MEDICAL TRIBUNE MAY 2012

www.medicaltribune.com

May 2012

Dramatic blood sugar control with gastric surgery

INDONESIA FOCUS

Bahaya konsumsi gula tambahan berlebih

UROLOGY

Odor may help signal UTI in children

IN PRACTICE

Managing acute otitis media: Strategies for GPs

NEWS

Bergamot orange a natural supplement

2 May 2012

Radha Chitale

Gastric 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 Cardiol-ogy meeting in Chicago, Illinois, US.

Patients who underwent Roux-en-Y gas-tric 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 in-tensive medical therapy alone. [N Engl J Med 2012 Mar 26. Epub ahead of print]

“Despite improvements in pharmacother-apy, fewer than 50 percent of patients with moderate-to-severe type 2 diabetes actually achieve and maintain therapeutic thresholds, particularly for glycemic control,” said re-searchers from the Cleveland Clinic in Ohio, US, Veterans Affairs Boston Healthcare Sys-tem and Brigham and Women’s Hospital in Boston, Massachusetts, US.

“Observational studies have suggested that bariatric or metabolic surgery can rap-idly 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 un-controlled type 2 diabetes to receive inten-sive medical therapy alone, medical therapy

plus Roux-en-Y gastric bypass surgery or medical therapy plus sleeve gastrectomy.

Intense medical therapy followed the guidelines of the American Diabetes Asso-ciation and included lifestyle counselling, weight management, and drug therapy.

Patients randomized to surgery experi-enced significantly more weight loss com-pared with those receiving medical therapy after 12 months (-29.5 kg gastric bypass, -25.1 kg sleeve gastrectomy, -5.4 kg medical ther-apy, 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 gas-tric bypass group (P<0.001), 6.6 percent in the sleeve gastrectomy group (P=0.003) and

Dramatic blood sugar control with gastric surgery

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

3 May 2012

7.5 percent among patients receiving medi-cal therapy.

Patients who underwent surgery also sig-nificantly reduced or halted use of glucose control and cardiovascular medications.

“Reductions in the use of diabetes medica-tions occurred before achievement of maxi-mal weight loss, which supports the concept that the mechanisms of improvement in dia-betes 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-

tute, Melbourne, VIC, Australia, and Dr. K. George M. M. Alberti, Kings College Hospi-tal, 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 sur-gery 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.

4 May 2012

Electronic skin patches for health monitoring Radha Chitale

Ultra 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 Il-linois at Urbana-Champaign, who developed the device. “These new materials for electron-ics can intimately integrate with the human body.”

The electrical components of the patches are designed to withstand water, sweat and movement. Rogers and colleagues accom-plished this by preparing the same silicone used in rigid electronic wafers, in thin mem-branes cut into a web-like mesh and integrat-ed 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, Califor-nia, US.

The patch’s 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 cer-tain heart conditions can be spotted based on the body’s fluid retention.

The device should also be particularly use-ful 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 sur-face 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 reha-bilitation.

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.

5 May 2012 ForumBiobanks: 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 data-bases during the Asia-Pacific Research Ethics Conference, held recently in Singapore.

Biobanks, 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 informa-tion 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 bio-commons.

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 research-ers 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 world’s largest re-source of genetic health and lifestyle data. It includes over 500,000 participants aged 40-69 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 con-sultations. 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

6 May 2012 Forumthan minor initial tests for basic things like blood pressure levels.

Consent for use of participant data is re-scindable 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 won’t 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 au-thorities 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 participant’s trust was abused, they say so, acting as proxy for the people involved.

The governance of the UK Biobank is in-dependent, and they alone guard the ethics and governance framework. They advise on revisions, monitor the UK Biobank and re-port their findings publicly and provide gen-eral advice.

This kind of data consolidation lends itself to growing into virtual biobanks. Virtual bio-banks are gaining popularity as researchers push to share and use population informa-tion 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 con-sistency 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 bio-banks to link registries with safeguards to prevent identification. A person would be as-signed 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 in-dependent 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 prop-erty for the common good, uninfluenced by commercial or nationalist interests. The pros-pect for large-scale data sharing – for health not profit – could lead to greater information and more justice in healthcare.

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.

7 May 2012 Indonesia Focus

Local events calendar The 3rd Asia Oceanian Conference of Physical and Rehabilitation MedicineBali, 21-24 Mei 2012Hotel Discovery Kartika Plaza, BaliSekr : Jl. Cakalang Raya No. 28 A, Rawamangun, Jakarta TimurTel / Fax : 021-47866390Email : aocprm2012bali@ pharma-pro.comWebsite : www.aocprm2012.org

Perhimpunan Respirologi Indonesia (Pertemuan Ilmiah Respirasi 3 Makassar)Makassar, 25-27 Mei 2012Hotel Grand Clarion MakassarSekr : 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 902145Tel / Fax : 0411-582002Email : konasperpari [email protected]

