Medical Tribune December 2012 ID

December 2012

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CABG superior to stents in diabetics with CAD

Science and health policy: Lost in translation

FORUM

Monoclonal antibody aids statin-refractory patients

CONFERENCE

NEWS

AFTER HOURS

Malacca: A journey through time

Important benefits for women who quit smoking early

2 December 2012

Important benefits for women who quit smoking early

Elvira Manzano

Smoking nearly triples the risk of prema-ture death in women and quitting the habit well before middle-age reduces this

risk, according to the Million Women Study.In this prospective study, the largest in the

history of studying the dangers of smoking, 12-year mortality rates among women who smoked throughout their adult years were al-most three times higher than those of women who never smoked (rate ratio 2.97, 95% CI, 2.88-3.07). Even light smokers (those who smoked fewer than 10 cigarettes per day) had twice the mortality rate of never-smokers (rate ratio 1.98, 95% CI, 1.91-2.04). [Lancet 2012.DOI.org/10.1016/S0140-6736(12)61720-6]

What was encouraging, however, was the positive effect that quitting seemed to have on women’s life span. Stopping the habit before age 40 avoided more than 90 percent of excess mortality from cigarettes. Quitting before age 30 avoided 97 percent of this added risk.

“Smokers who stop before reaching mid-dle-age will on average gain about an extra 10 years of life,” said study author Professor Sir Richard Peto, of the University of Oxford, Ox-ford, UK.

“This does not, however, mean that it is safe to smoke until age 40 and then stop,” the au-thors warned. Decades later throughout life, women who smoked and stopped still have “1 to 2 times the mortality rate of never-smokers.” For those who continued to smoke past age 40, the risk is 10 times greater.

The study enrolled 1.3 million women (age

50-65) in the UK followed for 12 years. At base-line, 20 percent were smokers, 28 percent were former smokers and 52 percent never smoked.

By 2011, 66,000 had died. Compared with non-smokers, smokers lost at least 10 years of life and died from smoking-related diseases such as lung cancer, heart disease and stroke. While the absolute hazards of prolonged smoking are substantial, so are the benefits of quitting.

“Even cessation at about 50 years of age avoids at least two-thirds of the continuing smoker’s excess mortality in later middle age,” the authors said. The benefits are, however, greater in those who quit earlier.

In a linked comment, Dr. Rachel Huxley, from the University of Minnesota, Minneapo-lis, US, and Dr. Mark Woodward, from the University of Sydney, Australia, welcomed the findings. “Aside from its impressive sample size, the Million Women Study is distinct from previous large cohorts—and superior for as-sessment among women of the full hazards of prolonged smoking and the full benefits of long-term cessation because the participants were among the first generation of women in the UK in which smoking was widespread in early adult life, and although many continued smoking, many stopped before age 30 or 40 years.”

The results emphasize the need for effec-tive sex-specific and culturally-specific to-bacco control policies that encourage adult smokers to quit and discourage children and young adults from starting smoking, they concluded.

3 December 2012

Multivitamins may protect against cancerRajesh Kumar

Daily multivitamin use for more than a decade caused a modest but statistically

significant 8 percent reduction in all cancers among men in a large randomized, double-blind, placebo control trial.

Researchers analyzed data from the Physi-cians’ Health Study II involving 14, 641 male US physicians aged 50 years or older, includ-ing 1,312 men with a history of cancer. The men were randomized in 1997 to receive either mul-tivitamin supplements or placebo and were fol-lowed up through June 1, 2011. [JAMA 2012; DOI:10.1001/jama.2012.14641]

The primary outcome was total cancer (ex-cluding non-melanoma skin cancer), with pros-tate, colorectal, and other site-specific cancers among the secondary end points. During the trial, 2,669 cases of cancer were detected, in-cluding 1,373 cases of prostate cancer and 210 cases of colorectal cancer, with some men expe-riencing multiple events.

Men taking a daily multivitamin had a sta-tistically significant reduction in the incidence of total cancer compared with those taking placebo (17.0 and 18.3 events, respectively, per 1,000 person-years; hazard ratio [HR] 0.92; 95% CI, 0.86-0.998; P=0.04).

The multivitamin group had a similar re-duction in total epithelial cell cancer, but not in other site specific cancers such as colorectal, lung and bladder cancer. The men who had a history of cancer at baseline also saw a reduc-tion in their total cancer risk but this was not any different from the case of healthier men.

A 12 percent difference was seen in the risk of cancer mortality in multivitamin and place-bo groups (4.9 and 5.6 events, respectively, per

1,000 person-years; HR 0.88; 95% CI, 0.77-1.01; P=0.07), but this was not statistically significant.

Previous observational studies of long-term multivitamin use and cancer have been incon-sistent and large-scale randomized trials test-ing single or small numbers of higher-dose in-dividual vitamins and minerals for cancer have been negative or inconclusive.

“Although the main reason to take multivita-mins is to prevent nutritional deficiency, these data provide support for the potential use of multivitamin supplements in the prevention of cancer in middle-aged and older men,” said Dr. J. Michael Gaziano of Brigham and Women’s Hospital and Harvard Medical School in Bos-ton, Massachusetts, US.

Those with nutritional deficiencies would likely benefit more, since the current study co-hort was of healthy physicians, said Gaziano.

Also, total cancer rates in the trial were like-ly influenced by the increased surveillance for prostate-specific antigen (PSA) and subsequent diagnoses of prostate cancer during PHS II fol-low-up starting in the late 1990s, he added.

Several individual vitamins and miner-als contained in the multivitamin supplement used in the study have been ascribed chemo-preventive roles, but it is difficult to definitively identify any single mechanism that may have reduced the cancer risk, said the researchers.

A similar analysis of the PHS II cohort failed to find cardiovascular protective benefits of multivitamin supplementation. The rate of myocardial infarction, stroke, or cardiovascular death was no different between the multivita-min and placebo groups (HR 1.01, 95% CI 0.91 to 1.10) [Proceedings of the American Heart As-sociation (AHA) 2012 Annual Meeting scientific sessions].

4 December 2012 Forum

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

How are science, evidence and health policy related to each other, and what are the dynamics?

Policymakers see the policy process differ-ently from how the academy in general sees it. Policymakers work in a chaotic world exposed to a wide variety of influences and what comes out of academia can be a tiny issue for them. In contrast, scientific evidence is the major issue for us. One of the main actors in modern epi-demiology, the late Emeritus Professor Geof-frey Rose, from the London School of Hygiene and Tropical Medicine, London, UK, said: “We know what is desirable, but the obstacles to its achievement are economic, industrial, and po-litical.” I would say the opportunities to this achievement are economic, industrial and po-litical.

When it comes to evidence-informed policy, opinions vary by discipline. Economic analy-sis is extremely important, as well as foresight from family and community views. All these bring different kinds of evidence which all play a part in the cocktail of decision making.

Foresight and strategic decision processes are also key elements in policy-making. In Fin-land, policy actors practice strategic alliance and sense-making before selection of priorities and implementation. These are as important as the results of randomized trials. How does this work for the big problems of our time?

Every country in the world is confronted

with a tsunami of lifestyle-related diseases – an epidemic of non-communicable diseases such as heart disease and stroke, cancer and diabe-tes. With increasing longevity, ever more peo-ple are living with dementia and Alzheimer’s disease, most in low middle-income countries. The burden on society will be enormous, par-ticularly as traditional family structures are changing and no longer taking care of the el-derly.

Climate change also has a huge impact on health. Extreme weather changes will lead to the emergence of food-borne and vector-borne diseases. Because of this, epidemics will never be far away. The world will continue to produce new viruses and emerging infections .While the cost on the health sector is fairly minimal, the economic cost and disruption will be significant. We should see beyond the health sector when we think about the impact of such diseases and what to do about it. This is the big problem of our time, for this region of the

5 December 2012 Forumworld in particular.

With the exception of climate change, modi-fication of behavioral risks is something we can do. There are effective and feasible interven-tions — tobacco control, salt, fat and alcohol reduction, weight control and physical activity — and yet, these are not happening.

In the 7 years since the international public health policy commitment that is the Frame-work Convention on Tobacco Control (2005) took effect, only 5 percent of the global popula-tion is covered by it. Clearly, there are stronger factors at work than scientific evidence. The fight is never over. We have to continue to rein-vent new approaches for tobacco control.

In the UK, innovative approaches for salt re-duction produced remarkable results, leading to a decline in the average salt consumption of 0.9 grams per person per day. This reduction is estimated to prevent more than 6,000 pre-mature deaths and save £1.5 billion a year in health care costs. This is a major achievement and can be done in many countries.

Throughout Eastern Europe, alcoholism is a major problem that the authorities seem un-willing to tackle. Another problem in this re-gion is HIV infection and injection drug use.

Denmark recently imposed a fat tax, the first in the world, on all obesogenic food — butter, full-fat milk, pizza. New York City’s latest ac-tion is to ban big soda. The health sector can-

not do it alone. It is only through this kind of regulation that we can hope to change people’s behavior and begin to turn the tide on non-communicable diseases.

Nevertheless, many of the effects of legisla-tion on lifestyle changes and its impact on the economy are still unknown. We need more information. We should broaden our analy-sis way beyond the classic ways of analyzing health interventions. For political decisions at the highest level, we need to take a macroeco-nomic view as much as we need good technical information.

Is science lost in translation? Yes and no. The robustness of our evidence is not that great. More research is needed. There are also para-doxes of science communication. We’ve seen papers and press releases claiming discoveries of new ‘cures’ for cancer all too frequently. We are partly to blame for over-selling our results.

For decision makers, results issues and soci-etal priorities are as important as scientific evi-dence. We can’t ignore that politics is extremely important.

As scientists, we need to do a better job in terms of thinking through how to influence policy. This is also where a school of public health is essential. The role of the school of pub-lic health is to develop a science base, making sure that education and training programs are ‘in sync’ with society’s needs.

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6 Indonesia FocusDecember 2012

Perayaan Hari Diabetes Sedunia

Hardini Arivianti

Tanggal 18 November 2012 lalu, Hari Diabetes Sedunia (‘World Diabetes Day’/WDD) 2012 diselenggarakan

oleh Persatuan Diabetes Indonesia (PERSA-DIA) dan Institut Diabetes Indonesia (IN-DINA) bersama PT Novo Nordisk Indonesia dan didukung oleh Perkumpulan Endokri-nologi Indonesia (PERKENI) dan Perhim-punan Edukator Diabetes Indonesia (PEDI). Kampanye WDD ini juga diprakarsai oleh ‘International Diabetes Federation’ (IDF). Acara WDD 2012 yang digelar di Jogjakarta ini dihadiri sekitar 600 penyandang diabetes dari beberapa kota lainnya, seperti Klaten, Solo, Lampung, dan sebagainya.

