terlalu banyak, hanya 12,8%. Hal ini menunjukkan masyarakat tidak tahu risiko mengonsumi gula secara berlebihan, lanjut pakar gizi klinik dari Ujung Pandang ini. Kematian penduduk Indonesia menurut kelompok umur masih dikuasai penyakit tidak menular. Sesuai data Riskesdas 2007 menunjukkan kematian akibat penyakit tidak menular mencapai 59,5%, lebih dari penyakit

May 2012

Indonesia Focus
buruk masa programming yang salah. Saat anak lahir dengan programming yang salah dengan kekurangan gizi maka akan menimbulkan masalah seperti yang dihadapi Indonesia kini. Strategi global yang perlu dilakukan adalah 1000 hari pertama kehidupan anak. Dengan fokus pada kelompok window of opportunity (calon ibu, ibu hamil, bayi dan baduta). Bagi calon ibu dan ibu hamil, perlu mengonsumsi makanan beraneka ragam semua kelompok makanan, menjaga berat badan ideal, mengupayakan pencapaian BB ideal mempertahankan pertambahan BB sesuai usia kehamilan dengan menambah porsi makanan sumber karbohidrat, protein, dan vitamin, mineral.

menular (28,1%). Stroke, hipertensi, diabetes, tumor dan penyakit jantung adalah lima teratas penyakit tidak menular yang menyebabkan kematian. Presentasi kematian di Indonesia akibat penyakit tidak menular pada penduduk < 60 tahun pada 2008, yang ternyata lebih tinggi daripada angka global. Diabetes misalnya, secara global 23% sementara di Indonesia 25%. Sedangkan penyakit jantung 18% (global) dan 23% di Indonesia. Uniknya, pergeseran pola diet tidak sehat ini justru semakin mengarah ke negaranegara dengan pendapatan rendah, seperti Indonesia. Beberapa ciri yang ditemukan adalah meningkatnya konsumsi minuman/jajanankayakalori/gulaterutamapada negara dengan pendapatan rendah, peningkatan asupan makanan olahan padat energi/ gula, penurunan asupan buah, sayur dan kacang-kacangan serta makin singkatnya waktu proses makanan dan meningkatnya penggunaan makanan setengah matang dan siap saji yang padat energi/gula. Belum lagi teknologi pengolahan makanan yang makin maju, mengolah air menjadi minuman kaya kalori/gula (Gambar 1). Pada acara Summit Meeting September lalu, isu paling penting adalah kegagalan negara berkembang dalam menangani gizi. Ada 2 jenis program yaitu specific nutrition program (mencakup pola/perilaku makan) dan sensitive nutrition program. Kita mengajarkan anak agar makan sehat namun dimana-mana ada izin begitu banyak waralaba akibat kebijakan perdagangan sehingga makanan padat energi sangat murah, jelas Prof Thaha. Mengenai anak, sebenarnya yang perlu diperbaiki adalah 9 bulan pertama kehidupan. Kekurangan gizi saat hamil dapat memper-

Ulah gula lainnya

Gula yang harus dihindari adalah gula tambahan, jelas Prof Sidartawan. Gula merupakan salah satu sumber karbohidrat yang diperlukan untuk proses metabolisme dan termasuk ke dalam refined carbohydrate, bisa berupa glukosa dan fruktosa. Kedua jenis gula ini dimetabolisme di hati dengan cara berbeda. Glukosa masuk ke hati dan disimpan dalam bentuk glikogen. Sedangkan fruktosa dimetabolisme dan diekstraksi dari hati hampir dalam bentuk seutuhnya dan bila berlebihan dengan cepat akan diubah menjadi glukosa, glikogen, asam laktat maupun lemak sehingga bisa menimbulkan perlemakan hati. Fruktosa membentuk advanced glycation end products (AGE) 7 kali lebih banyak dan terbukti secara ilmiah fruktosa bisa memicu proses toksisitas liver dan menjadi sumber berbagai penyakit kronis. Fruktosa merupakan gula sederhana yang didapat dari buah, madu, gula pasir (table

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May 2012

Indonesia Focus
Selain itu, sinyal dopamin di pusat otak pun berkurang karena gula menimbulkan rasa nikmat saat berkurangnya konsumsi makanan sehingga orang cenderung untuk mengonsumi makanan lebih banyak lagi. Malik Vs dkk (Diabetes Care, November 2010) melakukan meta analisis tentang perilaku mengonsumsi minuman mengandung gula tambahan (sugar-sweetened beverages/SSB) yang dikaitkan dengan risiko sindrom metabolik dan DM tipe 2. Kesimpulan studi ini, selain meningkatkan berat badan, konsumsi SSB berlebihan dikaitkan dengan sindrom metabolik dan DM tipe 2. Data ini memberikan bukti empiris yang menunjukkan konsumsi SSB harus dibatasi untuk menurunkan risiko sindrom metabolik kronis yang terkait dengan obesitas. Dhingra dkk (Circulation, 2007) mengeluarkan hasil studi komunitas pada dewasa, konsumsi soft drink berkaitan dengan risiko tinggi terjadinya sindrom metabolik.

sugar). Fruktosa dalam bentuk high-fructose corn syrup (HFCS) banyak ditemukan di soft drink dan minuman energi. Fruktosa akan disalurkan ke sistem saraf pusat (SSP), hati, usus, dan jaringan adiposa yang menyebabkan konsekuensi klinis yang berbeda. Dulu, soft drink dibuat dengan menggunakan glukosa/sukrosa namun sukrosa harganya mahal. Kini banyak pabrik mencari alternatif gula dengan mencari yang lebih murah dan lebih manis, yaitu HFCS. Pada HCFS ini mengandung 55% fruktosa. Dalam penelitian menunjukkan, kalori dari glukosa/sukrosa dibandingkan dengan fruktosa sama namun akibatnya berbeda. Fruktosa menyebabkan perlemakan hati, meningkatnya trigliserida, dll. Fruktosa banyak terkandung di dalam soft drink. Ulah gula yang lain lagi antara lain, mengurangi supresi hormon ghrelin (merupakan sinyal lapar untuk otak) dan mengintervensi transportasi dan sinyal hormon leptin (berfungsi membantu membentuk rasa lapar.

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Indonesia Focus

21st Annual Scientific Meeting of Indonesian Heart Association, Jakarta, April 6-8 2012

Penyakit kardiovaskular pada perempuan

Hardini Arivianti
enurut data statistik AHA terbaru, 1 dari 3 perempuan memiliki bentuk tertentu penyakit kardiovaskular, seperti jantung koroner, stroke, gagal jantung atau hipertensi. Dalam 1 tahun setelah serangan jantung didapat data, 38% perempuan (dibandingkan dengan 25% pria) akan meninggal dan setelah 6 tahun, perempuan berisiko 2x lebih besar dibandingkan pria, akan mengalami serangan ulang dan menjadi cacat. Menurut survei besar pada wanita di Amerika Serikat, 61% teridentifikasi menderita kanker payudara (penyakit yang mereka takuti) padahal hanya 4% yang meninggal dunia akibat kanker tersebut. Yang peduli dengan penyakit jantung hanya sekitar 8%. Sedangkan wanita perokok memiliki risiko 2-6 kali mengalami serangan jantung. Hal ini menjadi salah satu topik pada Annual Scientific Meeting of Indonesian Heart Association (ASMIHA) pada awal April lalu dengan tema Advances in the Management of Cardiovascular Diseases: the Controversies Continues. Presentasi klinis pada wanita juga atipikal, yang berupa jarang mengalami nyeri pada retrosternum; nyeri dada yang timbul saat istirahat, pada malam hari dan stres; rasa tidak nyaman pada rahang, epigastrium, lengan, bahu dan punggung; dispnea, palpitasi, pra-sinkop; fatigue, diaforesis, mual. Guideline update 2011 Salah satu sesi dipresentasikan oleh dr. Dyah Siswanti Estiningsih, SpJP, dengan