KONAS PDPI XIIISurabaya, 4-7 Juli 2012Shangri-la SurabayaSekr : Bagian / SMF Ilmu Penyakit Paru, RSUD Dr. Soetomo Surabaya Jl. Mayjen Prof. Dr. Moestopo No. 6-8 Surabaya 60286Telp/Fax : 031 - 5036047Email : konaspdpixiii [email protected] : http://www. konaspdpi2012.com

The 9th Congress Of Indonesian Society of EndocrinologyManado, 5–7 Juli 2012Hotel Grand Kawanua Convention Centre, ManadoSekr : 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 : [email protected] : www.perkeni.net

7th Symposium on Nutri Indonesia in conjunction with 1st International Symposium on Nutrition (From Evidence to Practice)Jakarta, 5-8 Juli 2012Hotel Acacia, Jakarta Sekr : Pacto Convex Ltd Lagoon Tower, Level B1, The Sultan Hotel Jl. Jend. Gatot Subroto, Jakarta 10270Tel : 021-5705800Fax : 021-5705798Email : secretariat@ nutriindonesia.orgWebsite : www.nutriindonesia.org

PIN X PB PAPDI (Emergency in Internal Medicine)Balikpapan, 29 Juni–1 Juli 2012Hotel Gran Senyiur, BalikpapanSekr : Gedung ICB Bumiputera, Ground Floor 2B, Jl. Probolinggo No.18 , Gondangdia, Menteng, Jakarta 10350Tel : 021-2300818Fax : 021-2300755/2300588Email : pin9pbpapdi@gmail. com ; pin9pbpapdi@ yahoo.co.id; pb_papdi@ indo.net.id

KOGI 2012 (Congress Obstetry & Gynecology)30 Juni – 4 Juli 2012, BaliNusa Dua Convention CentreSekr : Pogi JakartaTel : 021-3143684Fax : 021-3910135Email : [email protected]

54th Anniversary PAPDI JAYA Preset: Jakarta Internal Medicine in Daily Practice31 Agustus – 2 September 2012, JakartaHotel Borobudur, JakartaSekr : Gedung ICB Bumiputera Lt.1, Jl. Probolinggo 18, Gondangdia, Menteng, Jakarta 10350Tel : 021-2301267Fax : 021-2301267Email : [email protected], [email protected]

The 14th International Meeting on Respiratory Care Insonesia (Respina) 20125 - 6 Oktober 2012, JakartaHotel Shangri-la, JakartaSekr : Gedung Asma Lt.2, Jl. Persahabatan Raya No.1, Jakarta 13230Tel : 021-47864646, 47864321Fax : 021-47866543Email : info.respina@yahoo. com, info.respina. [email protected] : www.respina.org

8 May 2012 Indonesia Focus

Bahaya konsumsi gula tambahan berlebihHardini Arivianti

Menurut WHO, masalah obesitas su-dah 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% men-jadi 14%.

Tahun 2020 diperkirakan berbagai penya-kit akibat pola diet yang salah tersebut, akan menyebabkan hampir ¾ 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 terse-but akan terjadi di negara berkembang yang nantinya akan meningkatkan beban angga-ran 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 mengantisi-pasi 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 pem-berian makanan tambahan yang terlalu cepat. Akibatnya, saat dewasa akan berisiko men-derita penyakit kronik.

Penambahan berat badan yang cepat pada anak kurang gizi akan meningkatkan risiko penyakit kronis saat dewasa. Anak-anak dengan pertumbu-han awal terganggu kemudian diintervensi sehing-ga mencapai penambahan berat badan dengan cepat cenderung memiliki penyakit tekanan darah tinggi, diabetes, penyakit kardiovaskular dan sin-drom metabolik.

Gula merupakan ’makanan’ kedua terban-yak 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

9 May 2012 Indonesia Focusmenular (28,1%). Stroke, hipertensi, diabetes, tumor dan penyakit jantung adalah lima tera-tas penyakit tidak menular yang menyebab-kan kematian.

Presentasi kematian di Indonesia akibat penyakit tidak menular pada penduduk < 60 tahun pada 2008, yang ternyata lebih tinggi daripada angka global. Diabetes misalnya, se-cara 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 nega-ranegara dengan pendapatan rendah, se-perti Indonesia. Beberapa ciri yang dite-mukan adalah meningkatnya konsumsi minuman/jajanan kaya kalori/gula terutama pada negara dengan pendapatan rendah, pening-katan 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 nu-trition program (mencakup pola/perilaku makan) dan sensitive nutrition program. “Kita mengajarkan anak agar makan se-hat namun dimana-mana ada izin begitu banyak waralaba akibat kebijakan perda-gangan sehingga makanan padat energi sangat murah,” jelas Prof Thaha.

Mengenai anak, sebenarnya yang perlu di-perbaiki adalah 9 bulan pertama kehidupan. Kekurangan gizi saat hamil dapat memper-

buruk masa ‘programming’ yang salah. Saat anak lahir dengan ‘programming’ yang salah dengan kekurangan gizi maka akan menim-bulkan masalah seperti yang dihadapi Indo-nesia 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, per-lu mengonsumsi makanan beraneka ragam semua kelompok makanan, menjaga berat badan ideal, mengupayakan pencapaian BB ideal mempertahankan pertambahan BB se-suai usia kehamilan dengan menambah porsi makanan sumber karbohidrat, protein, dan vitamin, mineral.