Pertama kali WDD diperingati pada tahun 1991 oleh IDF dan WHO dalam menghadapi keprihatinan terhadap peningkatan ancaman kesehatan akibat diabetes dan WDD juga menjadi hari resmi PBB pada tahun 2007 den-gan berlakunya Resolusi PBB 61/225. Hari Diabetes yang sebenarnya jatuh pada tanggal 14 November ini, merupakan hari kelahiran Frederick Banting yang bersama rekannya Charles Best yang berhasil menemukan hor-mon insulin tahun 1922. Kali ini, WDD di In-donesia bertemakan “Protect Our Future”.

Logo WDD berupa lingkaran biru yang menandakan simbol global untuk diabetes yang diadopsi tahun 2007 untuk menandai diakuinya Resolusi PBB. Lingkaran tersebut melambangkan kehidupan dan kesehatan sedangkan warna biru mencerminkan warna langit yang menyatukan semua bangsa dan juga sebagai sesuai dengan warna bendera PBB.

Diabetes perlu perhatian khususJumlah penduduk dunia yang terkena dia-

betes mencapai angka 366 juta di tahun 2011 dan pada tahun 2012 ini, mengalami pe-ning-katan menjadi 371 juta dan separuhnya tidak sadar terkena diabetes. Hal ini diungkapkan oleh Prof. Dr. dr. Sidartawan Soegondo, Sp-PD-KEMD. Sepuluh negara dengan peyan-dang diabetes terbanyak adalah Cina, India, Amerika Serikat, Brazil, Rusia, Meksiko, In-doesia, Mesir, Jepang dan Pakistan. Dipre-diksi, Indonesia akan menduduki pering-kat ke-7 dan dua propinsi yang menduduki prevalensi tertinggi (11,1%) adalah Maluku Utara dan Kalimantan Barat.

Dari data dinyatakan sekitar 74% pe-nyandang diabetes, tidak sadar/tahu dirinya terkena diabetes. “Itu sebabnya kita harus mencari yang termasuk 74% ini dengan cara membuat berbagai penyuluhan agar mer-eka datang dan sadar untuk memeriksakan dirinya,” tukas Ketua PB PERSADIA ini lebih lanjut.

Tema yang diangkat WDD adalah ling-kungan yang baik untuk semua, terutama lingkungan untuk anak dan remaja agar me-


reka yang berisiko tinggi, tidak akan men-derita diabetes kelak, mengingat selama ini gaya hidup membuat semuanya berisiko dia-betes. Selain itu PBB juga telah sepakat agar diabetes ini harus benar-benar diperhatikan. ”Pengendalian diabetes perlu multisektor yang meliputi pemerintah, edukator, klinisi, dll.”

IDF merekomendasikan pemeriksaan oportunistik mandiri dengan penggunaan kuesioner singkat untuk membantu tenaga kesehatan dalam mengidentifikasi orang-orang yang berisiko lebih tinggi dan yang memerlukan pemeriksaan lebih lanjut. Kue-sioner ini dapat digunakan untuk menilai faktor risiko dan dapat digunakan oleh indi-vidu, dan kuesioner ini berisikan data yang meliputi usia, lingkar pinggang, riwayat ke-luarga, riwayat penyakit kardiovaskular, dan sejarah kehamilan.

Bukti ilmiah menunjukkan, berat badan ideal dan aktivitas fisik sedang dapat mem-bantu mencegah perkembangan diabetes tipe 2. IDF merekomendasikan latihan fisik minimal 30 menit per hari yang telah terbukti

dapat mengurangi risiko diabetes tipe 2 sebe-sar 35-40%.

Selanjutnya dr. Ida Ayu Kshanti, SpPD-KEMD menjelaskan edukasi diabetes yang spesifik dibutuhkan untuk profesi kesehatan dan penyandang diabetes. ”Kendala utama untuk mendapatkan akses pendidikan adalah minimnya edukator yang berkualitas. In-vestasi program edukasi diabetes dan pence-gahannya akan menghemat jangka panjang dengan didapatnya perbaikan kualitas hidup penyandang diabetes dan orang-orang yang berisiko terhadap penyakit ini,” tukas SekJen PEDI ini lebih lanjut.

Perwakilan dari Kementerian Kesehatan Dr.Eko Rahajeng, SKM, M.Kes menjelaskan, semua desa di seluruh Indonesia melakukan gerakan poswindu (sekarang sudah ada seki-tar 5000) dan diharapkan tahun depan diper-cepat dan berharap dari berbagai sektor akan membantu mempercepat program poswindu ini. ”Poswindu merupakan pos penyakit ti-dak menular agar masyarakat sehat dapat melakukan pemeriksaan berkala seperti body fat analysis, konseling, dll.”


Upaya peningkatan akses dan mutu pelayanan kesehatan

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

Hardini Arivianti

Masyarakat sehat, sejahtera dan mandiri merupakan tujuan yang akan dicapai

dengan adanya jaminan kesehatan semesta (universal health coverage). Upaya ini terma-suk langkah persiapan regulasi dan men-cukupi jumlah tempat tidur di rumah sakit, tenaga kesehatan, pembiayaan, obat, alat ke-sehatan serta sarana penunjang lainnya. Hal ini dikemukakan oleh Menteri Kesehatan, dr. Nafsiah Mboi, SpA, MPH pada pembukaan ‘Hospital Expo’ 2012 awal November lalu. Kali ini, Hospex mengusung tema “Strategi Rumah Sakit Menghadapi Arus Kuat Pe-rubahan sebagai Dampak akan Berlakunya UU SJSN dan Internasionalisasi Akreditasi”.

Isu akreditasi internasional juga san-gat relevan yang berfokuskan pada pem-bangunan kesehatan 2010-2014 yaitu den-gan meningkatkan akses masyarakat pada pelayanan kesehatan yang bermutu terma-suk pelayanan rumah sakit yang bermutu. “Hingga saat ini jumlah rumah sakit di In-donesia mencapai 2.068 dengan jumlah total tempat tidur sebanyak 229.612. Bila jumlah ini ditambah dengan tempat tidur di puskes-mas perawatan dan klinik pratama, menjadi lebih dari 240 ribu, dan secara nasional, jum-lah ini mencukupi.”

Kesenjangan jumlah rumah sakit juga ma-sih terjadi, misalnya rumah sakit terkonsen-trasi di perkotaan sedangkan masih banyak daerah yang kekurangan tempat tidur, mis-

alnya daerah terpencil, perbatasan, atau kep-ulauan. “Pengembangan rumah sakit harus dibahas dengan pemerintah daerah (Pem-da) agar memperhatikan tingkat kepadatan rumah sakit di wilayah yang akan dibangun dan Persatuan Rumah Sakit Indonesia (PER-SI) di seluruh Indonesia perlu melakukan advokasi terhadap Pemda agar ke-timpan-gan-ketimpangan dan kesenjangan seperti itu tidak terjadi,” himbau Menteri Kesehat-an ini. Dalam hal ini, PERSI sebagai mitra pemerintah, dihimbau untuk benar-benar melakukan advokasi sehingga pelayanan ke-sehatan terhadap masyarakat lebih merata dimanapun mereka berada.

Kekurangan dan ketimpangan yang ter-jadi, diusahakan dipenuhi oleh pemerin-tah dengan meningkatkan kapasitas rumah sakit kelas 3 dan menambah jumlah puskes-mas dengan tempat tidur, dan RS pratama (rumah sakit se-tingkat kelas D dengan seki-tar 50 tempat tidur yang dilayani oleh dokter umum). Dalam rangka menyambut diber-lakukannya SJSN, MenKes menjelaskan, yang harus diperkuat adalah primary health care sehingga pelayanan kesehatan lebih ban-yak berfokus pada usaha promotif, preven-tif dan kuratif ringan yang sedekat mungkin dengan tempat tinggal pasien.

“Dalam menyongsong universal heatlh cov-erage dan meningkatkan mutu pelayanan rumah sakit, saya minta tidak ada rumah sakit atau dokter yang menolak pasien dalam kondisi darurat dengan alasan apapun.”


Hingga kini dari 2.068 rumah sakit, baru 1.192 yang terakreditasi dan 5 rumah sakit terakreditasi internasional. Diharapkan PERSI mendorong anggotanya melaku-kan langkah-langkah yang diperlukan agar mendapatkan akreditasi dan pemerintah berusaha meningkatkan jumlah rumah sakit dengan akreditasi internasional.

Di penghujung pidatonya, dr. Nafsiah

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

Hardini Arivianti

Pada tahun 2009-2011 terdapat sekitar 126.908 kasus DB dengan rerata ke-matian sekitar 1100 kasus dan Indone-

sia menempati posisi ke-2 kejadian tertinggi setelah Brazil. Bila dibandingkan tahun 2010, saat ini kasus secara nasional mengalami penurunan secara signifikan, namun tetap harus waspada mengenai adanya kemungki-nan peningkatan kasus di tahun-tahun yang akan datang.

Virus DB memiliki 4 serotipe, DEN 1, DEN 2, DEN 3, dan DEN 4 yang penyebarannya di-perantarai oleh nyamuk Aedes agypti. Hingga saat ini belum ada obat spesifik dan vaksinasi merupakan salah satu alternatif yang potensial untuk memerangi DBD. Namun vaksin dengue yang teregistrasi juga belum tersedia dan masih dilakukan penelitian/uji klinis untuk mendapat-kan vaksinasi yang optimal. Ada vaksin dengue yang dikembangkan dan diujicobakan dengan fase berbeda, ada yang baru masuk pra-klinis dan uji klinis. Yang sudah memasuki fase 2 dan fase 3 adalah CYP14 Sanofi Pasteur. Hal ini dike-mukakan oleh Drs. Ondri Dwi Sampurno, Msi,

Apt, perwakilan dari Kementerian Kesehatan pada acara peresmian Kemitraan Sanofi Pasteur dan Lembaga Eijkman dalam Penelitian Dengue di Indonesia beberapa waktu lalu.