judul Cardiovascular Disease in Women: 2011 Guideline Update. Klasifikasi risiko penyakit kardiovaskular (cardiovascular disease/ CVD) pada wanita sesuai dengan guideline 2011 adalah risiko tinggi, berisiko dan kardiovaskular yang ideal. Kriteria risiko tinggi meliputi manifestasi klinis CHD, CVD, PAD, DM, aneurisma aorta abdominalis, CKD dan memiliki risiko prediksi CVD dalam 10 tahun mendatang sebesar 10%. Sindroma metabolik pada perempuan memiliki 3 dari beberapa kriteria berikut: obesitas abdomen (lingkar pinggang 35 inci), kadar trigliserida 150 mg/dL, kadar HDL < 50mg/dL, tekanan darah 130/85 mmHg, dan kadar glukosa puasa 100mg/dL. Dari data obstetrik ginekologi, didapat bila seorang perempuan pernah mengalami diabetes gestasional, preeklamsia dan sindrom polikistik ovarium, relative risk (RR) mengalami CVD sesudahnya akan lebih tinggi. Begitu pula dengan kebiasaan merokok. Perbandingan kejadian koroner antara perokok dan non-perokok, yang tidak pernah merokok memiliki RR 1, perokok 1-4 rokok/hari memiliki RR sebesar 3,12 kali dan RR akan meningkat sebesar 5,48 kali bila merokok hingga 15 rokok/hari. Sebagai dokter kita harus memberi semangat pada pasien perempuan perokok untuk menghentikan kebiasaan ini. Namun mereka kadang tidak mau berhenti karena takut berat badannya naik atau akan depresi, tukas dr. Dyah. Untuk itu, kadang dokter

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Indonesia Focus
marital stress berisiko 3 kali lipat mengalami rekuren CHD. Sedangkan pada wanita yang tinggal sendiri dan menjadi wanita karir, kondisi ini tidak meningkatkan risiko kejadian CHD rekuren secara signifikan. Kadar HDL yang rendah pada perempuan jauh lebih penting dibandingkan pada pria. Karena setiap kenaikan 1mg/dL pada kadar HDL akan menurunkan risiko CHD sebesar 3% dan 2% pada pria. Kenaikan kadar trigliserida pada perempuan dikaitkan dengan proses aterogenik dibandingkan pada pria. Itu sebabnya dokter harus menganjurkan pasien perempuan untuk melakukan aktivitas fisik yang cukup agar dapat menjaga kadar HDL yang normal, jelas dr. Dyah lebih lanjut. Dokter perlu menganjurkan perubahan gaya hidup dahulu sebelum memutuskan untuk memberikan terapi medis. Penurunan kadar LDL < 70 mg/dL pada wanita yang berisiko tinggi CHD (atau yang memiliki faktor risiko CHD tidak terkontrol) mungkin memerlukan terapi kombinasi penurun kadar LDL. Pada guideline 2011, tindakan preventif CVD pada perempuan adalah tindakan intervensi pada gaya hidup yang mencakup merokok, aktivitas fisik, rehabilitasi kardio, diet, konsumsi asam lemak omega-3 dan intervensi faktor risiko (tekanan darah, kadar lipid, lipoprotein, DM, serta intervensi obatobatan seperti aspirin, beta blocker, ACE inhibitor dll.

perlu meminta mereka berhenti merokok saat hamil dan tetap tidak merokok setelah masa itu. Walau FDA sudah menyetujui beberapa terapi farmakologi untuk berhenti merokok, namun sesuai ACOG hingga kini belum ada terapi farmakologis yang telah disetujui FDA untuk menghentikan kebiasaan merokok pada wanita hamil. Oleh sebab itu, kami menganjurkan untuk berhenti merokok secara alami. Selanjutnya dr. Dyah menjelaskan RR yang membandingkan berat badan dengan mortalitas yang diakibatkan oleh chronic heart disease/CHD. Bila indeks massa tubuh (Body mass index/BMI) dalam nilai normal (< 24,9), RR mortalitas akibat CHD, sangat rendah. Namun bila BMI tersebut mencapai hingga 32, maka RR akan meningkat sekitar 6 kali lipat dibandingkan dengan perempuan yang memiliki BMI normal. Keterkaitan antara kenaikan berat badan yang dihitung sejak usia 18 tahun dan RR, dr. Dyah menukaskan, kenaikan berat badan sebesar 10-19 kg, maka RR mortalitas akibat CHD sebesar 3 kali lipat. Bila kenaikan berat badan 20 kg, maka RR menjadi 7,4 kali lipat. Ada hal yang baru dalam guideline ini, yaitu stres psikososial pada perempuan. Sesuai data dari Stockholm Female Coronary Risk Study, wanita yang mengalami

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May 2012

Indonesia Focus

Peran laparoskopi dalam bedah anak

Arlina Pramudianto
eknik bedah laparoskopi telah cukup lama dikenal dalam area bedah umum, yang a-plikasinya memberikan manfaat dan pemulihan yang lebih cepat dibandingkan teknik bedah umum konvensional. Bagaimana dengan aplikasinya dalam bedah anak? Laparoskopi pada pasien dewasa tidak sama dengan laparoskopi bedah anak, selain ukuran organ pada anak lebih kecil, diperlukan keahlian dan modalitas yang berbeda walau diterapkan pada kasus yang sama. Salah satu pioner bedah anak yang piawai dalam bedah invasif minimal dan bedah urologi pediatrik adalah Prof. Tan Hock Lim, MBBS, MD, FRACS, FRCS. Beliau adalah dokter bedah anak pertama di Universitas Adelaide yang memprakarsai program bedah invasif minimal di rumah sakit Great Ormond Street Hospital, London. Selain itu, Prof Tan adalah ahli bedah anak pertama yang menerapkan laparoscopic pyloromyotomy pada kasus-kasus stenosis adesiolisis, eksisi laparoskopi kista koledokus dan menggunakan laparaskopi diagnostik pada kasus Necrotising Enterocolitis (NEC). Beliau juga dokter pertama yang melakukan percutaneous nephrolithotomy (PCNL) pada anak di Melbourne. Profesor Tan berpendapat bahwa dengan mengubah teknik sayatan besar dalam bedah konvensional yang mengakibatkan disabilitas, disfungsi dan disfigurement (kecacatan/parut) pada pasien, maka dengan sayatan kecil dalam teknik laparoskopi, akan mempercepat pemulihan pasien, meminimalisir komplikasi dan tidak meninggalkan parut yang besar. Dalam kesempatan nasional dengan lima senter pendidikan bedah Fakultas Kedokteran di Universitas Syiah Kuala (Aceh), Universitas Gadjah Mada (Yogyakarta), Universitas Airlangga (Surabaya)