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 men-jadi glukosa, glikogen, asam laktat maupun lemak sehingga bisa menimbulkan perlema-kan hati. Fruktosa membentuk ‘advanced glycation end products’ (AGE) 7 kali lebih banyak dan terbukti secara ilmiah fruktosa bisa memicu proses toksisitas liver dan men-jadi sumber berbagai penyakit kronis.

Fruktosa merupakan gula sederhana yang didapat dari buah, madu, gula pasir (table

10 May 2012 Indonesia Focussugar). 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 menyebab-kan konsekuensi klinis yang berbeda.

Dulu, soft drink dibuat dengan menggunakan glukosa/sukrosa namun sukrosa harganya ma-hal. Kini banyak pabrik mencari alternatif gula dengan mencari yang lebih murah dan lebih manis, yaitu HFCS. Pada HCFS ini mengan- dung 55% fruktosa. Dalam penelitian menun-jukkan, kalori dari glukosa/sukrosa dibanding-kan 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, men-gurangi supresi hormon ghrelin (merupakan sinyal lapar untuk otak) dan mengintervensi transportasi dan sinyal hormon leptin (ber-fungsi membantu membentuk rasa lapar.

Selain itu, sinyal dopamin di pusat otak pun berkurang karena gula menimbulkan rasa nikmat saat berkurangnya konsumsi makan-an sehingga orang cenderung untuk mengon-sumi makanan lebih banyak lagi.

Malik Vs dkk (Diabetes Care, Novem-ber 2010) melakukan meta analisis tentang perilaku mengonsumsi minuman mengand-ung gula tambahan (sugar-sweetened beve-rages/SSB) yang dikaitkan dengan risiko sin-drom 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 menun-jukkan konsumsi SSB harus dibatasi untuk menurunkan risiko sindrom metabolik kronis yang terkait dengan obesitas.

Dhingra dkk (Circulation, 2007) menge-luarkan hasil studi komunitas pada dewasa, konsumsi soft drink berkaitan dengan risiko tinggi terjadinya sindrom metabolik.

11 May 2012 Indonesia Focus

Penyakit kardiovaskular pada perempuanHardini Arivianti

Menurut data statistik AHA terbaru, 1 dari 3 perempuan memiliki bentuk

tertentu penyakit kardiovaskular, seperti jan-tung koroner, stroke, gagal jantung atau hiper-tensi. Dalam 1 tahun setelah serangan jantung didapat data, 38% perempuan (dibanding-kan 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 men-derita kanker payudara (penyakit yang me-reka takuti) padahal hanya 4% yang mening-gal 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 Scien-tific Meeting of Indonesian Heart Association’ (ASMIHA) pada awal April lalu dengan tema “Advances in the Management of Cardiovas-cular 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, len-gan, bahu dan punggung; dispnea, palpitasi, pra-sinkop; fatigue, diaforesis, mual.

Guideline update 2011Salah satu sesi dipresentasikan oleh dr.

Dyah Siswanti Estiningsih, SpJP, dengan

judul “Cardiovascular Disease in Women: 2011 Guideline Update”. Klasifikasi risiko pe-nyakit kardiovaskular (cardiovascular disease/CVD) pada wanita sesuai dengan guideline 2011 adalah risiko tinggi, berisiko dan kar-diovaskular 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: obe-sitas 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 dia-betes gestasional, preeklamsia dan sindrom polikistik ovarium, relative risk (RR) mengala-mi CVD sesudahnya akan lebih tinggi. Begitu pula dengan kebiasaan merokok. Perban-dingan kejadian koroner antara perokok dan non-perokok, yang tidak pernah merokok memiliki RR 1, perokok 1-4 rokok/hari memi-liki RR sebesar 3,12 kali dan RR akan mening-kat 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 depre-si,” tukas dr. Dyah. Untuk itu, kadang dokter

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

12 May 2012 Indonesia Focusperlu 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 se-cara alami.”

Selanjutnya dr. Dyah menjelaskan RR yang membandingkan berat badan dengan mor-talitas 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 kena-ikan 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 Coro-nary Risk Study’, wanita yang mengalami

marital stress berisiko 3 kali lipat mengalami rekuren CHD. Sedangkan pada wanita yang tinggal sendiri dan menjadi wanita karir, kon-disi 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 trig-liserida pada perempuan dikaitkan dengan proses aterogenik dibandingkan pada pria. ”Itu sebabnya dokter harus menganjurkan pasien perempuan untuk melakukan aktivi-tas 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 preven-tif 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 obat-obatan seperti aspirin, beta blocker, ACE inhibitor dll.