“Pengembangan vaksin dengue yang dapat memberikan respon antibodi netralisasi ter-hadap ke-4 serotipe masih menjadi tantangan, karena Indonesia memiliki serotipe dan genotip yang berbeda dengan negara lain. Itu sebabnya perlu strategi pengembangan vaksin yang ber-asal dari strain universal dengan menggunakan berbagai teknologi vaksin agar mendapatkan vaksin dengue yang optimal.”

Kementerian Kesehatan, Kementerian Riset dan Teknologi, beberapa perguruan tinggi nasi-onal dan industri nasional mendirikan konsor-sium penelitian vaksin DB untuk mensinergi-kan sumber daya dan efisiensi penatalaksanaan penelitian. “Penelitian yang dilakukan oleh kon-sorsium tidak duplikasi dengan yang dilakukan Sanofi Pasteur karena pengembangan teknologi vaksinnya berbeda,” tukas Drs. Ondri lebih lan-jut.

Guna mendukung pemerintah dalam peneli-tian dengue di Indonesia, Sanofi Pasteur (divisi vaksin Sanofi) bermitra dengan Lembaga Eijk-

Penelitian dengue di Indonesia


man. “Sanofi Pasteur bertujuan mengembang-kan vaksin DB yang aman dan efektif, dan dapat diakses dengan mudah terutama di negara-neg-ara dengan prevalensi DB tinggi.” tukas Jean-Louis Grunwald, Vice President Asia Pasific-Ja-pan, Sanofi Pasteur.

Kemitraan ini akan mencakup program pen-ingkatan kapasitas bagi peneliti yang terpilih dari Lembaga Eijkman melalui dukungan ‘Glob-al Clinical Immunology Research and Develop-ment Center’ di Amerika Serikat dengan mem-pelajari secara spesifik teknik ‘Plaque Reduction Neutralization Test’ (PNRT) guna memonitor re-spons imunitas anak-anak yang telah mendapat-kan vaksinasi dengue.

Penelitian epidemiologi“Dengue masih merupakan tantangan bagi

kesehatan masyarakat secara global dan hingga tahun 2003, kasus tertinggi dilaporkan di Thai-land, sedangkan 2004 kasus tertinggi ditemu-kan di Indonesia,” papar Prof. Dr. dr. Sri Rezeki S Hadinegoro, SpA(K). Pada tahun 2006, sekitar 57% semua kasus dilaporkan dari Indonesia. Dalam periode 1968-2008, ledakan dengue di In-donesia terjadi pada tahun 1988, 1998 dan 2007.

Program Kontrol DB terdiri dari beberapa hal yang meliputi surveilans epidemiologi, kontrol vektor, manajemen kasus, melakukan kampa-nye, jaringan intersektor, partisipasi komunitas dan pelatihan secara rutin. Sebagai indikator, target morbiditas nasional kasus DB/100.000 populasi pada 2011 adalah <20, namun real-isasinya mencapai 58,55 pada tahun 2008. Target mortalitas <1%, dan realisasinya mencapai 0,86 (tahun 2008).

Hingga kini vaksin DB masih belum terse-dia, papar Prof. Sri, karena banyak sekali tan-tangannya seperti uji coba tidak bisa dilakukan pada hewan, memiliki 4 serotipe virus, dan membutuhkan data studi efikasi vaksinasi un-

tuk menunjukkan daya proteksi pada manusia. “Penelitian di Indonesia membandingkan bera-pa jumlah anak yang terkena DB setelah divak-sinasi dengan anak yang tidak mendapatkan vaksin.”

Selanjutnya Prof. Sri memaparkan studi efi-kasi vaksin DB tetravalent fase 3 yang dilakukan pada anak sehat berusia 2-14 tahun di Indonesia, Thailand, Vietnam, Filipina, dan Malaysia. Jum-lah subyek pada studi CYP14 yang dilakukan secara acak dan multinasional ini adalah 10.278, dimulai dari Juni 2011 dan dilakukan follow up jangka panjang yaitu 3 tahun setelah dosis ke-3 (2015). Dosis vaksin yang diberikan 0,5 ml CYD vs plasebo dan jangka pemberian 6 bulan (0, 6, dan 12 bulan).

Di Indonesia melibatkan 3 kota besar yaitu Ja-karta, Bandung dan Bali. Jakarta diwakili oleh 5 puskesmas yang mewakili 5 wilayah DKI Jakar-ta, Bali berpusat di 1 tempat yaitu RS Sanglah, sedangkan Bandung melibatkan 3 puskesmas. Jumlah subyek secara keseluruhan mencapai 10 ribu (dari 5 negara),1870 subyek dari Indonesia dan pada perjalanannya 20 subyek mengalami drop out dikarenakan beberapa hal, misalnya pindah rumah, dll. Subyek kebanyakan berusia sekolah dasar.

Dosis pertama diberikan pada periode Juni-Agustus 2011 dan dosis ke-3 diberikan pada 10 September 2012 lalu. Bila subyek mengalami de-mam tinggi lebih dari 2 hari, dilakukan pemer-iksaan laboratorium. Surveilans secara aktif juga dilakukan setahun setelah imunisasi, dan bekerjasama dengan sekolah, petugas puskes-mas dan orang tua.”Penelitian ini diharapkan dapat bermanfaat dan dapat membantu menu-runkan angka kematian di Indonesia.”

Genetik virus dengue di IndonesiaAda 3 faktor yang mempengaruhi DN, yaitu

host, virus, dan vektor. Faktor host, dipengaruhi


oleh status imunitas, etnis, genetik, jenis kela-min dan status gizi. Faktor yang mempengaruhi virus antara lain genotip, struktur antigen, dll. Sedangkan vektor dipengaruhi oleh perubahan iklim dan resistensi terhadap insektisida. Hal ini diungkapkan oleh Dr. Tedjo Sasmono pada acara yang sama.

Dikatakan genotip terkait dengan penye-baran geografis dan dikaitkan dengan tingkat keparahan penyakit. Berdasarkan penelitian tipe Asian dan American yang pernah dilaku-kan di Amerika Selatan, tipe Asian akan men-imbulkan penyakit yang lebih parah. ”Namun perdebatan mengenai hal ini masih berlang-sung hingga kini.”

Indonesia merupakan negara kepulauan yang memiliki keanekaragaman etnis, dll. Kini human migration lebih mudah sehingga penya-kit juga meluas karena tidak adanya lagi isolasi geografis dan perbatasan sehingga keragaman tersebut juga berpengaruh menjadi patogen.

”Kami di lembaga Eijkman, melakukan pene-litian epidemiologi molekuler, pemetaan virus, kekebalan virus, deteksi virus dengue pada nyamuk, dll, untuk mengetahui jenis-jenis sero-tipe dan genotip virus disini,” tukasnya. Semua serotipe ada di Indonesia, dan dulu didominasi oleh DEN 2 namun sekarang mengarah ke DEN 1. Genotip DEN di Indonesia meliputi DEN 1 (genotip I dan IV), DEN 2 (Cosmopolitan), DEN

3 (genotip I dan IV) dan DEN 4 (genotip II). Setiap serotipe DEN memiliki banyak geno-

tip. Goncalves dkk (2002) memaparkan sero-tip DENV1 memiliki 4 genotip (genotip I-V). DENV2 memiliki genotip Asian I, Asian II, Cos-mopolitan, Asian/American, American (Twid-dy dkk, 2002). Sedangkan DENV3 memiliki genotip I-IV (Lanciotti dkk, 1994) dan serotipe DENV4 memiliki genotip I-II.

”Pada tahun-tahun lalu, di Indonesia di-dominasi oleh genotip 4 namun akhir-akhir ini didominasi oleh genotip I. Jadi ada pergeseran strain-strain virus yang masuk, bukan strain baru namun strain lama yang masuk ke neg-ara kita.” Kawasan Asia Tenggara bagian Se-latan (Indonesia, Singapura, Malaysia) muncul genotip baru yang mungkin disebabkan oleh perubahan asam amino dan sekuen protein A pada genotip 1 DEN 1 mengalami sedikit mu-tasi.

DEN 1 lebih banyak terdapat di Indone-sia menggantikan genotip 4. ”Kita melakukan kultur dan mengukur kecepatan tumbuh dan ternyata hasil kultur menunjukkan genotip 1 lebih cepat tumbuh dibandingkan genotip 4,” tukas Dr. Tedjo. Genotip 1 secara perlahan menggantikan genotip 4. Namun dari segi klinis belum tahu korelasi genotip 1 dan keparahan penyakit dan peran klinisi disini sangat berarti guna berbagi data.

Susu berkalsium tinggi dan pelepasan mineral tulangHardini Arivianti

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

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


sedangkan fungsi osteoklas diukur dengan hidroksiprolin (OHP), crossed type collagen (N-telopeptida, C-telopeptida/CTX, deoksipiridi-nolina), hidroksilisin glikosida, dan tratrate resistant acid phospatase. “Bila hasil CTX tinggi berarti pelepasan kalsium tulang ke dalam da-rah rendah, jadi CTX berbanding terbalik den-gan pelepasan mineral tulang,” ungkap Dr. dr. Fiastuti Witjaksono, SpGK beberapa waktu lalu.

Kruger dkk (2006) melakukan penelitian ‘Ef-fect of Calcium Fortified Milk Supplementa-tion With or Without Vitamin K on Biochemical Markers of Bone Turn Over in Premenopausal Women’ pada 82 wanita usia pra menopause (20-35 tahun) selama 16 minggu. Penelitian tersamar ganda ini dibagi menjadi 3 kelompok. Kelompok 1 mendapatkan 2 porsi susu berkal-sium tinggi/hari dengan jumlah kalsium tamba-han 1000 mg dan vitamin K 80 µg/hari. Kepada kelompok 2 diberikan 2 porsi susu berkalsium tinggi/hari dengan jumlah kalsium tambahan 1000 mg, tanpa vitamin K, sedangkan kelom-pok 3, tidak mendapatkan susu. Pengukuran os-teokalsin total, prokolage, CTX dilakukan pada minggu ke-2, 12 dan 16. Hasil studi ini menun-jukkan pada 2 kelompok yang mendapatkan 2 porsi susu berkalsium tinggi terjadi penurunan berbagai ukuran penanda yang dilakukan. Hal ini menandakan susu berkalsium tinggi menu-runkan pelepasan/penghancuran kalsium tu-lang pada wanita usia pra menopause.