dan Universitas Padjadjaran (Bandung), dan Universitas Indonesia lalu, Prof Tan menyampaikan kuliah singkat bertajuk The Past, Present and Future of Laparoscopy Surgery. Beliau mengutarakan asal usul dan perkembangan laparoskopi pada bedah anak, yang semula digunakan untuk memotong organ seperti pada laparoskopi splenektomi, dengan perbaikan teknologi dan instrumen selanjutnya berkembang menjadi tindakan laparoskopi konstruktif. Tindakan laparoskopi konstruktif anak yang pertama dilakukan adalah laparoscopic fundoplication yang selanjutnya menjadi standard emas untuk tindakan fundoplication. Beberapa kasus lain yang dapat dilakukan bedah laparoskopi pada anak adalah choledochal cyst, esophageal atresia repair, microlaparoscopy, dan sebagainya. Karena kontribusi dan dedikasi Prof Tan sebagai konsultan laparoskopi bedah anak dan bersedia membagikan ilmu dan pengetahuannya di FKUI-Indonesia, maka FKUI menganugerahkan gelar Adjunct Professor beberapa waktu yang lalu. Seremonial gelar ini dilakukan bersamaan dengan penyerahan bantuan enam alat endolaparoscopy dari perusahaan Jerman kepada Departemen Ilmu Bedah Divisi Bedah Anak FKUI-RSCM oleh Karl Christian Storz, pemilik perusahaan Karl Storz Endocopy yang dapat diyakinkan oleh Prof Tan akan potensi perkembangan bedah laparoskopi di Indonesia. Saat ini, terdapat ahli bedah anak FKUI yang telah dilatih oleh Prof Tan, yaitu dr. Iskandar Rahardjo Budianto, SpB.,SpBA dan dr. Riana Pauline Tamba, SpB., Sp.BA yang selanjutnya akan bekerja dalam tim bedah anak untuk kemajuan teknik laparoskopi di Indonesia.

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Peran penambahan isomaltulosa bagi anak

Hardini Arivianti

ntuk menjaga fungsi otak, kadar glukosa dalam darah harus selalu terpenuhi. Hal ini penting pada anak-anak mengingat aktivitas belajar dan banyaknya kegiatan yang dijalani di sekolah. Di sinilah salah satu fungsi penting sarapan, yaitu memberikan asupan karbohidrat atau glukosa untuk beraktivitas dan belajar hingga siang hari. Sarapan penting untuk memperbaiki kemampuan memperhatikan, memahami, memecahkan masalah, dan menjaga daya ingat. Nutrisi juga memiliki efek jangka pendek dan jangka panjang terhadap kinerja otak, jelas Dr. dr. Saptawati Bardosono, MSc, sebagai salah satu peneliti Tim Unit Riset Kedokteran FKUI yang melakukan penelitian berjudul Efek Susu yang Diperkaya dengan Lactose-Isomaltulose terhadap Performa Kognitif Anak Indonesia: Studi Cross-Over. Pakar lain yang termasuk ke dalam tim ini adalah spesialis anak, Dr. dr. Rini Sekartini, SpA(K) dan spesialis jiwa anak, Dr. dr. Tjhin Wiguna, SpKJ (K). Penelitian ini merupakan hasil kerjasama antara FrieslandCampina (induk perusahaan Frisian Flag Indonesia) dan Unit Riset Kedokteran Fakultas Kedokteran Universitas Indonesia. Hasil studi ini telah dipaparkan beberapa waktu lalu, dan dr. Dwiputro Widodo, SpA(K) bertindak sebagai moderator.

Anton Susanto, Victoria Valentina, Anne Schaafsma, Saptawati Bardosono, Tjhin Wiguna, Dwiputro Widodo

Mengenal isomaltulosa
Sebuah hipotesa menyatakan, kadar glukosa darah sangat penting untuk menjaga fungsi otak dan banyak studi telah dilakukan untuk meneliti hal tersebut. Bila kadar glukosa tetap terjaga secara stabil untuk jangka

waktu yang lama, maka diharapkan fungsi atensi pun dapat bertahan lebih lama, jelas Anne Schaafsma, PhD. Isomaltulosa termasuk ke dalam golongan karbohidrat yang secara alami terdapat pada madu dan tebu, serta dapat pula diproduksi dari sukrosa. Bedanya hanya pada ikatan antar gugus molekulnya, yang menyebabkan pemecahannya lebih lama, sehingga memerlukan waktu lebih lama pula untuk diserap oleh usus. Karena memerlukan waktu yang lebih lama, maka glukosa yang masuk ke dalam aliran darah juga lebih lama, sehingga kadar glukosa darah tetap terjaga relatif lebih stabil. Jika sukrosa normal membutuhkan sekitar 1 jam untuk dicerna, maka isomaltulosa membutuhkan waktu lebih dari 3 jam. Mengapa hal ini penting? Karbohidrat seperti maltosa, glukosa, dan maltodekstrin, akan meningkatkan gula darah dengan cepat dan memicu respons insulin dengan cepat, namun kadarnya akan menurun dengan cepat pula hingga di bawah baseline. Bila hal ini terjadi pada anak, respon tubuh yang tim-

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ingat dan pengenalan gambar dengan susu yang ditambahkan isomaltulosa dibandingkan terhadap susu dengan sukrosa. Hal ini perlu dikonfirmasi dengan melakukan penelitian di Indonesia untuk melihat efek positif susu pertumbuhan anak terhadap kemampuan kognitif anak usia 5-6 tahun terkait daya ingat dan perhatian, tukas dr. Saptawati. Setelah menjalani skrining, dari 100 anak dari berbagai posyandu di Jakarta (Pusat dan Timur) hanya 54 anak yang memenuhi kriteria. Semua diharapkan homogen baik status gizi, intelektual, dan kadar hemoglobin. Jumlah laki-laki dan perempuan sebanding dan tinggi badan/berat badan sesuai dengan angka kecukupan gizi anak Indonesia dengan kadar Hb batas normal. Studi double blind randomized cross-over ini membandingkan 4 jenis susu yang diberikan persaji 200 cc: A (susu pertumbuhan standar), B (A + 5 g isomaltulosa), C (A + 2,5 g isomaltulosa - 0,7 g protein + 0,48 g lemak + 0,22 dietary fiber) dan D (A + 2,5 g isomaltulosa + vitamin dan mineral). Masing-masing susu diberikan selama 2 minggu (14 hari) yang dicross over adalah susu A,B dan C, sedangkan susu D diberikan bersamaan pada 2 minggu terakhir. Pengukuran yang dilakukan pada penelitian ini adalah tingkat perhatian/atensi, tingkat perhatian berkelanjutan, kecepatan pemahaman angka, kecepatan dalam memilih, kualitas memori, pengenalan gambar dan kecepatan ingatan. Kesemuanya ini diukur dengan instrumen khusus menggunakan program komputer United Bio-source Corporation (UBC), Goring-on-Thames (UK). Terlebih dahulu setiap anak dilatih cara melakukan tes. Setelah semalam puasa dari jam 9 malam, anak tiba di tempat tes dan

bul adalah mudah merasa lapar dan timbul rasa ingin makan. Salah satu studi pernah dilakukan di Leeds (Inggris) pada orang dewasa untuk mengetahui perbedaan indeks glikemik dari sebuah produk, sebagai efek dari perbedaan dosis isomaltulosa. Hasilnya menunjukkan isomaltulosa dosis tinggi dapat menjaga kadar glukosa darah di atas baseline. Studi yang sama dilakukan oleh Taib MNM dkk (2012) di Malaysia dengan desain studi double-blind, cross-over. Perubahan kadar glukosa darah diperkirakan akan mempengaruhi kinerja kognitif dan perubahan ini dipengaruhi adanya zat-zat nutrisi tertentu. Studi ini mengevaluasi efek isomaltulosa yang dikombinasi dengan laktosa kadar tinggi terhadap performa kognitif pada anak usia 5-6 tahun. Tigapuluh anak menerima 4 macam minuman: susu pertumbuhan standar, susu pertumbuhan standar diformulakan, susu pertumbuhan standar dengan laktosa-isomaltulosa dan minuman glukosa standar. Kemudian diukur konsentrasi dan daya ingat anak. Hasil menunjukkan, lebih rendahnya penurunan tingkat perhatian, daya ingat dan pengenalan gambar pada yang diberikan susu dengan isomaltulosa dibandingkan susu biasa. (Hasil studi ini telah dipublikasikan pada jurnal Appetite 2012; 58:81-87).

