Diabetes and its hidden tollenews.mims.com/landingpages/mt/pdf/Medical_Tribune_March_2012_ID.pdf ·...

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March 2012

Advancements in the management of anal fistulas

IN PRACTICE

NEWSDaily milk boosts brainpower

CONFERENCEH. pylori eradication altersappetite hormone levels

Turf wars: Resolvinginterdisciplinary conflict incardiovascular imaging

FORUMJenjang subspesialisasi dalam RUU Dikdok

INDONESIA FOCUS

Diabetes and its hidden toll

Mayan ruins – remnantsof a lost civilization

AFTER HOURS

2 March 2012

Diabetes and its hidden toll

Rajesh Kumar

Chronic hyperglycemia can damage the heart beyond its effects on the

development of clinical atherosclerotic coronary disease.

This was a key finding of a US study which examined the association between different levels of HbA1c, a marker for diabetes, and cardiac troponin T (cTnT), a blood marker for myocardial injury, in 9,661 patients without clinically evident coronary heart disease or heart failure. [J Am Coll Cardiol 2012;59:484-489]

Using a novel high-sensitivity (hs) cTnT assay, the researchers found that higher baseline values of HbA1c were associated with increasingly higher levels of cTnT

(P<0.001 for the trend). After adjusting for traditional risk factors, patients with HbA1c levels in the ranges of 5.7 to 6.4 percent and ≥6.5 percent were 1.26 (95% CI: 1.01 to 1.56) and 1.97 (95% CI: 1.44 to 2.70) more likely to have elevated cTnT lev-els compared with those with HbA1c levels <5.7 percent, respectively.

Compared with patients with HbA1c 5.7 percent, hs-cTnT values were 25 per-cent higher in persons with HbA1c 5.7 percent to 6.4 percent and 70 percent higher among participants with HbA1c levels ≥6.5 percent. In fully adjusted models, every 1-percentage point higher HbA1c value was associated with a 0.7 ng/L higher value of hs-cTnT (95% CI: 0.5 to 1.0; P<0.001).

A novel high-sensitivity blood marker test has revealed that chronic hyperglycemia may play a role in myocardial injury independent of its effects on the development of atherosclerosis.

3 March 2012

“Our results suggest that chronically elevated glucose levels may contribute to heart damage,” said senior author Dr. Elizabeth Selvin, associate professor in the department of epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, US.

The levels of cTnT detected were about one-tenth of those usually found in patients diagnosed with a heart attack. This sug-gests that hyperglycemia may be related to cardiac damage independent of ath-erosclerosis. The relationship was present at HbA1c levels even below the threshold used to diagnose diabetes.

“Our study hints at other potential pathways by which diabetes and ele-vated glucose are associated with heart

disease,” said Selvin’s colleague Mr. Jonathan Rubin, an internal medicine fellow at the school and the lead study author. “Mainly, glucose might not only be related to increased atherosclerosis, but potentially elevated glucose levels may directly damage cardiac muscle.”

When asked about the findings’ rel-evance for Asian populations, Selvin said there is no reason to believe the relation-ship would be any different in Asians.

“The hs-cTnT test is not yet approved for clinical use, but may be in the future. These data help in our understanding of the clinical implications of this novel hs test for cardiac troponin and suggest that hyperglycemia may contribute directly to myocardial damage,” she said.

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4 March 2012 ForumTurf wars: Resolving interdisciplinary conflict in cardiovascular imaging

Professor Douglas VaughanChair, Department of MedicineFeinberg School of MedicineNorthwestern UniversityChicago, Illinois, US

Battles, discussions and conflicts have existed between departments for dec-

ades over management and development of cardiovascular imaging and institutions.

Unfortunately, departmental organiza-tion into separate “silos” can devastate organizations, killing productivity and push people out the door. It also jeop-ardizes achieving corporate, medicine, and academic goals. Such separation is also not helpful in terms of building a program or serving patients.