Berikutnya penelitian Kruger dkk (2009) “The Effect of a Fortified Milk Drink on Vitamin D Status and Bone Turn Over in Post Meno-pausal Women from South East Asia” yang di-lakukan selama 16 minggu pada 60 wanita (In-donesia) dan 60 wanita (Filipina) yang berusia diatas 50 tahun yang diacak menjadi 2 kelom-pok. Kelompok pertama mendapatkan 2 porsi susu tinggi kalsium 1200 mg yang difortifikasi dengan vitamin D (9,6 µg), magnesium (96 mg)

dan zink (2,4 mg). Kelompok 2 mendapatkan 2 porsi minuman yang berbahan dasar beras (powder milk rice-based). Kepadatan tulang diu-kur dengan hormon penanda PTH dan CTX. Penelitian menunjukkan hasil terdapat penu-runan PTH dan CTX pada minggu ke 2, 8 dan 16 pada kelompok perlakuan dibandingkan dengan kelompok kontrol. Pada kelompok 1 kadar CTX menurun sebesar 34% setelah 2 min-ggu mengonsumsi susu.

Penelitian Kruger pertama dilakukan oleh Massey University, Fonterra Brands Ltd dan St. Thomas Hospital (Inggris) dan penelitian yang kedua juga dilakukan oleh Massey University dan Fonterra Brands Ltd beserta Departemen Obstetri dan Ginekologi FKUI/RSCM.

Dari penelitian didapat fakta sebagai beri-kut: rerata asupan kalsium sebesar 218,7 mg/hari (Indonesia) dan 372 mg/hari (Filipina). Status vitamin D, diperkirakan > 70% wanita Indonesia mengalami kekurangan vitamin D (< 50nmol/L) sedangkan dengan wanita Filipina sebanyak 20%.

Kedua penelitian diatas, papar dr. Fiastuti, menunjukkan konsumsi susu tinggi kalsium dan vitamin D selama 2 minggu secara sig-nifikan dapat mengurangi kerusakan tulang. Sesuai data Puslitbang Gizi Departemen Kes-ehatan (2005), 2 dari 5 orang Indonesia berisiko terkena osteoporosis. Pada usia 50 tahun, risiko osteoporosis dijumpai pada 1 diantara 3 wanita dan 1 diantara 5 laki-laki. Pada usia 60-70 tahun didapat risiko osteoporosis > 30% wanita dan usia > 80 tahun didapat 70% wanita . “Konsum-si susu di Indonesia hanya 235 mg atau 9-11 li-ter/tahun,” tukasnya.

Saat ini Departemen Gizi FKUI bekerjasa-ma dengan Fonterra Brands Indonesia sedang melakukan riset serupa guna menilai manfaat susu tinggi kalsium pada pria dan wanita ke-lompok usia 35-45 tahun dan 46-55 tahun.


Hardini Arivianti

Konferensi Nasional ‘South East Asia Nutrition Survey’ (SEANUTS) yang berlangsung 14 November 2012 lalu

bertujuan untuk menyajikan hasil studi SE-ANUTS di Indonesia. Studi ini merupakan inisiatif Royal FrieslandCampina, induk perusahaan Frisian Flag Indonesia yang mencakup empat negara di wilayah Asia Tenggara yaitu Malaysia (3.542 anak), Thai-land (3.119 anak) dan Vietnam (2.872 anak). Dengan jumlah subyek penelitian terbesar, di Indonesia bersama PERSAGI sebagai tim melakukan pengumpulan data dan analisa pada 7.211 anak berusia 6 bulan hingga 12 tahun yang dilakukan Januari-Desember 2011 di 48 kabupaten/kota di Indonesia.

Selaku Direktur Nutrisi Masyarakat, Ke-menterian Kesehatan Republik Indonesia, Dr. Minarto menyampaikan, peme-rintah memiliki program Gerakan 1.000 Hari Perta-ma Awal Kehidupan atau hingga anak beru-sia 2 tahun, yang bertujuan untuk mencapai target MDG tahun 2015. Hasil SEANUTS ini bersifat komprehensif dan melengkapi data nasional yang dimiliki pemerintah In-donesia diantaranya Riset Kesehatan Dasar (Riskesdas), Survei Sosial Ekonomi Sosial (Susenas) dan sumber penelitian lainnya.

SEANUTS menunjukkan pencapaian program pemerintah meningkatkan sta-tus vitamin A pada anak melalui program pembagian kapsul vitamin A dosis tinggi 2 kali setahun kepada anak balita dan pen-ingkatan status yodium melalui yodinisasi

garam terbukti efektif. Namun hasil SEA-NUTS juga menunjukkan masih ada beber-apa indikator gizi yang harus diperhatikan diantaranya adalah status vitamin D pada anak, stunting (tubuh pendek), underweight (kurang gizi termasuk gizi buruk), dan ane-mia, serta hasilnya dapat menjadi landasan dalam pengembangan program yang lebih tepat sasaran dalam me-ngatasi masalah gizi anak Indonesia.

Hasil temuan Berdasarkan SEANUTS, tingkat defisien-

si vitamin A anak usia 24-59 bulan adalah 0,6%, sedangkan pada anak usia 5-12 ta-hun adalah 0,7%. Risiko defisiensi ini (ka-dar serum retinol 20-29 mcg/dL) pada usia 24-59 bulan sebesar 8,2% dan 6,9% pada usia 5-12 tahun. Pada yodium, ditemukan fakta, ekskresi yodium kategori defisien (<100 mcg/L) adalah 11,5%, dan 14,9% pada ekskresi yodium kategori >200 mcg/L.

Aktivitas juga diukur pada studi ini, den-gan cara menghitung jumlah langkah yang dilakukan selama 2 hari. Hasilnya menun-

SEANUTS, temuan terbaru gizi anak Indonesia


jukkan perbedaan signifikan aktivitas fisik antara laki-laki dan perempuan, anak laki-laki lebih aktif. Anak laki-laki yang tinggal di pedesaan lebih aktif dibandingkan di perkotaan sedangkan anak perempuan di perkotaan lebih aktif daripada anak laki-laki.

Fakta baru lainnya juga dipaparkan oleh Dr. Minarto. Sekitar 1,1% anak-anak di pede-saan mengalami kondisi wasting berat, dan sekitar 6,9%nya mengalami kondisi wast-ing. Kondisi stunting dibedakan stunting be-rat dan stunting. Stunting berat ditemukan lebih banyak pada balita laki-laki daripada perempuan dengan perbedaan sekitar 2,2%. Pada usia 5-12 tahun, terjadi lebih banyak pada anak laki-laki dengan perbedaan seki-tar 1%. Sedangkan kondisi stunting ditemu-kan pada balita perempuan dengan perbe-daan 0,2%. Pada usia 5-12 tahun juga sama (lebih banyak pada anak perempuan) yang bila diban-dingkan anak laki-laki memiliki perbedaan 1,1%.

Selanjutnya Dr. Sandjaja selaku Ketua Tim Peneliti SEANUTS Indonesia menam-bahkan, SEANUTS memberikan gambaran yang lebih komprehensif terkait dengan sta-tus gizi makro dan mikro anak serta meneli-ti karakteristik rumah tangga, karakteristik anak, konsumsi dan pola makanan sehari-hari, status gizi, pola pertumbuhan, status biokimia, kualitas tulang, aktivitas fisik, perkembangan kognitif dan psikomotorik

di seluruh Indonesia. “Kondisi kekurangan zat gizi mikro terutama vitamin A, anemia, dan yodium, sudah jauh menurun diband-ingkan dengan hasil Riskesdas 2010, namun masih ada masalah lain yang belum tersele-saikan, yakni jumlah anak pendek yang ma-sih mencapai 34%, berbeda sedikit dengan Riskesdas 2010 (35%). Sementara itu gizi kurang masih 6,9%.”

Teknik pengambilan dataPenelitian dilakukan se-suai dengan stan-

dar penelitian ‘World Health Organization’. Desain metode penelitian adalah studi po-tong lintang (cross sectional study) berupa kuesioner, antropometri dan biokimia. Den-gan kuesioner, data yang didapat adalah so-sial ekonomi (data perumahan dan sanitasi lingkungan), dan kesehatan dan konsumsi (aktivitas dan ritual konsumsi selama 24 jam, pola kebiasaan makan, menyusui dan pemeriksaan klinis).

Untuk memperoleh data biokimia pada studi ini meliputi antropometri (usia, berat badan, tinggi badan, tinggi duduk, lingkar lengan atas, lapisan lemak tubuh, lebar tung-kai, pergelangan tangan, siku); kognitif dan motorik (aktivitas 24 jam, raven test, WISC test, Denver test, bailey test), dan biokimia (serum vitamin A, serum vitamin D, hemoglobin, fer-itin, hs-CRP, AGP, EIU, densitas tulang den-gan USG, omnisence, DEXA).


Rabies dan penanganannyaThe 1st Indonesia-France Seminar in Medicine and Public Health, November 3-4 2012, Jakarta

Hardini Arivianti

Rabies pada manusia (human rabies) ma-sih merupakan masalah kesehatan ma-

syarakat yang perlu perhatian besar. Ber-dasarkan estimasi WHO, kematian akibat rabies mencapai 40.000-70.000 kasus per tahun di seluruh dunia. Sebagian besar ke-matian terjadi di negara-negara berkembang seperti Afrika, India, dan Asia Tenggara. Hal tersebut dipaparkan oleh Prof. Dr. dr. Ketut Tuti Parwati Merati, SpPD-KPTI, pada ‘The 1 st Indonesia-France Seminar in Medicine and Public Health’ yang berlangsung tang-gal 3-4 November 2012 lalu.

Risiko terinfeksi tergantung pada tingkat keparahan luka gigitan, bagian yang tergigit yang dikaitkan dengan jalur saraf dan ja-rak ke otak, serta kadar dan jenis virusnya. Gejala-gejala awal hampir mirip dengan in-feksi virus sistemik lainnya, seperti demam, sakit kepala, dan merasa tidak enak badan. Mungkin disertai dengan parestesia pada bgian yang terpapar virus (tergigit), diikuti dengan gejala disfungsi serebral, ansietas, konfusi, agitasi, delirium, perilaku abnor-mal, halusinasi dan insomnia misalnya pada furious (ensefalitis) rabies. Gejala lain yang menyertai adalah disfungsi otonom berupa hipersalivasi, berkeringat, piloereksi, dan priapisme (pria). Manifestasi lainnya berupa hidrofobia (50-90% pasien).