Studi di Indonesia
Berbagai penelitian tentang isomaltulosa telah dilakukan, salah satunya di Jepang (Kashimura J dkk, 2003) yang hasilnya menunjukkan performa mental turun lebih sedikit dibandingkan dengan yang mengonsumsi sukrosa. Penelitian tahun 2012 (Taib dkk) di Malaysia, membuktikan lebih sedikitnya penurunan tingkat perhatian, daya

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Saptawati. Hasil studi ini juga bermanfaat pada anak terutama sebagai sumber daya manusia di generasi yang akan datang. Mengenai penelitian di Indonesia ini, Anne Schaafsma, PhD juga menambahkan, hasil penelitian ini merupakan langkah yang sangat baik bagi perusahan kami di Belanda dan Indonesia, karena dari segi pandang pakar ilmiah, studi ini membuktikan hipotesa yang ada. Selain itu, hasil studi ini ke depan diharapkan akan bermanfaat untuk membantu performa anak-anak. Sebagai peneliti utama studi ini, Dr.dr Rini Sekartini, SpA(K) menjelaskan penelitian di Indonesia ini menunjukkan hasil yang signifikan, setelah mengonsumsi susu pertumbuhan yang mengandung isomaltulosa, parameter kinerja kognitif anak pada 3 jam setelah konsumsi, relatif stabil. Susu dengan isomaltulosa yang diperkaya dengan vitamin dan mineral spesifik, kemungkinan besar memiliki efek positif terhadap kerja kognitif pada anak, tukas dr. Rini saat peluncuran inovasi susu pertumbuhan anak dengan isomaltulosa sekitar pertengahan April lalu. Orangtua perlu memahami bahwa otak memerlukan tingkat asupan energi yang berbeda dengan tubuh. Otak akan tetap aktif walau anak sedang istirahat. Berat otak pada anak kurang dari 10% dari total berat tubuhnya, namun otak mengonsumsi 40% dari total energi tubuh yang dibutuhkan. Untuk itu anak perlu mendapatkan asupan energi yang konsisten dan lebih tahan lama agar dapat mendukung kinerja otak yang optimal, baik saat aktif maupun beristirahat.

melakukan tes pertama kali sebagai baseline. Lalu anak diberikan susu dan dites kembali setiap 60 menit selama 3 jam berikutnya. Hasil studi dipaparkan oleh dr. Saptawati, menunjukkan efek lebih baik yang bermakna terhadap tingkat perhatian, tingkat perhatian berkelanjutan dan kecepatan ingatan setelah 3 jam pemberian susu. Efek positif terhadap penurunan perhatian dan daya ingat didapatkan pada pemberian susu yang diperkaya dengan isomaltulosa. Memperkaya susu dengan tambahan vitamin dan mineral tertentu juga menunjukkan efek positif tambahan pada performa kognitif. Hasil penelitian ini mirip dengan hasil penelitian terdahulu. Namun pada penelitian ini lebih spesifik terutama pada susu yang ditambahkan dengan isomaltulosa (2,5gr) dengan vitamin dan mineral. Tampak hasilnya lebih baik dibandingkan dengan susu lain. Isomaltulosa memiliki indeks glikemik lebih rendah dibandingkan dengan susu lain, sehingga dapat memberikan energi lebih lama bagi tubuh - termasuk otak - yang kemudian diharapkan dapat membantu fungsi kognitif. Sebagai pakar gizi, saya melihat susu adalah sebagai salah satu bahan makanan yang kaya protein dan kalsium. Studi juga membuktikan dengan tambahan isomaltulosa dapat membantu mempertahankan atensi dan daya ingat pada anak, tentu hal ini sangat bagus dan bermanfaat sekali. Dengan kadar glukosa darah yang dapat dipertahankan, maka diharapkan anak akan tetap konsentrasi saat di sekolah karena tidak cepat merasa lapar hingga 3 jam, jelas dr.

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Novell Research Grant, bentuk apresiasi terhadap penelitian di Indonesia

Hardini Arivianti

ovell Pharmaceutical Laboratories sebagai bentuk Corporate Social Responsibility (CSR) menyediakan dana riset Novell Research Grant(NRG) sebesar Rp 200 juta (untuk 2 orang pemenang) yang akan diberikan kepada kalangan medis untuk melakukan riset penelitian di Indonesia. Hal ini sesuai dengan visi dan misi yang dimiliki oleh Novell untuk membantu kemajuan riset di Indonesia. Pada kegiatan ini Novell bekerjasama dengan Pengurus Besar Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PB PAPDI). Sebenarnya kegiatan penelitian di Indonesia cukup banyak yang dilakukan pada subyek-subyek dengan lingkup lebih kecil dan tidak sedikit penelitian tersebut putus tengah jalan akibat keterbatasan dana. Hal ini diungkapkan oleh Roy Lembong, selaku Direktur PT Novell. Novell menggandeng PAPDI karena organisasi ini merupakan sebuah organisasi yang terbiasa dengan topik-topik ilmiah dan mengetahui riset penyakit di Indonesia serta berkaitan dengan penelitian penyakit apa yang sangat dibutuhkan. Ini pertama kali Novell bekerjasama dengan PAPDI, yang juga bertujuan untuk memicu kalangan lain untuk melakukan hal yang sama dalam hal mendukung penelitian medis di Indonesia, dan bukan hanya farmasi tetapi juga lembaga-lembaga lain atau perusahaan non-farmasi guna menjaga kesinambungan dalam hal riset, tukas Roy. Kami dari PAPDI memberikan acungan jempol pada farmasi ini karena telah menghibahkan sejumlah dana demi kepentingan penelitian dan tidak terkait dengan produk-

Pemenang 1: dr. Noor Asyiqah Sofia, MSc, SpPD, dr. Agus Siswanto, SpPD-KPsi, Prof. dr. AH Asdie, SpPD-KEMD, bersama Roy Lembong dan tim juri

Pemenang 2: dr. Anna Uyainah, SpPD-KP MARS, bersama Roy Lembong dan tim juri

produk serta kami juga berharap hal ini akan diikuti oleh farmasi-farmasi atau lembaga lainnya guna mendukung dokter serta memajukan ilmu terkait, ungkap Dr. dr. Aru W. Sudoyo, SpPD-KHOM selaku Ketua PAPDI. PAPDI berharap penelitian ini bisa menjadi bahan masukan untuk Kementerian Kesehatan dalam memperkaya usaha kita khususnya dalam menurunkan morbiditas dan mortalitas dari penyakit dan mendorong dokter untuk melakukan penelitian.