13 May 2012 Indonesia Focus

Peran laparoskopi dalam bedah anakArlina Pramudianto

Teknik bedah laparoskopi telah cukup lama dikenal dalam area bedah umum, yang

a-plikasinya memberikan manfaat dan pemuli-han yang lebih cepat dibandingkan teknik bedah umum konvensional. Bagaimana dengan ap-likasinya 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 ber-beda 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 mempra-karsai 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 melaku-kan percutaneous nephrolithotomy (PCNL) pada anak di Melbourne.

Profesor Tan berpendapat bahwa dengan men-gubah teknik sayatan besar dalam bedah konven-sional yang mengakibatkan disabilitas, disfungsi dan disfigurement (kecacatan/parut) pada pasien, maka dengan sayatan kecil dalam teknik laparos-kopi, akan mempercepat pemulihan pasien, me-minimalisir komplikasi dan tidak meninggalkan parut yang besar.

Dalam kesempatan nasional dengan lima senter pendidikan bedah Fakultas Kedokteran di Univer-sitas Syiah Kuala (Aceh), Universitas Gadjah Mada (Yogyakarta), Universitas Airlangga (Surabaya)

dan Universitas Padjadjaran (Bandung), dan Uni-versitas Indonesia lalu, Prof Tan menyampaikan kuliah singkat bertajuk ‘The Past, Present and Fu-ture of Laparoscopy Surgery’. Beliau mengutara-kan asal usul dan perkembangan laparoskopi pada bedah anak, yang semula digunakan untuk ‘memotong’ organ seperti pada laparoskopi sple-nektomi, dengan perbaikan teknologi dan instru-men selanjutnya berkembang menjadi tindakan laparoskopi konstruktif.

Tindakan laparoskopi konstruktif anak yang pertama dilakukan adalah laparoscopic fundoplica-tion yang selanjutnya menjadi standard emas un-tuk 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 pengeta-huannya di FKUI-Indonesia, maka FKUI men-ganugerahkan gelar ‘Adjunct Professor ‘beber-apa waktu yang lalu.

Seremonial gelar ini dilakukan bersamaan den-gan penyerahan bantuan enam alat endolaparos-copy dari perusahaan Jerman kepada Departe-men 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 laparos-kopi 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 Pau-line Tamba, SpB., Sp.BA yang selanjutnya akan bekerja dalam tim bedah anak untuk kemajuan teknik laparoskopi di Indonesia.

14 May 2012 Indonesia Focus

Peran penambahan isomaltulosa bagi anakHardini Arivianti

Untuk menjaga fungsi otak, kadar glukosa dalam darah harus selalu terpenuhi. Hal

ini penting pada anak-anak mengingat akti-vitas belajar dan banyaknya kegiatan yang dijalani di sekolah. Di sinilah salah satu fung-si 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 den-gan 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 (in-duk 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.

Mengenal isomaltulosa

”Sebuah hipotesa menyatakan, kadar glu-kosa darah sangat penting untuk menjaga fungsi otak dan banyak studi telah dilakukan untuk meneliti hal tersebut. Bila kadar glu-kosa 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 golo-ngan karbohidrat yang secara alami ter-dapat 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-

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

15 May 2012 Indonesia Focusbul 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 ka-dar glukosa darah diperkirakan akan mem-pengaruhi 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 stan-dar, susu pertumbuhan standar diformu-lakan, 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 diband-ingkan susu biasa. (Hasil studi ini telah di-publikasikan pada jurnal Appetite 2012; 58:81-87).

Studi di Indonesia

Berbagai penelitian tentang isomaltulo-sa telah dilakukan, salah satunya di Jepang (Kashimura J dkk, 2003) yang hasilnya menunjukkan performa mental turun lebih sedikit dibandingkan dengan yang mengon-sumsi sukrosa. Penelitian tahun 2012 (Taib dkk) di Malaysia, membuktikan lebih se-dikitnya penurunan tingkat perhatian, daya

ingat dan pengenalan gambar dengan susu yang ditambahkan isomaltulosa dibanding-kan 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 kri-teria. Semua diharapkan homogen baik sta-tus gizi, intelektual, dan kadar hemoglobin. Jumlah laki-laki dan perempuan sebanding dan tinggi badan/berat badan sesuai dengan angka kecukupan gizi anak Indonesia den-gan kadar Hb batas normal.

Studi double blind randomized cross-over ini membandingkan 4 jenis susu yang diberi-kan 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 di-cross over adalah susu A,B dan C, sedangkan susu D diberikan bersamaan pada 2 minggu terakhir.