There are three main contributors to interdisciplinary conflict related to cardi-ovascular imaging: radiology, cardiology and administration. Radiologists may say things like “it’s my machine” or “I was here first.” Cardiologists may lay claim to patients and the administration of a hos-pital holds the funds. You can see how that conversation doesn’t get very far.

The silo mentality that still exists in many academic institutions and practices is representative of early 20th century organization of labor that really isn’t fit for the way we operate and try to work today in the 21st century.

Many fascinating techniques in imag-ing that are improving the field such as nuclear imaging, computed tomography angiography or cardiovascular magnetic

resonance imaging are often areas around which there is turf conflict because it is unclear who manages the imaging.

Traditionally, most of the imaging field was populated by radiologists. CT and MRI scanning have become highly adopted in the cardiovascular world now, even though radiologists have been using those devices for decades.

These departments can go head-to-head and toe-to-toe to determine who has control over such imaging modali-ties. In the case of the irresistible force versus the immovable object, you can imagine there’s going to be a collision and somebody is going to get hurt.

The reality in 2012 is further compli-cated by the fact that our imaging modal-ities are constantly evolving. In the very near future, the field will be adding new imaging strategies and techniques to our repertoires that allow us to do molecular imaging, to image stem cells and other things we only dreamed of a decade ago.

As we see with tissue echocardiog-raphy, CT and MRI scanning, these are areas where we can do battle or partner and grow these programs.

As a high stakes game, perhaps game theory should be applied to the conversa-tion when we think about how to create interdisciplinary practice with respect to cardiovascular imaging.

Cardiovascular imaging accounts for nearly one-third of all the diagnostic images performed annually in the US. Another third of that one-third are probably

5 March 2012 Foruminappropriate or questionable procedures.

And while the number of imaging pro-cedures continues to grow, revenues for studies continue to fall. If we think people used to battle when there was healthy reimbursement a decade ago, imagine what the battle will be like when reimbursement falls even further.

Technology is complex and evolves rapidly. This is an important determinant in who is involved in performing imaging procedures at any institution. Too often we see individuals interested in gaining control and sacrificing success. However, even with greater numbers of imaging centers that improve access to cardiac CT scans, we cannot be sure this adds to overall patient health.

But there are many stakeholders in the conversation about cardiac imag-ing beyond radiology and cardiology. Hospitals need capital to invest in imag-ing equipment and keep it updated over time. Individual departments are involved, especially in a world where we live in our own financial bubbles without interdisciplinary funds flow or multispe-cialty practice groups.

Faculty are involved as they need to do work that will advance their own careers and practices. Doctors in training need to be proficient in imaging techniques to develop their careers in investigation and clinical practice.

Patients contribute to the conversa-tion. They want safe tests that can give them a prognosis about the state of their health, but they may not know which test is best or provides the most information.

Payers are vitally interested, especially with reduced reimbursements, as they can be gatekeepers of cardiovascular imaging.

So how do we solve the problem? In general, such issues are best dealt with prospectively rather than retrospec-tively. Developing imaging practices and setting guideline benchmark with frank, fair understanding between par-ties ahead of time can save trouble later. Departments should commit to operat-ing on principles rather than politics. It is difficult to put toothpaste back in a tube if there are preexisting arrangements between parties.

For example, during my time at the Vanderbilt integrated cardiovascular institute in Nashville, Tennessee, US, everything lived in that institute — MRI, CT, echocardiology, nuclear and every other kind of imaging. All professional revenues flowed to the institute and people were paid based on activity and their productivity.

The result was less fighting over rev-enues and less fighting over who had to pay for devices. That was a healthy envi-ronment for growing a program, allowing vigorous and robust activity rather than a divisive attitude.

In general, institutions have to grow partnerships between interested parties. It makes a big difference at the end of the day whether all players have healthy, satisfactory relationships with positive partners when dealing with complex issues like cardiovascular imaging.