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Dua pemenang
Pada tanggal 3 April 2012 lalu, NRG pertama ini jatuh pada dr. Noor Asyiqah Sofia, MSc, SpPD dan tim (FK UGM Yogyakarta) dengan judul Pengaruh Kombinasi Fluoxetine dan Latihan Pasrah Diri terhadap Kontrol Gula Darah, Derajat Inflamasi dan Kualitas Hidup. Proposal ini berbeda dengan proposal riset lain karena dilakukan oleh berbagai ahli dari disiplin ilmu yang berbeda-beda termasuk spiritual, dengan harapan memberikan hasil optimal bagi pasien diabetes yang di Indonesia jumlahnya sudah mencapai jutaan orang. Pemenang berikutnya jatuh pada dr. Anna Uyainah, SpPD-KP, MARS (FKUI RSCM, Jakarta), dengan proposal berjudul Faktor yang Mempengaruhi Eksaserbasi Akut Penyakit Paru Obstruktif Kronik pada Jamaah Haji Embarkasi Jakarta akan sangat berguna bagi para calon jamaah haji yang berjumlah jutaan orang setiap tahunnya guna membantu meringankan penderitaan bagi yang memiliki PPOK selama *ibadah haji. Penyerahan dana dilakukan secara simbolik oleh Ketua Umum PB PAPDI yang dilanjutkan dengan penandatanganan MoU.

Kriteria pemilihan
Kriteria seleksi proposal riset mencakup: originalitas (belum pernah dilakukan sebelumnya dan bukan penggandaan riset sebelumnya di Indonesia dan luar negeri), fungsionalitas (hasil riset berguna sebagai tindakan aplikasi medis dan bukan hanya sekadar hasil riset secara statistik yang tidak dapat diterapkan secara klinis-medis pada pasien), morbiditas dan mortalitas (hasil riset dapat mengurangi angka mobiditas dan mortalitas), frekuensi kasus, dan probabilitas aplikasi (kemungkinan suksesnya hasil riset agar dananya dapat digunakan sebagai pedoman aplikasi medis pada pasien). Dewan juri terdiri dari Dr. dr. Aru W. Sudoyo, SpPD-KHOM, Prof. Dr. dr. Idrus Alwi, SpPD, K-KV, FINASIM, dr. Tjahjadi Robert Tedjasaputra, SpPD, K-GEH, FINASIM dan dr. Sally A Nasution, SpPD-KKV, FINASIM. Kami sepakat mengenai topik penelitian tidak molekuler, tidak high tech, dan bukan sesuatu yang merupakan translational research (dari laboratorium ke klinik), namun melainkan yang sudah teraplikasi, jelas dr. Aru.

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World Sepsis Day to highlight global emergency

Rajesh Kumar

he acute care community has designated 13 September 2012 as World Sepsis Day to highlight a global medical emergency that kills more than 10,000 people worldwide every day more than from prostate cancer, breast cancer and HIV/ AIDS combined. Sepsis arises when the bodys response to an infection injures its own tissues and organs. If not recognized and treated promptly, it can lead to shock, multiple organ failure or death. With hospital mortality rates of 30 to 60 percent, sepsis remains the primary cause of death from infection in both the developed and developing world despite advances in modern medicine, including vaccines, antibiotics, and acute care. According to the Global Sepsis Alliance (GSA), which represents about 250,000 intensive and critical care physicians around the world, the prevalence of sepsis has increased dramatically over the last decade, by 8 to 13 percent annually in the developed world alone. The GSA attributes this trend largely due to ageing populations and the increased use of high-risk interventions, alongside the development of drug resistance and more virulent varieties of pathogens. It has also been suggested that the way sepsis interventions are being delivered is haphazard, with less than one in five patients receiving appropriate or adequate care according to international guidelines. Rapid initiation of simple, timely interventions can halve the risk of dying. Early sepsis treatment is cost effective and reduces hospital and critical care bed days for patients. Unfortunately,

sepsis is still mostly overlooked and recognized too late, said Dr. Ron Daniels, Chairman of the UK Sepsis Group and executive director of GSA. Professor Younsuck Koh of the department of pulmonary and critical care medicine at University of Ulsan College of Medicine in Seoul, Korea, cited an Asian observational study which showed the basic principles of giving fluid on time, taking blood culture samples to detect pathogen, and administering antibiotics on time were closely related to patient outcomes. The three components could be followed even in resource limiting countries. However, we found that blood cultures and broad spectrum antibiotics on time were performed in around two-thirds of the patients, and the central venous pressure measurement as an index for fluid resuscitation was performed only around onethird, said Koh. The study involved 1,285 adult patients with severe sepsis admitted in 150 intensive care units in 16 Asian countries in July 2009. The main outcome measure was compliance with the Surviving Sepsis Campaigns resuscitation (6 hours) and management (24 hours) components. High income countries, university hospitals, intensive care units with an accredited fellowship program and surgical intensive care units were more likely to be compliant with the resuscitation component. The situation is not much better in developed countries. World Sepsis Day aims to change that through education and active engagement of physicians, decision makers and the general public all over the world.

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White rice link to diabetes stirs debate

Rajesh Kumar
recent meta-analysis linking regular white rice consumption to significantly elevated risk of type 2 diabetes has stirred up some controversy. The analysis, conducted by researchers from the Harvard School of Public Health in Boston, Massachusetts, US, included data from four primary prospective cohort studies, two of which were conducted in Asia (China and Japan) and the other two in the West (USA and Australia). [BMJ 2012; DOI:10.1136/bmj.e1454] The results showed that higher white rice intake is associated with a significantly elevated risk of type 2 diabetes. Assuming a serving size of white rice of 158 grams, the researchers estimated that the risk of type 2 diabetes is increased by 10 percent with each additional serving. Dr. Daphne Gardner, associate consultant in the department of endocrinology at Singapore General Hospital, cautioned physicians against a simplistic interpretation of the study data, saying the methods used to quantify white rice consumption in the primary studies were very imprecise, which made the analysis based on their pooled summary data also imprecise. Asian diets are known to rely on white rice as a staple food, with some studies reporting white rice contributing to nearly three-quarters of the glycemic load. Should Western diets contain equivalent amounts of carbohydrates (glycemic load), but of an alternative form (eg, bread or potatoes), would the same effect be seen? asked Gardner.

She suggested that the main question ought to be: How much of the diet (ie, proportion of macronutrient) should consist of carbohydrates and what implications does this have for the increased risk of type 2 diabetes? Dr. Cho Li Wei, consultant in the department of endocrinology at Changi General Hospital agreed, saying the observational nature of the study limited the ability to state cause and effect and controlled studies were needed to determine if white rice indeed increases the risk of type 2 diabetes. Gardner said the study had few immediate implications for physicians, patients or public health authorities. It should certainly not support large scale action to change the dietary habits of Asian populations which have been present for centuries. In order to determine the contribution of white rice to developing type 2 diabetes, one would need a prospective large-scale randomized controlled trial, with the intervention group having modified white rice consumption. However, such a trial is unlikely to happen. The important take home message is: more fiber is always beneficial. And this may take the form of increased consumption of vegetables or less-processed foods (raw oats rather than processed cereal). In addition, portion control of calorie intake (whether this is protein, carbohydrate or fat) is important in maintaining a healthy weight and reducing the overall risk of developing type 2 diabetes, she said.