Pengukuran yang dilakukan pada pene-litian ini adalah tingkat perhatian/atensi, tingkat perhatian berkelanjutan, kecepatan pemahaman angka, kecepatan dalam memi-lih, kualitas memori, pengenalan gambar dan kecepatan ingatan. Kesemuanya ini diu-kur dengan instrumen khusus menggunakan program komputer ‘United Bio-source Cor-poration’ (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

16 May 2012 Indonesia Focusmelakukan 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 perha-tian 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. Memper- kaya 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 pene-litian ini lebih spesifik terutama pada susu yang ditambahkan dengan isomaltulosa (2,5gr) dengan vitamin dan mineral. Tam-pak hasilnya lebih baik dibandingkan dengan susu lain. Isomaltulosa memiliki indeks glikemik lebih rendah dibandingkan dengan susu lain, sehingga dapat memberi-kan 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 isomaltulo-sa dapat membantu mempertahankan atensi dan daya ingat pada anak, tentu hal ini sangat bagus dan bermanfaat sekali. Den-gan kadar glukosa darah yang dapat diper-tahankan, maka diharapkan anak akan tetap konsentrasi saat di sekolah karena tidak cepat merasa lapar hingga 3 jam,” jelas dr.

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 hipo-tesa 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 pene-litian di Indonesia ini menunjukkan hasil yang signifikan, setelah mengonsumsi susu pertumbuhan yang mengandung iso-maltulosa, parameter kinerja kognitif anak pada 3 jam setelah konsumsi, relatif stabil. “Susu dengan isomaltulosa yang diper-kaya dengan vitamin dan mineral spesifik, kemungkinan besar memiliki efek positif terhadap kerja kognitif pada anak,” tukas dr. Rini saat peluncuran inovasi susu per-tumbuhan anak dengan isomaltulosa seki-tar pertengahan April lalu.

Orangtua perlu memahami bahwa otak memerlukan tingkat asupan energi yang ber-beda dengan tubuh. Otak akan tetap aktif walau anak sedang istirahat. Berat otak pada anak kurang dari 10% dari total berat tubuh-nya, namun otak mengonsumsi 40% dari to-tal 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.

17 May 2012 Indonesia Focus

Novell Research Grant, bentuk apresiasi terhadap penelitian di IndonesiaHardini Arivianti

Novell Pharmaceutical Laboratories – seb-agai bentuk ‘Corporate Social Responsi-

bility’ (CSR) – menyediakan dana riset ‘Novell Research Grant’(NRG) sebesar Rp 200 juta (un-tuk 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 Pengu-rus Besar Perhimpunan Dokter Spesialis Penya-kit Dalam Indonesia (PB PAPDI).

Sebenarnya kegiatan penelitian di Indo-nesia 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 den-gan penelitian penyakit apa yang sangat dibutuhkan.

“Ini pertama kali Novell bekerjasama den-gan PAPDI, yang juga bertujuan untuk memi-cu 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 meng-hibahkan sejumlah dana demi kepentingan penelitian dan tidak terkait dengan produk-

produk serta kami juga berharap hal ini akan diikuti oleh farmasi-farmasi atau lembaga lainnya guna mendukung dokter serta me-majukan ilmu terkait,” ungkap Dr. dr. Aru W. Sudoyo, SpPD-KHOM selaku Ketua PAPDI.

PAPDI berharap penelitian ini bisa menjadi bahan masukan untuk Kementerian Kesehat-an dalam memperkaya usaha kita khususnya dalam menurunkan morbiditas dan mor-talitas dari penyakit dan mendorong dokter untuk melakukan penelitian.

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 Lem-bong dan tim juri

18 May 2012 Indonesia FocusKriteria pemilihan

Kriteria seleksi proposal riset mencakup: originalitas (belum pernah dilakukan se-belumnya 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 pedo-man 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, FINA-SIM dan dr. Sally A Nasution, SpPD-KKV, FINASIM. “Kami sepakat mengenai topik penelitian tidak molekuler, tidak high tech, dan bukan sesuatu yang merupakan transla-tional research (dari laboratorium ke klinik), namun melainkan yang sudah teraplikasi,” jelas dr. Aru.

Dua pemenang

Pada tanggal 3 April 2012 lalu, NRG perta-ma 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 disip-lin ilmu yang berbeda-beda termasuk spiritual, dengan harapan memberikan hasil optimal bagi pasien diabetes yang di Indonesia jum-lahnya 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 Penya-kit Paru Obstruktif Kronik pada Jamaah Haji Embarkasi Jakarta’ akan sangat berguna bagi para calon jamaah haji yang berjumlah jutaan orang setiap tahunnya guna membantu merin-gankan penderitaan bagi yang memiliki PPOK selama *ibadah haji. Penyerahan dana dilaku-kan secara simbolik oleh Ketua Umum PB PAPDI yang dilanjutkan dengan penandatan-ganan MoU.

19 May 2012 News

World Sepsis Day to highlight global emergency

Rajesh Kumar

The acute care community has designated 13 September 2012 as World Sepsis Day to high-

light 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 body’s 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 hos-pital mortality rates of 30 to 60 percent, sepsis remains the primary cause of death from infec-tion 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 crit-ical care physicians around the world, the preva-lence 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, along-side 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 ap-propriate or adequate care according to interna-tional guidelines.

“Rapid initiation of simple, timely interven-tions can halve the risk of dying. Early sepsis treat-ment 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 Univer-sity 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 re-lated 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 ve-nous pressure measurement as an index for fluid resuscitation was performed only around one-third,” 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 out-come measure was compliance with the Surviv-ing Sepsis Campaign’s resuscitation (6 hours) and management (24 hours) components.