Integrating clinical and financial goals can work and we’re seeing more of that today than we did a decade ago.

Building walls is not a good strategy for growth and success. Walls divide the haves and have nots. Tearing down walls can make for thriving, robust environ-ment for opportunity and success.

7 March 2012 Indonesia FocusKebutuhan cairan pada DBDHardini Arivianti

Sepanjang tahun 2011 berdasarkan data Departemen Kesehatan RI, di Indonesia

terdapat lebih dari 60.500 penderita demam berdarah dengue (DBD) dengan jumlah angka kematian sekitar 1 persen dari total penderita, atau mencapai lebih dari 500 orang.

Salah satu penyakit tropik ini tak lepas dari aksi virus dengue di dalam darah. Penyakit yang ditularkan oleh gigitan nyamuk Aedes aegypti itu pertama kali menjadi wabah di Indonesia pada tahun 1968 dan ada empat varian virus dengue yakni virus DEN 1, 2, 3, dan 4. “Ke-4 va-rian tersebut sudah ada di Jakarta sejak tahun 1970,” tukas dr.Leonard Nainggolan, SpPD-KPTI, dalam acara ‘Pocari Sweat Conference’ 2012 di Jakarta beberapa waktu lalu. Sampai saat ini untuk pende-rita yang telah pernah terjangkit DBD tidak ada jaminannya memiliki antibodi untuk tidak tertular lagi, karena virus yang ada di Indonesia akan berbeda dengan jenis virus di negara lainnya.

Kadar trombosit dari pemeriksaan darah dinilai sangat penting pada pasien DBD. Padahal, peningkatan hematokrit (Ht) jauh lebih penting dalam menentukan kegawa-tan kasus DBD ini. Nilai Ht menjadi pen-anda adanya kebocoran plasma yang bisa berakibat fatal. Biasanya kebocoran plasma terjadi pada hari ke-3 hingga ke-4 yang bisa menjadi masa kritis akibat kemungki-nan adanya kebocoran plasma yang tidak ditangani dengan tepat bisa menyebabkan syok atau kematian. “Sebenarnya derajat beratnya DBD dilihat dari nilai Ht dan kadar

trombosit merupakan sebagai ‘petunjuk arah,” jelas pakar penanganan demam berdarah dan penyakit infeksi tropik FKUI ini lebih lanjut.

Saat terjadi gigitan nyamuk, tubuh akan memberikan reaksi imun yang menyebabkan pelepasan zat-zat sitokin. Mekanisme inilah yang menyebabkan gejala demam, pegal, atau sakit kepala. Sitokin itu bermuara ke pembuluh darah kapiler yang sangat tipis sehingga ter-jadilah kebocoran plasma.

Dikatakan suspek DBD bila ada demam mendadak disertai 2 atau lebih gejala-gejala lain seperti sakita kepala, nyeri di belakang mata, nyeri otot, nyeri tulang, ruam kulit, tanda perdarahan, lekosit <5000/mm3, trombosit < 100.000/mm3, nilai Ht meningkat dan uji serologi DBD (+).

Terapi DBDPenderita DBD akan mengalami kekuran-gan cairan tubuh yang signifikan, sehingga asupan cairan tubuh yang cukup sangat diperlukan terutama yang mengandung air, gula, dan elektrolit yang mirip den-gan cairan pada tubuh. Seperti diketahui, cairan tubuh merupakan komponen ter-besar tubuh, yang mencapai 55-65% berat badan. Cairan tubuh ini tidak hanya terdiri dari air biasa, tetapi juga ion positif dan negatif guna mempertahankan keseimba-ngan cairan tubuh.