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C-section raises breathing problem risk in preemies

Rajesh Kumar
esarean delivery may contribute to breathing problems among pre-term babies, according to new research presented at the 32nd Annual Society for Maternal-Fetal Medicine meeting held recently in Dallas, Texas, US. In the study, small-for-gestational-age babies delivered by a Cesarean section (C-section) before 34 weeks of pregnancy had a 30 percent increased risk of developing respiratory distress syndrome (RDS) than babies born vaginally at a similar gestational age. Researchers from the department of maternal-fetal medicine at the Johns Hopkins and Yale schools of medicine in the US reviewed birth certificate and hospital discharge information for 2,560 small-for-gestational-age babies who were delivered preterm. The increased odds for RDS persisted after controlling for maternal age, ethnicity, education, pre-pregnancy weight, gestational age at delivery, diabetes and hypertension. C-section compared with vaginal delivery was associated with increased odds of 5-minute APGAR (appearance, pulse, grimace, activity, respiration) score of <7 using unadjusted odds (odds ratio: 1.4; 95% CI 1.1-1.9), although this difference dissipated after adjusting for confounding factors. The findings overturn conventional wisdom that C-sections have few or no risks for the baby and are consistent with the effort(s) to end medically unnecessary deliveries before 39 weeks of pregnancy, said Dr. Diane

Ashton, deputy medical director of the March of Dimes, an American charity that works with hospitals and health policy experts to reduce the number of medically unnecessary C-sections. Although in many instances, a C-section is medically necessary for the health of the baby or the mother, this research shows that in some cases the surgery may not be beneficial for some infants, said Ashton. Singapore obstetrician and gynaecologist Dr. Kelly Loi said the study results are likely to be skewed because it was done retrospectively. Small and premature babies born through C-section are more likely to have respiratory distress anyway, said Loi. Babies who need early delivery are compromised already and the outcome may not be due to the C- section. For full term babies, the risk of respiratory distress following Csection falls from 37 weeks to 39 weeks, she said. One million babies worldwide die each year as a result of their early birth. Babies who survive an early birth often face the risk of lifelong health challenges, such as breathing problems, cerebral palsy, learning disabilities and others. If a pregnancy is healthy and there are no complications that require an early delivery, women should wait until labor begins on its own, or until at least 39 weeks of pregnancy, since many of the babys important organs, including the brain and lungs, are not completely developed until then, said Ashton.

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Breast cancer survivors can learn to handle hot flushes, night sweats
Radha Chitale
ognitive behavioral therapy (CBT) is effective at reducing the hot flushes and night sweats (HFNS) that are common following treatment for breast cancer, according to a study. HFNS, which the study researchers reported affect up to 85 percent of women after breast cancer treatment, are sources of distress and negatively impact patient quality of life. Hormone replacement therapy for HFNS, used among affected women who are menopausal, is contraindicated or undesirable in cancer patients. Previous research has shown reductions in HFNS with paced breathing and the researchers reported pilot trials showed promise for CBT. The improvement in social functioning after CBT is relevant because women report finding hot flushes especially difficult to deal with at work and in other social situations, the researchers said. Additionally, group CBT provided sustained benefits to depressed mood and sleep and some improvements in dimensions of quality of life. Women from breast clinics in the UK who had at least 10 HFNS episodes per week after breast cancer treatment were randomized to receive usual care (N=49) or usual care plus one 90-minute session per week of group CBT (N=47). [Lancet Oncol 2012 Mar;13:309-318]

Usual care included follow-up visits to oncologists or clinical nurse specialists every 6 months and as needed, telephone support from a cancer survivorship program, information leaflets, and advice about HFNS and treatment options, including symptoms management, paced breathing and relaxation. The CBT program was based on the causal and maintaining factors of HFNS, including anxiety, stress, embarrassment, negative beliefs and catastrophic thoughts, and the resultant behaviors, which can impact patient outcomes, such as avoidance activities. Women receiving CBT spent 6 weeks in structured, interactive group classes where they were given information about the physiology of HFNS, taught paced breathing, relaxation techniques and behavioral strategies to manage HFNS. The weekly plan included discussions on topics including handling HFNS, the role of stress, and what cognitive factors might contribute to it. Women were given the opportunity to describe their own experiences with HFNS as a result of breast cancer, their triggers and outline their treatment goals. CBT significantly reduced HFNS after 9 weeks and the results were maintained at

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News
tions are still restricted for these women the most cost effective method of delivering the group CBT would probably be to include it as part of survivorship support program, delivered by trained and supervised breast-care nurses.

26 weeks compared with usual care (adjusted mean difference in HFNS problem rating [1-10 scale] -1.67 and -1.76, respectively; P<0.0001). Women reported sustained benefits to mood, sleep and quality of life. Current treatments for HFNS are nonhormonal drugs such as selective serotonin reuptake inhibitors (SSRIs) or gabapentin that result in moderate reductions in HFNS frequency about 37 percent across trials, the researchers reported, but with few improvements in quality of life. We do not know whether HFNS were caused by breast cancer treatments or whether women were naturally menopausal when they had breast cancer, the researchers said. However, treatment op-

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25

May 2012

News

Bergamot orange a natural supplement for cholesterol control

Rajesh Kumar
An Australian cardiologist has found a natural ally in his fight against metabolic disorders an extract of the bergamot orange, an Italian citrus fruit which has long been believed to possess heart health benefits. Dr. Ross Walker, who runs a private practice in Sydney, said he has successfully used the extract in about 700 of his registered patients who are overweight with dyslipidemia and elevated blood sugar levels. Within a few weeks of starting the supplement, some of those patients have totally avoided the need for statins while others have reduced their statin dose to control dyslipidemia. As a bonus outcome, their blood glucose and middle obesity have also significantly reduced, said Walker. His findings are consistent with those of an unpublished clinical study conducted in Italy involving more than 200 patients with hyperlipidemia. In the study, 1 months supplementation with bergamot reduced LDL cholesterol by 39 percent and blood sugar by 22 percent, and raised HDL cholesterol by 41 percent. Bergamot contains extremely large amounts of polyphenols, as compared to other citrus species. Two of these, Brutelidin and Metilidin, directly inhibit cholesterol biosynthesis in a similar way to statins and they are not found in any other citrus derivatives, said lead study author Dr. Vincenzo Mollace, professor in the faculty of pharmacology at the University of Cantanzaro in Italy. Bergamot extract blocks the HMG CoA reductase enzyme at a different level than statins. As a result, myalgia and other side effects typically associated with statins can be avoided because bergamot does not block the component that depletes the muscular co-enzyme q10, said Walker. Bergamot extract (BergametTM) also inhibits cholesterol absorption in the gut, the same way plant sterols do. Thats why I ask my patients to take it 15 minutes before meal twice a day, in the afternoons and evenings, to block cholesterol absorption from food, he said. The unique and most important action of bergamot, due to which cardiologists (like me) are supporting this, is that it affects metabolic syndrome as a whole: raising HDL cholesterol, lowering LDL and blood sugar and reducing arterial stiffness and middle obesity. Could patients be advised to consume bergamot juice as part of a healthy diet to prevent metabolic syndrome, rather than taking its extract in a pill form? Walker said it is not that easy since bergamot orange is extremely bitter/sour and large amounts of its juice would be needed to get the desired benefit. [Bergamot extract] is not a replacement for statins. Patients who have had a heart attack or have vascular disease do need to take statins. [But] the extract can be useful in preventing metabolic syndrome, correcting it in early stages and as a supplement to reduce statin dose, he said.

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May 2012

News

Omega-3 fatty acids help slow aging of the brain

Rajesh Kumar

he status of omega-3 fatty acids as brain food is well established. However, research now suggests a diet lacking in these fatty acids may cause brain to age faster and lose some of its memory and thinking abilities. The finding has prompted a study author to recommend that physicians should remind patients to regularly consume fatty fish or other food sources of omega-3 as part of a balanced diet. [In the study] people with lower blood levels of omega-3 fatty acids had lower brain volumes that were equivalent to about 2 years of structural brain aging, said lead researcher Dr. Zaldy Tan of the Easton Center for Alzheimers disease research and the division of geriatrics at the University of California at Los Angeles, California, US. A total of 1,575 people with an average age of 67 and free of dementia underwent MRI brain scans for the study. They were also given tests that measured mental function, body mass and omega-3 fatty acid (comprising docosahexaenoic acid or DHA, and eicosapentaenoic acid, EPA) levels in their red blood cells. [Neurology 2012;78: 658-664]. Fatty acid composition of red blood cells (RBC) reflects dietary fatty acid intake averaged over the RBC lifespan of up to 120 days, whereas plasma concentrations reflect intake over only the last few days. The researchers found that people whose

The regular consumption of fatty fish or other food sources of omega-3 fatty acids is well known to be part of a balanced diet.