High income countries, university hos-pitals, intensive care units with an accred-ited fellowship program and surgical in-tensive 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.

20 May 2012 News

White rice link to diabetes stirs debateRajesh Kumar

A 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 stud-ies, 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 el-evated 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 Sin-gapore General Hospital, cautioned physi-cians against a simplistic interpretation of the study data, saying the methods used to quantify white rice consumption in the pri-mary 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 re-porting white rice contributing to nearly three-quarters of the glycemic load. Should Western diets contain equivalent amounts of carbohydrates (glycemic load), but of an al-ternative 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, pro-portion of macronutrient) should consist of carbohydrates and what implications does this have for the increased risk of type 2 dia-betes?”

Dr. Cho Li Wei, consultant in the depart-ment 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 in-creases the risk of type 2 diabetes.

Gardner said the study had few immedi-ate 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 pres-ent for centuries. In order to determine the contribution of white rice to developing type 2 diabetes, one would need a prospec-tive large-scale randomized controlled trial, with the intervention group having modified white rice consumption. However, such a tri-al 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 diabe-tes,” she said.

21 May 2012 News

C-section raises breathing problem risk in preemies

Rajesh Kumar

Cesarean delivery may contribute to breathing problems among pre-term ba-

bies, 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 ba-bies delivered by a Cesarean section (C-sec-tion) before 34 weeks of pregnancy had a 30 percent increased risk of developing respi-ratory distress syndrome (RDS) than babies born vaginally at a similar gestational age.

Researchers from the department of mater-nal-fetal medicine at the Johns Hopkins and Yale schools of medicine in the US reviewed birth certificate and hospital discharge infor-mation for 2,560 small-for-gestational-age ba-bies who were delivered preterm.

The increased odds for RDS persisted after controlling for maternal age, ethnicity, educa-tion, pre-pregnancy weight, gestational age at delivery, diabetes and hypertension. C-section compared with vaginal delivery was associ-ated with increased odds of 5-minute APGAR (appearance, pulse, grimace, activity, respira-tion) score of <7 using unadjusted odds (odds ratio: 1.4; 95% CI 1.1-1.9), although this differ-ence dissipated after adjusting for confound-ing factors.

“The findings overturn conventional wis-dom that C-sections have few or no risks for the baby and are consistent with the effort(s) to end medically unnecessary deliveries be-fore 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 benefi-cial for some infants,” said Ashton.

Singapore obstetrician and gynaecologist Dr. Kelly Loi said the study results are like-ly to be skewed because it was done retro-spectively. Small and premature babies born through C-section are more likely to have re-spiratory distress anyway, said Loi.

“Babies who need early delivery are com-promised already and the outcome may not be due to the C- section. For full term babies, the risk of respiratory distress following C- section 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 breath-ing problems, cerebral palsy, learning dis-abilities 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 baby’s important organs, including the brain and lungs, are not com-pletely developed until then, said Ashton.

23 May 2012 News

Breast cancer survivors can learn to handle hot flushes, night sweats

Radha Chitale

Cognitive behavioral therapy (CBT) is ef-fective at reducing the hot flushes and

night sweats (HFNS) that are common fol-lowing treatment for breast cancer, according to a study.

HFNS, which the study researchers re-ported 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 meno-pausal, 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 af-ter breast cancer treatment were random-ized 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 pro-gram, information leaflets, and advice about HFNS and treatment options, includ-ing symptoms management, paced breath-ing and relaxation.

The CBT program was based on the caus-al and maintaining factors of HFNS, includ-ing anxiety, stress, embarrassment, negative beliefs and catastrophic thoughts, and the resultant behaviors, which can impact pa-tient 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 breath-ing, 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 con-tribute to it. Women were given the opportu-nity to describe their own experiences with HFNS as a result of breast cancer, their trig-gers and outline their treatment goals.

CBT significantly reduced HFNS after 9 weeks and the results were maintained at

24 May 2012 News26 weeks compared with usual care (ad-justed mean difference in HFNS problem rating [1-10 scale] -1.67 and -1.76, respec-tively; P<0.0001). Women reported sus-tained benefits to mood, sleep and quality of life.

Current treatments for HFNS are non-hormonal 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 im-provements in quality of life.

“We do not know whether HFNS were caused by breast cancer treatments or whether women were naturally meno-pausal when they had breast cancer,” the researchers said. “However, treatment op-

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

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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 dis-orders – an extract of the bergamot orange, an Italian citrus fruit which has long been be-lieved to possess heart health benefits.

Dr. Ross Walker, who runs a private prac-tice in Sydney, said he has successfully used the extract in about 700 of his registered pa-tients who are overweight with dyslipidemia and elevated blood sugar levels.

Within a few weeks of starting the supple-ment, some of those patients have totally avoided the need for statins while others have reduced their statin dose to control dys-lipidemia. As a bonus outcome, their blood glucose and middle obesity have also signifi-cantly 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 month’s sup-plementation 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 bio-synthesis 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 ef-fects typically associated with statins can be avoided because bergamot does not block the component that depletes the muscular co-en-zyme q10, said Walker.