Periode akut penyakit ini biasanya bera-khir setelah hari ke-10. Setelah gejala klinis muncul, penyakit hampir dikatakan fatal dan penatalaksanaannya berupa terapi suportif. Rabies memiliki 2 bentuk klinis, pertama

adalah ensefalitis (hebat) pada 80% pasien dan ke-2 adalah paralisis pada 20% pasien. Bila penyakit semakin progresif, pasien akan mengalami koma. “Teknik PCR dan pemer-iksaan antibodi monoklonal dapat memasti-kan jenis virus yang berbeda yang dikaitkan dengan jenis hewan dan geografis,” tukas dr. Tuti.

Pemberian vaksinasiRabies merupakan penyakit yang hampir

100% dapat dicegah asal dilakukan 3 lang-kah yaitu pencucian luka, vaksinasi lengkap dan serum antirabies. Hal ini dikemukakan oleh Prof. Dr. drh. IGN Ngurah Marhadika. Dari total kasus di Bali yang dialami oleh manusia, rerata usia 36,6 tahun, sebagian besar laki-laki dan berasal dari daerah pede-saan. Hampir semuanya memiliki riwayat pernah digigit anjing dan hanya 5,8% yang lukanya dirawat dan menerima vaksin an-tirabies setelah tergigit. namun tidak ada yang mendapatkan rabies immunoglobuline (RIG). Dari saat tergigit hingga menimbukan gejala-gejala, memerlukan waktu kira-kira 110,4 hari. Pada saat dibawa ke rumah sakit sekitar 21,6% pasien menunjukkan mani-festasi paralisis, sedangkan lainnya menun-jukkan gejala rabies berat lainnya. Tingkat fatalitas kasus 100%.

Bila diberikan vaksin pada hari ke-0, atau sebelum menunjukkan tanda-tandanya ra-bies, bisa selamat. Pemberian suntikan se-cara intramuskular sebenarnya hampir sama dengan intradermal, namun intradermal memerlukan dosis yang lebih sedikit sehing-ga persediaan dapat lebih panjang dan efek


samping lebih minimal. “Keduanya mem-berikan proteksi yang sama, namun pertim-bangannya biaya dan persediaan vaksin.”

Inkubasi virus tergantung pada banyak faktor yaitu tempat gigitan, kedalaman luka, jenis virus dan patogenitasnya. Kebanyakan masa inkubasi kurang lebih 3 bulan atau 10-12 hari bila gigitan terjadi di leher dan gejala kadang bahkan timbul 3-6 tahun kemudian. Risiko tertular rabies tanpa pemberian ‘Post Exposure Prophylaxis’ (PEP) sebesar 15,2% dan setelah PEP menjadi 4,17%.

Selanjutnya Kepala Laboratorium Bio-medik dan Biologi Molekuler Hewan pada Fakultas Kedokteran Hewan (FKH) Uni-

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


Local events calendar

KOPAPDI XV MedanMedan, 12-15 Desember 2012JW Marriot International, Aryaduta, Grand Aston, MedanSekr : DepartemenPenyakit Dalam Fakultas Kedokteran Universitas Sumatera Utara /Rumah Sakit Umum Pusat H. Adam Malik Lt. III , Jl. Bungalau 17, Medan Tel/Fax : 061-4528075Email : papdicabsumut@ gmail.com, kopapdixv@pharma- pro.comWebsite : www. kopapdimedanxv.com

The 6th National Symposium of Aesthetic Medicine and Cosmetic SurgeryJakarta, 15-16 December 2012Hotel Grand Sahid Jaya, JakartaSekr : Jl. Semolowaru Elok I/11-12A, SurabayaTel : 031-34339288Fax : 031-3957929Email : perbeki.jtm@gmail. com

The 1st ISICM National Clinical Case Conference On Intensive and Critical Care Medicine & ExhibitionMakassar, 19-20 Januari 2013Swiss-Belinn Panakkukang, MakassarSekr : Indonesian Society of Intensive Care Medicine (PERDICI), Gedung Makmal Lt.2, Komplek FKUI, Jl. Salemba Raya No.6, Jakarta PusatTel : 021-685991557 Fax : 021-31909033Email : [email protected] : www.perdici.org

PIPKRA : Towards Respiratory Healthy for the FutureJakarta, 7-10 Februari 2013Hotel Borobudur, JakartaSekr : Poliklinik Paru Lt.2 RS Persahabatan, Jl. Persahabatan Raya No.1 Rawamangun, JakartaTel : 021-70726355, 4893536Fax : 021-4705684Email : [email protected]

3rd Asian Society for Neuroanesthesia and Critical Care (ASNACC)Bali, 20-23 Februari 2013Hotel Sanur Paradise Plaza, BaliSekr : Departemen Anestesi, Fakultas Kedokteram Universitas Padjajdaran/ RS Dr. Hasan Sadikin Bandung, Jl. Pasteur No.38, BandungTel : 022-2038285, 2034853 ext 3221Fax : 022-2038306

InaSHJakarta, 22-24 Februari 2013Hotel Ritz Carlton, JakartaSekr : PERKI House Building, 2nd Floor, Jl. Danau Toba No. 139A-C, Bendungan Hilir, Jakarta PusatTel : 021-5734978Fax : 021-5734978Email : [email protected] : www. Inash.or.id karta 22- 24 Februari 2012

Kursus Penyegar & Penambah Ilmu Kedokteran FKUI 2013 (KPPIK)Jakarta, 2-3 Maret 2013Hotel Ritz Carlton, Jakarta Sekr : CME-CPD FKUI, Salemba Raya No.6, Jakarta 10430Tel : 021-3106737Fax : 021-3106443Email : [email protected] : http://cme.fk.ui.ac.id

KONAS 1 Psikiatri ‘ Excellent Psychiatry’Yogyakarta, 8-10 Maret 2013Hotel Inna Garuda YogyakartaSekr : Bagian Psikiatri Fakultas Kedokteran Universitas Gadjah Mada / RSUD Dr. Sardjito. Jl. Kesehatan No.1 Sekip Utara, YogyakartaTel : 0274- 587333Fax : 0274 553112 Email : [email protected] : www.pdskjiclp.wordpress. com

National Symposium & Workshop of Anti Aging Medicine (NASWAAM)Bali, 22-24 Maret 2013Hotel Sanur Beach BaliSekr : Center for Studi of Anti Aging Medicine, Medical Faculty Udayana University, Denpasar, BaliTel : 022 4262063 Fax : 022 4262065 Email : [email protected]

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19 December 2012 Conference Coverage

CABG superior to stents in diabetics with CADRajesh Kumar

Coronary artery bypass graft (CABG) surgery was found to be superior to percutaneous coronary intervention

(PCI) using drug-eluting stents in diabetic pa-tients with multi-vessel coronary artery dis-ease in a large international trial.

The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREE-DOM) trial enrolled 1,900 adults with diabe-tes and blockage of multiple coronary arter-ies (but not the left main artery which usually requires immediate CABG) from 18 countries between 2005 and 2010. [N Engl J Med 2012; DOI: 10.1056/NEJMoa1211585]

At 140 clinical centers, teams of specialists in neurology, heart disease, diabetes, and gen-eral medicine screened potential participants to ensure that they were eligible for both CABG and PCI. Those who were selected for the trial were randomly assigned to receive either of the two interventions and followed up for at least 2 years.

At a cumulative 5-year follow-up, the CABG group had a lower combined rate of strokes, heart attacks and deaths (18.7 per-cent vs. 26.6 percent, respectively; P=0.005). Strokes, which are a well-known risk of by-pass surgery, occurred slightly more often in the CABG group than in the PCI group (5.2 percent vs. 2.4 percent, respectively; P=0.03).

The benefit of CABG was driven by differ-ences in rates of both myocardial infarction

(13.9 percent in PCI vs. 6.0 percent in CABG; P<0.001) and death from any cause (16.3 in PCI group vs. 10.9 in CABG; P=0.049). This survival advantage over PCI was consistent regardless of race, gender, number of blocked vessels, or disease severity.

During the trial, participants received stan-dard medical care for all major cardiovascular risk factors such as high LDL cholesterol, high blood pressure, and high blood sugar. They were counseled about lifestyle choices such as smoking cessation, diet, and regular exercise.

Also, as recommended by international guidelines for patients who receive drug-elut-ing stents, the PCI group also received anti-clotting therapies. Abciximab was adminis-tered intravenously during the procedure, and clopidogrel was given orally for at least 12 months after the procedure, accompanied by aspirin for those who could tolerate it.

“The advantages of CABG over PCI were striking in this trial and could change treat-ment recommendations for thousands of in-dividuals with diabetes and heart disease,” said principal investigator Dr. Valentin Fuster of Mount Sinai School of Medicine in New York City, New York, US.

But the results of the trial apply to only the type of patients enrolled in the trial, said Dr. David Williams of Brigham and Women’s Hospital in Boston, Massachusetts, US, while commenting on their clinical implications.

It is well established that there are patients with multi-vessel disease for whom CABG of-fers no benefit in terms of death or MI over

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

20 December 2012 Conference CoveragePCI. FREEDOM, which was limited to pa-tients with diabetes, represents a different type of patient, he said.

“PCI is especially effective in relieving an-gina. So far, we know little of angina relief in FREEDOM…..therefore, presence of diabe-tes should strongly influence our decisions in managing patients with multi-vessel coro-

nary artery disease,” concluded Williams.Dr. Alice Jacobs of the Boston University

Medical Center said whether the continual evolution of the new drug eluting stents tech-nology will diminish the advantage of CABG was unclear, but appeared less likely if CABG protects the myocardium against the new disease.

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LATEST TREATMENT OPTIONS FOR DIABETESMIMS Video Series features 5-minute interviews with leading experts.

In this Series, find out what these medical experts have to say about latest updates in the treatment of diabetes:

Professor Juliana Chan talks about advances in diabetes management and the recent controversy on insulin therapy and cancer risk.

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


Elvira Manzano

Aspirin therapy did not significantly reduce the rate of repeat venous thromboembolism (VTE) in the AS-

PIRE* trial but significantly reduced major vascular events, with improved net clinical benefit.

In the study, which involved 822 adult pa-tients who had a first episode of unprovoked deep vein thrombosis or pulmonary embo-lism, the annual rate of VTE recurrence (the primary outcome) was not significantly differ-ent in patients randomized to aspirin (100 mg/day) or placebo (4.8 percent vs. 6.5 percent; HR 0.74, 95 % CI 0.52–1.05; P=0.09). Aspirin however reduced the secondary composite outcome of major vascular events (VTE, MI, stroke and death) by 34 percent without in-creasing bleeding. [NEJM 2012.DOI:10.1056/NEJMoa 1210384]

Patients had completed initial anticoagula-tion therapy before switching to aspirin for a mean of 37 months.