DHA levels were among the bottom 25 percent of the participants had lower brain volume compared to people who had higher DHA levels. Similarly, participants with levels of all omega-3 fatty acids in the bottom 25 percent also scored lower on tests of visual memory and executive function, such as problem solving and multi-tasking and abstract thinking. Lower DHA levels are associated with smaller brain volumes and a vascular pattern of cognitive impairment, even in persons free of clinical dementia, concluded the researchers. It may be premature for physicians to advise their patients to consume adequate amounts of food rich in omega-3 specifically for their brain health, without evidence from a large randomized control trial. But Tan said there is already ample evidence supporting the benefits of this fatty acid in cardiovascular and overall health and such an advice could only be beneficial.

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May 2012

News

Even mild hearing loss increases risk of falling

Rajesh Kumar

dults aged 60 and older should be routinely screened for hearing loss and treated according to best practice guidelines, according to Dr. Frank Lin, assistant professor of otolaryngology at the Johns Hopkins University School of Medicine and Bloomberg School of Public Health in Baltimore, Maryland, US. The advice follows research findings that link even mild hearing loss to a three-fold risk of falls. Hearing loss among the elderly is already associated with a range of social and cognitive problems, including dementia. But the researchers feel the latest finding could help in the development of new ways to prevent falls and resulting injuries that cost billions of dollars in health care. We still do not know if treating hearing loss can reduce falls. But hearing loss treatment entails no risks and could potentially only lead to benefits for cognitive, social and physical functioning, said Lin, adding that hearing loss was only one of many potential risk factors for falls. To determine whether hearing loss and falling are connected, Lin and colleagues used data from the 2001 to 2004 cycles of the US National Health and Nutrition Examination Survey. A total of 2,017 participants aged 40 to 69 had their hearing tested and answered questions about whether they had fallen over the past year. [Arch Intern Med 2012;172:369371] They also collected demographic information, including age, sex and race, and tested

participants vestibular function, a measure of how well they kept their balance. They found that people with a 25-decibel hearing loss, classified as mild, were nearly three times more likely to have a history of falling. Every additional 10-decibels of hearing loss increased the chances of falling by 1.4 fold (95% CI, 1.3-1.5).

Gait and balance are ... actually very cognitively demanding

The finding held true even when researchers accounted for other factors linked with falling, including age, sex, race, cardiovascular disease and vestibular function. Excluding participants with moderate to severe hearing loss from the analysis also didnt change the results. Among the possible explanations for the link is that people who cant hear well might not have good awareness of their overall environment, making tripping and falling more likely, said Lin. Another reason hearing loss might increase the risk of falls is cognitive load, in which the brain is overwhelmed with demands on its limited resources. Gait and balance are things most people take for granted, but they are actually very cognitively demanding. If hearing loss imposes a cognitive load, there may be fewer cognitive resources to help with maintaining balance and gait, he said.

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May 2012

Urology

Odor may help signal UTI in children

Elvira Manzano

oul-smelling urine may predict urinary tract infection (UTI) in children with unexplained fever, according to a leading pediatrician. Dr. Marie Gauthier, from the department of pediatrics, Sainte-Justine University Hospital Center, Montreal, in Quebec, Canada, cited the results of her own study which showed that malodorous urine was associated with UTI (odds ratio [OR] 2.83, 95% CI 1.54 to 5.20). [Pediatrics 2012; DOI:10.1542/peds.2011-2856] The association persisted despite adjustment for other UTI risk factors such as gender and the presence of vesicoureteral reflux abnormal flow of urine from the bladder to the upper urinary tract (OR 2.73, 95% CI 1.46 to 5.08). Parental reporting of malodorous urine increased the probability of UTI among young children, Gauthier said. However, she cautioned that the association is not strong enough to definitely rule in or out a diagnosis of UTI. In this prospective consecutive cohort study, Gauthier and colleagues surveyed the parents of 331 children, aged 1 to 3, tested in the emergency department of a hospital in Canada for suspected UTI, about their childs past medical history and symptoms. Of eight questions, two were on whether their childs urine smelled stronger than normal. Of the 331 children, 51 met the UTI diagnosis criteria. Bad-smelling urine was the risk factor most strongly linked to UTI 57 percent of the children who tested positive for a UTI had malodorous urine, while only 32

A study conducted in Canada suggests that malodorous urine may predict UTI in children.

percent of children who tested negative had pungent urine. Patients with UTI also had a fever of unknown origin as did 92 percent of those without. Gauthier suspects that the foul odor may be due to the production of ammonia from bacteria. She said the study findings are more useful for doctors than parents who, very often, would not ask about urine odor when a child is assessed in the ER for non-specific symptoms such as unexplained fever or irritability. It should make the clinician more suspicious of this type of infection, Gauthier concluded. The bacterium Escherichia coli causes the vast majority of UTIs in children. Throughout childhood, the risk of having a UTI is 2 percent for boys and 8 percent for girls. Most cases respond to antibiotics but serious infections may cause kidney scarring or blood poisoning if left untreated.

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May 2012

In Practice

Managing acute otitis media: Strategies for GPs

Dr. Eng Soh Ping
Consultant ENT Surgeon Ascent Ear Nose Throat Specialist Group Mount Elizabeth Medical Centre Singapore

Disease of childhood Acute otitis media (AOM) inflammation of the middle ear is the second most common disease of childhood after upper respiratory tract infection (URTI). Most children have at least one or two episodes during childhood; many have repeated episodes with the peak incidence occurring between ages 2 and 5. Obstruction of the Eustachian tube is the most important antecedent event linked to this condition. Children are particularly susceptible because they have shorter and more horizontal Eustachian tubes than adults which are not fully developed and are more difficult to drain. With age, however, part of the tube ossifies to bone and the horizontal angle descends, increasing the downward flow of fluid.

Surgery takes only 10 minutes but recovery takes a few days.

A bulging erythematous tympanic membrane.

Otitis media with effusion resolves without surgery.

We cannot predict which

patients will go on to develop

complications. Thus, we should be aggressive, but a little cautious, when managing AOM

What causes AOM? Otitis media is caused by viral and bacterial inA grommet tube in position. fections. The most common bacteria responsible are Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus and Moraxella catarrhalis. Among older children, the most common cause is Haemophilus influenzae.

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May 2012

In Practice
accurate visualization of the tympanic membrane may lead GPs to the diagnosis of acute otitis media one of the three presentations of otitis media (OM), the other two being recurrent otitis media and otitis media with effusion (OME) or glue ear. A direct examination of the middle ear with an otoscope will reveal erythema, bulging and apparent opacity. The normal tympanic membrane moves in response to pressure changes. In AOM, mobility is reduced or absent with pneumatic otoscopy. An accurate clinical diagnosis is possible in most cases, but this is a challenge to physicians as the canal is small and the view may be obscured by earwax. Crying may also distend the small blood vessels in the eardrum, mimicking the redness associated with AOM. Another useful but lost skill among physicians is the use of tuning fork. If the child is cooperative, tuning fork tests both Weber and Rhine tests may be performed to distinguish between conductive and sensorineural hearing loss. Clinical guidelines for AOM GPs can refer to the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) guidelines when diagnosing and treating AOM. In the EENT circle, we use the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guidelines. The guidelines support the use of antibiotics, but an initial observation period of 48 to 72 hours is recommended for select cases to determine if the infection will resolve on its own. Current guidelines tend to be less aggressive although some parents may push for more active treatment due to anxiety and distress from seeing their children suffer.