“Bergamot extract (BergametTM) also in-hibits cholesterol absorption in the gut, the same way plant sterols do. That’s 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 meta-bolic syndrome as a whole: raising HDL cho-lesterol, lowering LDL and blood sugar and reducing arterial stiffness and middle obesity.”

Could patients be advised to consume ber-gamot 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 bit-ter/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 at-tack or have vascular disease do need to take statins. [But] the extract can be useful in pre-venting metabolic syndrome, correcting it in early stages and as a supplement to reduce statin dose,” he said.

26 May 2012 News

Omega-3 fatty acids help slow aging of the brainRajesh Kumar

The status of omega-3 fatty acids as ‘brain food’ is well established. However, re-

search 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 bal-anced 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 research-er Dr. Zaldy Tan of the Easton Center for Al-zheimer’s 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 giv-en tests that measured mental function, body mass and omega-3 fatty acid (comprising doc-osahexaenoic acid or DHA, and eicosapentae-noic 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 aver-aged 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

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 solv-ing and multi-tasking and abstract thinking.

“Lower DHA levels are associated with smaller brain volumes and a ‘vascular’ pat-tern of cognitive impairment, even in persons free of clinical dementia,” concluded the re-searchers.

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.

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.

27 May 2012 News

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

Even mild hearing loss increases risk of fallingRajesh Kumar

Adults aged 60 and older should be rou-tinely screened for hearing loss and

treated according to best practice guidelines, according to Dr. Frank Lin, assistant professor of otolaryngology at the Johns Hopkins Uni-versity School of Medicine and Bloomberg School of Public Health in Baltimore, Mary-land, 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 al-ready 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 pre-vent falls and resulting injuries that cost bil-lions of dollars in health care.

“We still do not know if treating hearing loss can reduce falls. But hearing loss treat-ment 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;172:369-371]

They also collected demographic informa-tion, including age, sex and race, and tested

The finding held true even when research-ers accounted for other factors linked with falling, including age, sex, race, cardiovascu-lar disease and vestibular function. Excluding participants with moderate to severe hearing loss from the analysis also didn’t change the results.

Among the possible explanations for the link is that people who can’t hear well might not have good awareness of their overall en-vironment, 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.

Gait and balance are ...

actually very cognitively

demanding

‘‘

28 May 2012 Urology

Odor may help signal UTI in children

Elvira Manzano

Foul-smelling urine may predict urinary tract infection (UTI) in children with un-

explained fever, according to a leading pedia-trician.

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 adjust-ment for other UTI risk factors such as gender and the presence of vesicoureteral reflux – ab-normal 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 child’s past medical history and symptoms. Of eight questions, two were on whether their child’s urine smelled stronger than normal.

Of the 331 children, 51 met the UTI diag-nosis criteria. Bad-smelling urine was the risk factor most strongly linked to UTI – 57 per-cent of the children who tested positive for a UTI had malodorous urine, while only 32

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 of-ten, would not ask about urine odor when a child is assessed in the ER for non-specific symptoms such as unexplained fever or irri-tability.

“It should make the clinician more suspi-cious of this type of infection,” Gauthier con-cluded.

The bacterium Escherichia coli causes the vast majority of UTIs in children. Through-out childhood, the risk of having a UTI is 2 percent for boys and 8 percent for girls. Most cases respond to antibiotics but serious in-fections may cause kidney scarring or blood poisoning if left untreated.

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

29 May 2012 In Pract ice

Managing acute otitis media: Strategies for GPs

Dr. Eng Soh PingConsultantENTSurgeonAscentEarNoseThroatSpecialistGroupMountElizabethMedicalCentreSingapore

Disease of childhoodAcute otitis media (AOM) – inflammation

of the middle ear – is the second most com-mon disease of childhood after upper respi-ratory 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 sus-ceptible 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.

A grommet tube in position.

A bulging erythematous tympanic membrane.

Otitis media with effusion resolves without surgery.

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

What causes AOM?

Otitis media is caused by viral and bacterial in-fections. The most common bacte-ria responsible are Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus and Moraxella catarrhalis. Among older chil-dren, the most common cause is Haemophilus influenzae.

We cannot predict which

patients will go on to develop

complications. Thus, we should

be aggressive, but a little cautious,

when managing AOM

‘‘

30 May 2012 In Pract iceThe vast majority of AOM episodes are

triggered by URTIs. Eustachian tube dysfunc-tion 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 child’s position during bottle-feeding, for example lying down, also predisposes the child to AOM. For this rea-son, breast-feeding position – semi-Fowler’s – may be good for normal Eustachian function.

Signs and symptoms to watch out forWhen 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 com-plain 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 difficul-ties. 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 phar-macological 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 struc-tures, affecting the brain and the facial nerves.