With fewer patients recruited than origi-nally planned, ASPIRE alone was not powered to show a significant reduction in the primary outcome. However, when combined with the results of the WARFASA** study, which was prospectively planned, “a clear effect is evi-dent,” said lead author Dr. Timothy Brighton, from the Prince of Wales Hospital in Sydney, Australia.

The WARFASA study, which involved 402 patients, showed that aspirin was able to re-

duce the rate of VTE recurrence by 42 percent as compared with placebo (P=0.02). Patients had baseline characteristics similar to those in the ASPIRE trial, making a meta-analysis pos-sible.

The pooled results from the two trials showed a 32 percent reduction in VTE re-currence rates P=0.007) and a 34 percent re-duction in the rate of major vascular events P=0.002) with aspirin.

“There’s consistent evidence now that as-pirin provide a net benefit with no real cost in terms of side effects or bleeding,” Brighton said. “For the greater number of patients who are not able to take anticoagulants, aspirin is a good choice in the long term.”

ASPIRE co-investigator Dr. John Simes, from the University of Sydney in Sydney, Aus-tralia, said they are not advocating that patients should stop anticoagulant therapy early as a result of these findings. “But in patients who are going to stop anyway, aspirin provides a moderately effective treatment compared with not having anything. We believe this is a cheap and relatively safe therapy that should be con-sidered to prevent further venous thromboem-bolic events. Not only is it of benefit, it is also cost saving.”

In an accompanying editorial, Dr. Theo-dore Warkentin, from McMaster University in Ontario, Canada however advises clini-cians to treat patients with effective antico-agulation for at least 3 months before consid-ering aspirin to avoid the high risk of early recurrence. “Aspirin is inexpensive, does not

23 December 2012 Conference Coveragerequire monitoring (in contrast to warfarin), and does not accumulate in patients with re-nal insufficiency (in contrast to dabigatran and rivaroxaban).

Treatment for unprovoked VTE consists of warfarin, followed by heparin or the newer anticoagulants for 3–12 months. However,

many patients do not get treatment for longer than 3 to 6 months despite recommendation to prolong therapy.

*ASPIRE: Aspirin to Prevent Recurrent Venous Thromboembolism**WARFASA: Warfarin and Aspirin study


Elvira Manzano

Short-term supplementation with omega-3 fatty acids prior to cardiac surgery appears

to have no benefits in terms of preventing ar-rhythmias, according to new research.

In the largest trial of fish oil in surgery ever conducted (OPERA*), administration of ome-ga-3 polyunsaturated fatty acids (n3-PUFAs) 2 to 5 days prior to surgery and until hospital discharge did not reduce the risk of postop-erative atrial fibrillation (AF). There was no difference in the incidence of postoperative AF of >30-second duration – the primary end-point – between the treatment and placebo groups (30 percent vs. 30.7 percent, respec-tively; P=0.74).

Results were similar for a number of sec-ondary endpoints – postoperative AF that was sustained, symptomatic or treated, ma-jor adverse cardiovascular events, 30-day and 1-year mortality and bleeding – among different patient subgroups. [JAMA 2012; DOI:10.1001/jama.2012.28733]

“Omega-3 fatty acids may not be powerful enough to be effective in preventing arrhyth-mias,” said study author Dr. Roberto Marchi-oli, from Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy.

OPERA involved 1,516 patients scheduled for cardiac surgery in 28 centers in the US, Ita-ly and Argentina randomized to a periopera-tive loading dose of placebo or n-3 PUFAs 8 to 10g, followed by 2 g/day postoperatively until hospital discharge. While previous small tri-als of perioperative fish oil on postoperative AF showed mixed effects, OPERA provides no evidence that n-3 PUFAs have anti-ar-

rhythmic actions.The findings were backed by another trial

(FORWARD**) presented at the same meeting which showed that 1 g/day of fish oil did not prevent recurrences in patients with previous AF (HR 1.28, P=0.17). [Circ Cardiovasc Qual Out-comes 2012; DOI:CIROUTCOMES.112.966168).

“Every time we’ve had a trial with omega-3s, we’ve come up short,” said Dr. Peter Wil-son, from the Emory University in Atlanta, Georgia, US. “It’s very discouraging for the omega story.”

Amiodarone and b-blockers have been test-ed for postoperative AF, but these drugs only partly reduced the risk. The effects of cardiac surgery on atrial remodelling may be too im-mense to be countered by most drugs, includ-ing n-3PUFAs, said OPERA lead author Dr. Dariush Mozaffarian, from the Brigham and Women’s Hospital in Boston, Massachusetts, US. “Postoperative AF remains an intractable and enigmatic complication of surgery. More investigations are needed to allow novel tar-geted preventive and therapeutic interven-tions,” he concluded.

*OPERA: Omega-3 Fatty Acids for Prevention of Postoperative AF**FORWARD: Fish Oil Research with Omega-3 for Atrial Fibrillation Recurrence Delay

Omega-3 fatty acids come up short in afib

Two trials failed to show that fish oil prevented arrhythmias.


Monoclonal antibody aids statin-refractory patients


Radha Chitale

Patients with high cholesterol who can-not tolerate statins can turn to a new drug to help them control their low-

density lipoprotein (LDL) levels, according to findings from a phase II study.

In the randomized controlled GAUSS* trial, which included a total of 630 adult pa-tients with high cholesterol who had failed statin therapy at least once, those random-ized to receive a high 420 mg dose of AMG 145, a monoclonal antibody that helps clear LDL cholesterol from the blood, had signifi-cantly lower LDL levels after 12 weeks com-pared with those given standard ezetimibe statin monotherapy (-51 percent vs. -15 per-cent; P<0.001). [JAMA 2012;1-10. DOI:10.1001/jama.2012.25790]

Combined 420 mg AMG 145 plus ezeti-mibe therapy reduced LDL even more, by 63 percent over the 12-week trial period (P<0.001 vs. ezetimibe monotherapy).

AMG 145 alone at 280 mg and 350 mg were less effective than the higher dose or com-bined therapies and resulted in 41 percent and 43 percent reductions in LDL from base-line, respectively.

Goal LDL levels for healthy people is <130 mg/dL. High-risk patients should aim for LDL <100 mg/dL and further control should yield LDL <70 mg/dL in patients at very high risk of heart disease.

Ninety-percent of patients achieved LDL <100 mg/dL on AMG 145 plus ezetimibe as

did 61 percent of patients on 420 mg of AMG 145 monotherapy, compared with 7 percent of those on ezetimibe monotherapy by week 12.

No patients on ezetimibe monotherapy achieved the more aggressive goal LDL <70 mg/dL at week 12 while 62 percent of patients on AMG 145 plus ezetimibe and 29 percent of patients on 420 mg AMG 145 did.

“Improvements were observed in other lipid and lipoprotein parameters,” said lead researcher Dr. Evan Stein, of the Metabolic and Atherosclerosis Research Center in Cin-cinnati, Ohio, US.

AMG 145 was associated with muscle-related side effects in 5 percent of recipients, with myalgia being the most common type (3 percent).

Dr. Peter Wilson, of Emory University in Atlanta, Georgia, US, said this phase II trial showed that the AMG 145 drug class demon-strated efficacy and a good amount of safety, but that more information on the long-term safety profile and immune effects in studies

AMG 145 delivered robust results in the GAUSS trial.

26 December 2012 Conference Coveragethat lasted beyond 12 weeks would be useful.

“These data are very exciting and may offer a new paradigm for LDL cholesterol reduc-tion. The next step will be a large-scale, long-term cardiovascular outcomes trial,” said Dr.

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

Chelation trial dredges up unexpected controversy Radha Chitale

Long-term chelation therapy had modest cardiovascular benefits in patients who

had previously experienced a heart attack, ac-cording to the results of a US trial.

In the 4-year Trial to Assess Chelation Therapy (TACT) involving 1,708 post-myo-cardial infarction (MI) patients, 26 percent of those randomized to infusions of chelation therapy experienced subsequent cardiovascu-lar events, including MI, stroke and coronary revascularization, compared with 30 percent of placebo recipients (HR 0.82, 95% CI 0.69 to 0.99, P=0.035).

“[This chelation regimen] showed some evidence of a potentially important treat-ment signal in post-MI patients already on evidence-based therapy,” said lead researcher Dr. Gervasio Lamas, of Mount Sinai Medical Center in Miami Beach, Florida, US. “Our find-ings are unexpected and additional research is needed to confirm or refute our results and explore possible mechanisms of therapy.”

The trial, supported by the US National Center for Complementary and Alternative Medicine and the US National Heart, Lung and Blood Institute, was meant to pin down the effects of chelation therapy, which in-

volves using disodium ethylenediaminetet-raacetic acid (EDTA) to remove heavy metals such as lead and iron from the body, on car-diovascular health.

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

27 December 2012 Conference CoverageSince it was developed in the 1950s, chela-

tion therapy has only been FDA-approved for treating lead poisoning. But consistent off-la-bel use to treat a variety of diseases, including cardiovascular disease, kept controversy over chelation therapy simmering.

“Some have suggested [chelation] is valu-able, effective and safe; others have suggest-ed it’s likely unsafe, certainly ineffective and should be abandoned,” said Dr. Paul Arm-strong, of the University of Alberta in Edmon-ton, Canada, during a discussion of the trial results.

A quality-of-life sub-study showed no dif-ference in functional status, mental well-be-ing or any other metric with chelation therapy compared with placebo over 2 years of follow up, which makes it even more unlikely to be-come a mainstream therapy down the road.

“The [sub-study results] don’t actually support or provide additional support for these clinical results, which we weren’t very sure about in the first place,” said Dr. Mark Hlatky, of Stanford University in Stanford, California, US.

The double-blind factorial trial random-ized heart patients, median age 65 years, to 40 infusions of chelation solution (included EDTA, 7 grams ascorbic acid, B-vitamins, electrolytes, anaesthetic, and heparin) or pla-cebo infusions.

The trial ran from 2002 to 2011 in the US and Canada and patients were followed for a median of 4 years. Patients were between overweight or obese, about one-third were

diabetic, and all were on either beta-block-er, statin, ACE inhibitor, ARB or antiplate-let therapy. Seventeen-percent of patients withdrew consent during the trial period.

The primary endpoint was a composite of death, MI, stroke, coronary revasculariza-tion and hospitalization for angina. Coronary revascularization occurred most frequently, 287 events out of 483 total composite events. Nearly one-third of diabetic patients (31 per-cent) experienced events.