The vast majority of AOM episodes are triggered by URTIs. Eustachian tube dysfunction is a major risk factor. If the Eustachian tube becomes blocked, fluid can build up and lead to infection. Other risk factors for acute ear infections are attending daycare, changes in altitude or climate, recent ear infection and genetic factors. The childs position during bottle-feeding, for example lying down, also predisposes the child to AOM. For this reason, breast-feeding position semi-Fowlers may be good for normal Eustachian function. Signs and symptoms to watch out for When the middle ear which is normally sterile becomes acutely infected, pressure builds up behind the eardrum, resulting in otalgia. The tissues surrounding the tubes swell and fluid accumulates in the middle ear. Pyrexia, with or without co-existing URTI, is a common symptom in children of any age. Aside from earache, older children may complain of fullness in the ear and conductive hearing loss, which is usually transient. In young children, complaints of ear pain can be muted and only represented by crying, irritability and sleeping or feeding difficulties. Severe infections or untreated cases may cause the eardrum to rupture, causing the pus to drain from the middle ear to the ear canal. The condition usually resolves with pharmacological treatment. However, what we are worried about are those cases that do not rupture and have become complicated. More commonly, it would lead to mastoiditis which requires emergency surgery. Untreated, the infection can spread to surrounding structures, affecting the brain and the facial nerves. Diagnosing AOM The presence of the above symptoms, combined with a complete clinical history and

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May 2012

In Practice
than 10 minutes although it takes a few days to fully recover. The tube will also self-extrude in 3 to 6 months. Take home message for GPs GPs, being at the heart of the community, have an important role to play in managing AOM. A sharp clinical acumen may not be enough to arrive at a good diagnosis. Paying attention to detail definitely has an added value. Rubbing of the ear, for example, may not mean anything, but it is a significant symptom in young children with AOM. Finally, it takes a sound judgment and due diligence to be able to spot early signs of complications. The infection can spread beyond the mucosal structures of the middle ear resulting in mastoiditis, facial nerve palsy, chronic otitis media, meningitis or brain abscess. Sagging of the posterior canal wall and swelling of post auricular areas with loss of skin crease usually signal danger signs that should alert clinicians and lead to ENT referral.

Treating AOM Most children with uncomplicated AOM recover fully without intervention, which is why some clinicians adopt the wait-and-see approach. However, we cannot predict which patients will go on to develop complications. Thus, we should be aggressive, but a little cautious, when managing AOM. AOM is treated just like any URTIs. Amoxicillin is the initial treatment of choice. Analgesics and antipyretics may be used for symptomatic management. If symptoms do not resolve after 48 hours and there is abscess, refer. Instrumentation and support may be limited under primary care setting. It helps to be on the careful side. Do not underestimate the problem. When in doubt, refer.

It takes a sound judgment and due diligence to be able to spot early signs of complications

Otitis media with effusion usually resolves without surgery. Complex cases that have not responded to antibiotic therapy however require tympanocentesis puncture of the tympanic membrane to aspirate fluid or to facilitate delivery of medication directly to the middle ear. In chronic cases with effusions, we do myringotomy with insertion of tympanostomy tube, called grommet, to allow ventilation and drainage. Surgery often takes less

Online Resources:
American Academy of Pediatrics www.aap.org American Academy of Otolaryngology, Head and Neck Surgery www.entnet.org Pediatrics pediatrics.aappublications.org/ content/113/5/1451.long

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May

May 2012

Calendar
19th WONCA Asia Pacific Regional Conference 24/5/2012 to 27/5/2012 Location: Jeju, Korea Tel: (82) 2 566 6031 Email: admin@woncaap2012.org Website: www.woncaap2012.org

5th European Clinam Conference for Clinical Nanomedicine 7/5/2012 to 9/5/2012 Location: Basel, Switzerland Info: Clinam, European Foundation for Clinical Nanomedicine Tel: (11) 41 61 695 9395 Fax: (11) 41 61 695 9390 Email: clinam@clinam.org Website: www.clinam.org 19th European Congress on Obesity 9/5/2012 to 12/5/2012 Location: Lyon, France Info: European Association for the Study of Obesity Tel: (44) 20 8783 2256 Fax: (44) 20 89796700 Email: enquiries@easo.org Website: www.eco2012.org American Thoracic Society International Conference 2012 18/5/2012 to 23/5/2012 Location: San Francisco, California, US Tel: (1) 212 315 8652 Email: conference@thoracic.org Website: www.thoracic.org/go/international-conference American Society of Hypertension 19/5/2012 to 22/5/2012 Location: New York, New York, US Info: American Society of Hypertension Tel: (1) 212 696 9099 Fax: (1) 212 696 0711 Email: symposia@ash-us.org Website: www.ash-us.org/Scientific-Meetings/Future-Meetings. aspx Digestive Diseases Week 2012 19/5/2012 to 22/5/2012 Location: San Diego, California, US Info: American Society of Gastrointestinal Endoscopy Tel: (1) 301 272 0022 Fax: (1) 301 654 3978 Email: nmurphy@gastro .org Website: www.ddw.org

June
2012 American Society of Clinical Oncology Annual Meeting 1/6/2012 to 5/6/2012 Location: Chicago, Illinois, US Tel: (1) 571 483 1300 Email: membermail@asco.org Website: chicago2012.asco.org 10th Royal College of Obstetricians and Gynecologists International Scientific Congress 5/6/2012 to 8/6/2012 Location: Kuching, Malaysia Tel: (60) 3 6201 1858 Email: info@rcog2012.com Website: www.rcog2012.com 15th International Congress of Infectious Diseases 13/6/2012 to 16/6/2012 Location: Bangkok, Thailand Tel: (1) 617 277 0551 Fax: (1) 617 278 9113 Email: info@isid.org Website: www.isid.org/icid 15th World Congress of Pain Clinicians 27/6/2012 to 30/6/2012 Location: Granada, Spain Info: Kenes International Tel: (41) 22 908 0488 Fax: (41) 22 9069140 Email: wspc2012@kenes.com Website: www.kenes.com/wspc

33

May 2012

Calendar

Upcoming
17th World Congress on Heart Disease 2012 27/7/2012 to 30/7/2012 Location: Toronto, Ontario, Canada Info: International Academy of Cardiology Tel: (1) 310 657 8777 Fax: (1) 310 659 4781 E-Mail: Klimedco@ucla.edu Website: www.cardiologyonline.com European Society of Cardiology Congress 2012 25/8/2012 to 29/8/2012 Location: Munich, Germany Info: European Society of Cardiology Tel: (33) 4 9294 7600 Fax: (33) 4 9294 7601 E-Mail: ascoregistration@jspargo.com Website: www.escardio.org/congresses/esc-2012 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: esid@kenes.com Website: www.kenes.com/esid 42nd Annual Meeting of the International Continence Society 15/10/2012 to 19/10/2012 Location: Beijing, China Tel: (41) 22 908 0488 Fax: (41) 22 906 9140 Email: ics@kenes.com Website: www.kenes.com/ics 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: WISC@worldallergy.org Website: www.worldallergy.org

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35

May 2012

Humor

Smile, youre on Candid Camera!

If you think these pills are too expensive, we will be more than happy to operate!

Sorry folks, Im running a little behind today!

Forget about possible damage to my liver. Will it make my skin smoother?

Nurse, theres a fly in my IV!

In order to qualify for medical benefits you have to be 65, not feeling like 65!

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