Diagnosing AOMThe presence of the above symptoms, com-

bined with a complete clinical history and

accurate visualization of the tympanic mem-brane may lead GPs to the diagnosis of acute otitis media – one of the three presentations of otitis media (OM), the other two being recur-rent otitis media and otitis media with effu-sion (OME) or glue ear.

A direct examination of the middle ear with an otoscope will reveal erythema, bulg-ing and apparent opacity. The normal tym-panic membrane moves in response to pres-sure 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 ca-nal 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 physi-cians is the use of tuning fork. If the child is cooperative, tuning fork tests – both Weber and Rhine tests – may be performed to distin-guish between conductive and sensorineural hearing loss.

Clinical guidelines for AOMGPs can refer to the American Academy

of Pediatrics (AAP) and the American Acad-emy 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 aggres-sive although some parents may push for more active treatment due to anxiety and dis-tress from seeing their children suffer.

31 May 2012 In Pract iceTreating 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. Amox-icillin is the initial treatment of choice. An-algesics and antipyretics may be used for symptomatic management. If symptoms do not resolve after 48 hours and there is ab-scess, refer. Instrumentation and support may be limited under primary care setting. It helps to be on the careful side. Do not under-estimate the problem. When in doubt, refer.

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 tympanos-tomy tube, called grommet, to allow ventila-tion and drainage. Surgery often takes less

Online Resources:American Academy of Pediatricswww.aap.org

American Academy of Otolaryngology, Head and Neck Surgerywww.entnet.org

Pediatricspediatrics.aappublications.org/content/113/5/1451.long

It takes a sound judgment

and due diligence to be

able to spot early signs of

complications

‘‘

than 10 minutes although it takes a few days to fully recover. The tube will also self-ex-trude in 3 to 6 months.

Take home message for GPsGPs, 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 pal-sy, 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.

32 May 2012 CalendarMay

5th European Clinam Conference for Clinical Nanomedicine7/5/2012 to 9/5/2012Location: Basel, Switzerland Info: Clinam, European Foundation for Clinical NanomedicineTel: (11) 41 61 695 9395Fax: (11) 41 61 695 9390Email: [email protected] Website: www.clinam.org

19th European Congress on Obesity9/5/2012 to 12/5/2012Location: Lyon, FranceInfo: European Association for the Study of ObesityTel: (44) 20 8783 2256Fax: (44) 20 89796700Email: [email protected] Website: www.eco2012.org

American Thoracic Society International Conference 2012 18/5/2012 to 23/5/2012Location: San Francisco, California, US Tel: (1) 212 315 8652Email: [email protected] Website: www.thoracic.org/go/international-conference

American Society of Hypertension19/5/2012 to 22/5/2012Location: New York, New York, US Info: American Society of HypertensionTel: (1) 212 696 9099Fax: (1) 212 696 0711Email: [email protected] Website: www.ash-us.org/Scientific-Meetings/Future-Meetings.aspx

Digestive Diseases Week 201219/5/2012 to 22/5/2012Location: San Diego, California, US Info: American Society of Gastrointestinal EndoscopyTel: (1) 301 272 0022Fax: (1) 301 654 3978Email: nmurphy@gastro .org Website: www.ddw.org

19th WONCA Asia Pacific Regional Conference24/5/2012 to 27/5/2012Location: Jeju, Korea Tel: (82) 2 566 6031Email: [email protected] Website: www.woncaap2012.org

June

2012 American Society of Clinical Oncology Annual Meeting1/6/2012 to 5/6/2012Location: Chicago, Illinois, US Tel: (1) 571 483 1300Email: [email protected] Website: chicago2012.asco.org

10th Royal College of Obstetricians and Gynecologists International Scientific Congress5/6/2012 to 8/6/2012Location: Kuching, Malaysia Tel: (60) 3 6201 1858Email: [email protected] Website: www.rcog2012.com

15th International Congress of Infectious Diseases13/6/2012 to 16/6/2012Location: Bangkok, ThailandTel: (1) 617 277 0551Fax: (1) 617 278 9113Email: [email protected] Website: www.isid.org/icid

15th World Congress of Pain Clinicians27/6/2012 to 30/6/2012Location: Granada, SpainInfo: Kenes InternationalTel: (41) 22 908 0488 Fax: (41) 22 9069140Email: [email protected] Website: www.kenes.com/wspc

33 May 2012 CalendarUpcoming

17th World Congress on Heart Disease 201227/7/2012 to 30/7/2012Location: Toronto, Ontario, CanadaInfo: International Academy of CardiologyTel: (1) 310 657 8777 Fax: (1) 310 659 4781 E-Mail: [email protected] Website: www.cardiologyonline.com

European Society of Cardiology Congress 201225/8/2012 to 29/8/2012Location: Munich, GermanyInfo: European Society of CardiologyTel: (33) 4 9294 7600 Fax: (33) 4 9294 7601 E-Mail: [email protected] Website: www.escardio.org/congresses/esc-2012

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

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

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

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35 May 2012 Humor

“Sorry folks, I’m running a little behind today!”

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happy to operate!”

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