Two unexpected serious adverse events oc-curred in each study arm, with one death in each arm, “possibly or definitely related to study therapy,” Lamas said.

He also noted that despite the modest sta-tistical significance of cardiovascular benefit with chelation, the upper confidence interval was 0.99. The mechanism of action is still not well understood.

Of note, the researchers saw no improve-ments in angina among chelated patients. Re-lief of angina pectoris was one of the driving factors in the initial use of chelation for heart disease. However, Mark said that improved management of angina could have kept pa-tients asymptomatic at follow-up, particular-ly when the incidence of angina was low at baseline.

“Intriguing as the results are, they are unexpected and should not be interpreted as an indication to adopt chelation into clini-cal practice,” said Dr. Elliott Antman, of the Harvard Medical School in Boston, Massa-chusetts, US.

READ JPOG ANYTIME, ANYWHERE. Download the digital edition today at www.jpog.com

28 December 2012 In Pract ice

Fecal incontinence (FI) is defined as in-voluntary loss of solid, liquid or gas from the anus. While no data is avail-

able on its prevalence in Asia, many popula-tion-based studies elsewhere put the figure between 5 to 15 percent, with higher preva-lence among the elderly.1 While not life-threatening, FI causes significant physical and emotional trauma and can be disabling. Its causes are usually multi-factorial.

The condition can be broadly classified into urge or passive FI with many patients having a mixed pattern. In a case of urge FI, the patient complains of difficulty delaying a bowel movement but does not stain the un-derwear at rest. For passive FI, the patient may not have difficulty delaying the bowel movement but may stain the underwear in sleep or after strenuous activity (eg, after a long walk or after work).

DiagnosisCommon factors associated with FI are

traumatic childbirth, previous anal sur-gery (especially anal dilatation), advanced age, obesity or neurological conditions such as multiple sclerosis, diabetic neuropathy, stroke or Parkinson’s disease. In all these cas-es, conditions that cause excessive mucoid discharge from the anus that mimic FI should be excluded first. These include colorectal

polyps/cancer, proctitis, perianal fistula-in-ano and anal fissures. Patients with FI should have colonic assessment with colonoscopy.

After excluding conditions mimicking FI, the patient should undergo anorectal physi-ology testing with anorectal manometry, anal electromyography, pudendal nerve terminal motor latency test (PNTML) and endoanal ultrasound. These tests help to define the anatomy and physiologic state of the anal sphincter to guide treatment.2-3

Practice guidelinesMost practice guidelines recommend tak-

ing a detailed history of a patient’s bowel habits, especially number of incontinent epi-sodes, getting the patient to complete a week-ly bowel diary of number of bowel move-ments and accidents, obstetric history with emphasis on number of deliveries, mode of deliveries, use of forceps, episiotomies and medical history, especially use of drugs that may cause diarrhea as well as drugs that re-duce anal sphincter tone such as anti-hyper-tensive drugs.

Clinical examination needs to be done for perianal conditions such as hemorrhoids, anal fissures and warts. Physicians should also look for other signs of FI such as patu-lous anus and perianal excoriation and pru-ritis ani. Change any drugs that may have caused FI, if medically possible, and avoid medications that may cause diarrhea. Try treating with anti-diarrheal medication first (such as diphenoxylate/atropine or low-dose loperamide) and refer to a specialist in FI management (colorectal surgeon) for further assessment if there is no improvement.

Treatment options for fecal incontinence

Dr. Lim Jit FongColorectal Surgeon and Director, Pelvic Floor DisordersFortis Colorectal Hospital, Singapore

29 December 2012 In Pract iceTreatment

Treatment includes lifestyle and behavioral modifications, oral and topical medications, anorectal biofeedback, injectable implants, anal sphincter and pelvic floor repair, sacral neuromodulation (SNM), anal sphincter re-placement techniques, dynamic stimulated gracilopasty (DG), artificial bowel sphincter (ABS) implant, antegrade continence enema (ACE) surgery and permanent colostomy.

The aim of treatment is to restore the pa-tient’s continence and quality of life. All pa-tients are taught simple behavioral modifica-tions to cope with the FI episodes. Some have dietary triggers which worsen their condition and these need to be identified. While under-going treatment, it is important to treat the secondary symptoms such as perianal exco-riation with topical agents. The topical creams used should be silicone based (to act as bar-rier against fecal content on skin) and contain zinc oxide (to aid healing of inflamed skin) and these are found in many commercially available diaper rash creams.

Patients are also taught anorectal biofeed-back, which combines counseling and life-style modification along with pelvic floor ex-ercises to strengthen the anal and pelvic floor muscles.

Injectable implants are useful for those with passive FI but their effect rarely lasts be-yond a year. These injections can be repeated. Anal sphincters that are torn may be repaired surgically with concurrent repair of the pelvic floor muscle. Those with severely damaged anal sphincters may be suitable for sphincter replacement operations but these are techni-cally complex and carry significant risks of infection.

Patients with neuropathic FI are best treat-ed with SNM which is easy to perform and

has very high chance of success. The risks are low and the procedure is well accepted by pa-tients. This treatment is also suitable for pa-tients with mixed pattern FI, which form the majority of cases with FI.

ACE and colostomy are considered last options because they are not well accepted by patients. The patient needs to have reg-ular clearing of their bowel and care of the colostomy bag in an elderly patient can be difficult. There is also a significant limitation to patient’s activities with ACE or colostomy.

Disease management toolsDifferent forms of treatment have different

risks, success and recurrence rates. These need to be explained to the patient when planning the optimal option for the patient. Non-surgi-cal managements are extremely low risk and necessary even if the patient requires surgery. The success rate of anorectal biofeedback de-pends on how motivated the patient is, but almost all patients who are able to follow the program will improve their bowel control to varying degrees. The majority of patients with milder FI will only require this option.

Injectable implants started with autolo-gous fat but current versions involve sili-cone4 (PTQTM), carbon beads (DurasphereTM), porcine collagen (PermacolTM) or synthetic resin (Gatekeeper TM). Most injectable im-plants have reported success rates based on improved continence severity scores but few report success rates in percentages of patients improved. The treatment is simple to perform but carries a small risk of infection and sec-ondary fistula-in-ano formation if not per-formed properly.

Anal sphincter and pelvic floor repair (anal sphincteroplasty and levatorplasty) are aimed at correcting structurally torn

30 December 2012 In Pract icestriated muscles of the levator ani and ex-ternal anal sphincter. The reported success rate after repair is 50 to 86 percent but this deteriorates with time to between 11 and 50 percent for studies with follow-up beyond 5 years.5

DG and ABS are technically complex pro-cedures. They also carry significant risk of complications. DG is associated with 55 to 71 percent rate of success in patients achieving > 50 percent improvement in incontinent epi-sodes but the risk of serious wound complica-tions may be as high as 30 percent.

There is also a 20 percent risk of pain either in the anus or donor limb which may require explantation of the stimulator.6 ABS involves the implantation of a silicone expandable cuff in then perineum surrounding the anus with a reservoir in the pre-peritoneal space ante-rior to the bladder. The reported infection rate of the implant is as high as 33 percent which almost always required a second surgery to remove the implant.7

SNM as the latest advancementSNM is carried out in two phases, the pe-

ripheral nerve evaluation (PNE) and perma-nent implant phases (Medtronic Interstim II). At the PNE stage, a straight electrode is inserted percutaneously and connected to an external battery. This procedure is done as a day surgery procedure and there is minimal discomfort as no incisions are made.8

The patient then wears the electrode for 2 to 4 weeks to determine whether there is any improvement in fecal incontinent episodes. Patients with >50 percent improvement in continence are then offered a permanent im-plant. The permanent implant is similar to the PNE stage except a 5cm incision is needed to insert the pulse generator and is similar to

cardiac pacemaker implantation. With careful selection of patients, more than 80 percent of patients who undergo PNE successfully un-dergo permanent implantation.

Newer treatment options that are being ex-plored include an implantable magnetic ring around the anus (FENIXTM) and injectable pu-dendal nerve stimulator, but it is too early to know where these new devices place in the treatment algorithm of FI. Currently, SNM is the first option of surgical treatment for pa-tients with FI in most leading centers in Eu-rope, UK, US and Australia.

ConclusionFI is a debilitating condition which is

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

31 December 2012 In Pract iceventions as they carry very low risk of com-plications with good success rates. In some patients, more than one type of treatment may be necessary in order to achieve optimal results.

References:1. Macmillan AK, Merrie AEH, Marshall RJ,

Parry BR. The prevalence of faecal incontinence in community dwelling adults: a systematic re-view. Dis Colon & Rectum. 2004 (47):1341-49.

2. Jorge JMN, Wexner SD. Etiology and manage-ment of fecal incontinence. Dis Colon Rectum 1993, 36:77–97.

3. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC. Fecal Incontinence Quality of Life Scale: quality of life instrument for pa-tients with fecal incontinence. Dis Colon Rec-tum. 2000;43(1):9-16.

4. Tjandra JJ, Lim JF, Hiscock R, Rajendra P. In-

jectable silicone biomaterial for fecal inconti-nence caused by internal anal sphincter dys-function is effective. Dis Colon Rectum. 2004; 47(12): 2138-46.

5. Brown SR, Nelson RL. Surgery for faecal in-continence in adults. Cochrane Database Syst Rev 2007(2):CD001757.

6. Chapman AE, Geerdes B, Hewett P, Young J, Eyers T, Kiroff G, Maddern GJ. Systematic review of dynamic graciloplasty in the treat-ment of faecal incontinence. Br J Surg 2002; 89(2):138-53.

7. Wong WD, Congliosi SM, Spencer MP, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum 2002; 45(9):1139-53.

8. Tjandra JJ, Lim JF, Matzel K. Sacral nerve stimulation: an emerging treatment for faecal incontinence. ANZ J Surg. 2004; 74(12):1098-106. Review.

33 December 2012 CalendarDecember1st Asia-Pacific Glaucoma Congress (APGC 2012)7/12/2012 to 9/12/2012Location: Bali, IndonesiaInfo: Kenes Asia (Singapore) Tel: (65) 6292 4710Fax: (65) 6292 4721E-mail: [email protected]: apgc2012.org/

54th American Society of Hematology Annual Meeting8/12/2012 to 11/12/2012Location: Georgia, Atlanta, USInfo: American Society of HematologyTel: (1) 202 776 0544Fax: (1) 202 776 0545Website: www.hematology.org

17th Congress of the Asian Pacific Society of Respirology14/12/2012 to 16/12/2012Location: Hong KongInfo: UBM Medica Pacific LimitedTel: (852) 2155 8557Fax: (852) 2559 6910E-mail: [email protected]: www.apsr2012.org

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

January16th Bangkok International Symposium on HIV Medicine16/1/2013 to 18/1/2013Location: Bangkok, ThailandInfo: Ms. Jeerakan Janhom (Secretariat)Tel: (66) 2 652 3040 Ext. 102Fax: (66) 2 254 7574E-mail: [email protected]: www.hivnat.org/bangkoksymposium

28th Congress of the Asia-Pacific Academy of Ophthalmology17/1/2013 to 20/1/2013Location: Hyderabad, IndiaInfo: APAO SecretariatTel: (852) 3943 5827Fax: (852) 2715 9490 Email: [email protected]: www.apaoindia2013.org

Emergency Medicine 201323/1/2013 to 24/1/2013Location: London, UKInfo: MA Healthcare Conferences (London) Tel: (44) 20 7501 6762 Fax: (44) 20 7978 8319Email: [email protected] Website: www.mahealthcareevents.co.uk/

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

FebruaryFood Allergy and Anaphylaxis Meeting (FAAM) 20137/2/2013 to 9/2/2013Location: Nice, FranceInfo: EAACI FAAM 2013 SecretariatTel: (33) 1 7039 3554Fax: (33) 1 5385 8283Email: [email protected] Website: www.eaaci-faam.org/

International Meeting on Emerging Diseases and Surveillance (IMED 2013)15/2/2013 to 18/2/2013Location: Vienna, AustriaInfo: International Society for Infectious DiseasesTel: (617) 277 0551Fax: (617) 278 9113 Email: [email protected]: www.isid.org/imed/Index.shtml

34 December 2012 Calendar

Asian Pacific Society of Cardiology 2013 Congress21/2/2013 to 24/2/2013Location: Pattaya, ThailandInfo: Kenes Asia (Thailand Office)Tel: (66) 2 748-7881Fax: (66) 2 748-7880Email: [email protected]: www2.kenes.com/apsc2013/pages/home.aspx

March23rd Conference of the Asia Pacific Association for the Study of the Liver7/3/2013 to 10/3/2013Location: SingaporeInfo: Gastroenterological Society of Singapore, The Asian Pacific Association for the Study of the LiverTel: (65) 6292 4710Fax: (65) 6292 4721Email: [email protected]: www.apaslconference.org

62nd American College of Cardiology (ACC)Annual Scientific Session9/3/2013 to 11/3/2013Location: San Francisco, California, USInfo: American College of Cardiology FoundationTel: (415) 800 699 5113Email: [email protected]: www.accscientificsession.org/Pages/home.aspx

4th Biennial Congress of the Asian-Pacific Hepato-Pancreato-Biliary Association27/3/2013 to 30/3/2013Location: Shanghai, ChinaInfo: Asian Pacific Hepato-Pancreato-Biliary AssociationTel: (86) 21 350 30066Fax: (86) 21 655 62400Email: [email protected]: www.aphpba2013shanghai.org

35 December 2012 After Hours

Standing atop St Paul’s Hill, facing the sea, you just need to close your eyes and get whisked away by the gentle

breeze to a time not very long ago when Malacca was a bustling port with ships, sailors and traders from the far corners of the world.

Nestled strategically between the Indian Ocean and the South China Sea, protected from winds, earthquakes and volcanoes, it is little wonder why Malacca was an interna-tional trading port.

It is precisely because of Malacca’s status as an international harbor that so many pow-

ers tried to conquer it. Today, as one strolls through the streets of Malacca town, it is easy to spot the various influences of the colonists who came and went over the centuries. Of course, it helps that there are little plaques in-serted into the walls, signs and fences to indi-cate when the structures were built and what they served as.

At the foot of St Paul’s Hill, you can see A’ Famosa, the landmark fort that was built by the Portuguese. Also a remnant of those times is the chapel on St Paul’s Hill. In Malac-ca’s town square, the Stadthuys, easily distin-guishable by its red walls, sits beside Christ


Church, also built by the Dutch. In the town square, tourists mill around, snap-ping pictures of the red buildings as colorful trishaws wait for passengers.

At the riverbank, one cannot ignore the large ship that appears to have docked there. The Malacca Maritime Museum is a replica of the Flora de La mar, a Portuguese trading ves-sel that sank off the coast of Malacca while en route to Portugal with loot plundered from Malacca. Inside, visitors can get a peek into the trading history of Malacca, from the time of the Sultanate and through the years of Por-tuguese, Dutch and British dominance.

Malacca has turned some of its historic buildings into museums housing precious relics of its past. The Stadthuys, once a Dutch administrative building, now houses histori-cal artifacts, guiding visitors through the his-tory of Malacca from its humble beginnings to its height of glory as a trading destination and onwards through the years of coloniza-tion by the European powers.

Everything in Malacca is within walking distance. From the A’Famosa to the Stadthuys, it is just a few minutes’ walk. In between are many attractions for tourists to feast their eyes on. And right by the town square is the famed Jonker Street.

Jonker Street is a delight for anyone who loves antiquities or just finds joy looking at curios. One of the shops is a cobbler’s, who still makes shoes worn by the ancient Chinese women with bound feet and authen-tic Nyonya beaded slippers. While wander-ing about these streets, you may also be ‘ac-costed’ by the wonderful smells of nyonya cuisine wafting from the little coffeeshops.

The beauty and charm of Malacca must be experienced first-hand. Just a 2-hour drive from Kuala Lumpur, it’s the perfect place for a weekend getaway. With good food and a rich culture, one leaves Malacca feeling sated in both body and mind, already longing for another round of ayam pongteh and chicken rice balls.


Getting around Berlin is quite a breeze if you can embrace the complexities of the different modes of transport. If you are

a train nut or you like Thomas the Tank engine like I do, or you want to see the world without leaving a huge carbon footprint, you have come to the right place.

There are officially five types of public trans-port: the subway known as the U-Bahn; the ur-ban rail network known as the S-Bahn; the bus; the tram; and a ferry service which takes you away from Berlin to more rustic and rural areas. In essence, if the trains do not cover your destina-tion, the bus, tram or ferry will take you where you need to go.

The best way to experience Berlin is by taking the S-Bahn or the bus. The S-Bahn is a particu-larly good option because the tracks are elevated and cut through some of the best parts of the city. Take the S-Bahn line 5 or 7 to Berlin’s green lung, the Tiergarten, the zoo (Zoologischer Garten) and the Olympiastadion, built for the 1936 Sum-mer Olympics and home of football club Her-tha Berlin. Looking out the window, you watch as the train glides past wide boulevards, quirky architecture and Berliners shopping at farmers markets. One of the great sights is the ‘graffiti’ on buildings. There are a great number of works of

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


art painted on buildings along the train line. Some train stations are actually destinations

themselves. The Hauptbahnhof (main train sta-tion) is a 6-storey glass behemoth – you will gawk and jaw drop at its cathedral glass ceiling. Some 11,000 pieces of glass cover this huge transit cen-ter. Be prepared to be lost in it as there are 12 or more platforms just on the top level of the station. To add to the confusion, it shares platforms with regional trains and the high-speed intercity ex-press. If getting lost causes you distress, you can get some shopping therapy at the multitude of shops in the station.

When the train is no longer doing the trick, take the bus, in particular number 100 from Zool-ogischer Garten, for a tour of the main attractions. It is a real bargain because it takes you pass the Brandenburger Tor (Brandenburg Gate), the Ger-man parliament known as the Reichstag/Bunde-stag, and various museums – and you don’t have to pay the price of a tour, which can be hefty.

You can get to virtually anywhere in Berlin af-fordably via public transport. Avoid getting be-hind the wheel if you want to avoid crazy Ber-liners in ultra-fast German machines of mass destruction, high fuel prices and a levy on driv-ing in parts of the city. The true benefit of public transport, apart from not burning fossil fuels and saving your heart from getting a coronary, is the opportunity to see the whole gamut of Berliners, which is as diverse as the United Nations. If lost, do not be afraid to ask for directions. Germans

may seem a bit reserved, but if you ask nicely and follow the unfailing formula of ‘guten tag’ (hello) or entschuldigung (excuse me), followed by sprechen sie englisch, Berliners are quite happy to put you back on your way.

Berlin in contextBerlin shares the trappings of most big cities, the predictable bad drivers, incessant smoking and drinking in public spaces, and an overly complex public transportation system. That being said, it still retains a charm that eludes many mod-ern cities. For one it has an enormous amount of open spaces, green areas, parks, playgrounds and walking paths that straddle the river Spree, which courses through the heart of the city.

Berlin has a very complex modern history: Hit-ler’s fascists taking over, going to war and bombed flat in World War 2, split in half by a wall (physi-cal and ideological) during the Cold War and the falling of that wall in 1989, and, finally, the Berlin of today, growing with scars, warts and all to be a very international city.

Geographically located in northeastern Germa-ny, Berlin is approximately 60 km west of the Polish border, in an area of low-lying marshy woodlands. It is part of the vast Northern European Plain, which stretches from northern France to western Russia. The Spree flows through Berlin and empties into the river Havel. The Havel flows through a chain of lakes, the largest of which are the Tegeler See and Großer Wannsee.

39 December 2012 Humor

“I think we should operate immediately!”

“Of course it’s second hand!”

“Your lab tests came back, and we don’t know what’s wrong with you.

We suspect that it’s something to do with your health!”

“Sorry, I can’t reveal the details of the operation.

It’s an old secret family recipe!”

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

hour before getting up!”

“I sent your brown suit to the cleaners. It will match the mahogany casket perfectly!”

“I sent your brown suit to the cleaners. It will match the mahogany casket perfectly!”

“You are saying there is nothing wrong with me?

Well, then I suppose I’ll have to find another doctor!”

“Remember what the doctor said, not to worry about the outcome of the operation. You won’t be

able to see the difference!”

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Medical Tribune is published 12 times a year (23 times in Malaysia) by UBM Medica, a division of United Business Media. Medical Tribune is on controlled circulation publication to medical practitioners in Asia. It is also available on subscription to members of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been pre-pared by professional editorial staff. Views expressed are not necessarily those of UBM Medica. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any con-sequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either gen-erally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions.

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ISSN 1608-5086

Medical Tribune December 2012 ID

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