Apabila pasien masih dapat minum berikan minum sebanyak 1-2 liter/hari. Parasetamol dapat diberikan bila suhu >38,5°. Pada pasien yang tidak bisa minum (muntah terus menerus), beri-kan infus NaCl (0,45%):dekstrosa (5%)

8 March 2012 Indonesia Focusdengan tetesan rumatan (sesuai berat badan). Lakukan pemeriksaan Ht, Hb, setiap 6 jam dan trombosit setiap 2 jam. Bila terjadi perbaikan klinis dan labora-torium, boleh dipulangkan. Namun bila kadar Ht cenderung meningkat dan trom-bosit menurun, infus dengan ringer laktat

dengan tetesan disesuaikan. Hingga saat ini belum ada antivi-

rus untuk membunuh virus dengue. Mengenai vaksinasi, dr. Leonard menje-laskan saat ini vaksinasi DBD sedang di uji coba di Koja dan diharapkan akan selesai tahun 2014 nanti.

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9 March 2012 Indonesia FocusPertemuan Ilmiah Pulmonologi dan Ilmu Kedokteran Respirasi (PIPKRA) ke-10, Februari 9-10, 2012, Jakarta

Peningkatan jumlah pasien kanker paruHardini Arivianti

Sesuai data dari RS Persahabatan, jum-lah pasien kanker paru yang berobat

di RS ini mencapai 800-1000 (25% per-empuan dan 75% laki-laki) pasien selama 2 tahun terakhir dan diperkirakan men-capai 1300 pada tahun 2013. Jumlah ini meningkat 20% setiap tahunnya. Kondisi pasien biasanya sudah mencapai stadium lanjut dan dari data di atas. Sembilan dari sepuluh pasien kanker paru diantaranya memiliki riwayat perokok. Hal ini menjadi salah satu bahasan pada Pertemuan Ilmiah Pulmonologi dan Ilmu Kedokteran Respirasi (PIPKRA) ke-10, awal Februari lalu.

Peningkatan jumlah pasien dibarengi dengan peningkatan jumlah perokok di Indonesia (peringkat ke-3 di dunia) yang tidak dibarengi dengan peningkatan angka harapan hidup bagi mayoritas pasien kanker paru. Angka kematian akibat kanker paru di Indonesia adalah 20,5 per 100.000 orang, menduduki peringkat 58 dari 192 negara di dunia. “Kesadaran masyarakat akan kanker ini masih rendah, dan hanya 1,3 per seratus pasien yang berhasil men-deteksi dini kanker paru ini,” jelas dr. Achmad Hudoyo, SpP(K).

Standar penatalaksanaan kanker tak bergejala ini masih sama dengan yang konvensional yaitu operasi, radioterapi dan kemoterapi. Bila hal ini sudah dilaku-kan dan hasilnya belum memuaskan, ditambahkan dengan krioterapi. Namun bila sudah masuk dalam stadium 3 dan 4, terapinya berupa paliatif atau ditambah

dengan paradigma pengobatan baru yaitu terapi target.

Efek samping terapi target berbeda den-gan kemoterapi. Terapi ini menimbulkan efek samping berupa ruam kulit, diare, kulit menjadi kering dan jerawat. Obat ini diberikan sekali sehari. “Bila ada jerawat, justru menandakan ada mutasi pada epi-dermal growth factor receptor (EGFR) dan merupakan pertanda respon yang bagus,” tukas dr. Hudoyo. Penelitian yang mem-bandingkan kemoterapi dan terapi target (tanpa dikaitkan dengan mutasi) maka hasilnya sama. Namun pada pasien den-gan mutasi, hasilnya jauh lebih bagus pada terapi target.

Selain itu, penelitian juga menunjukkan pada stadium 3 atau 4, sulit untuk meng-gunakan 5 years survival dan mengguna-kan median survival. Kira-kira 50% pasien masih dapat bertahan hidup. Pada pasien dengan mutasi yang menjalani kemoter-api, median survival stadium 3 dan 4, diperkirakan 5,4 bulan. Bila dibandingkan dengan terapi target, median survival ini menjadi 10,8 bulan. Perbedaan survival ini tergantung pada genetik, psikologis, dll.

Tipe utama kanker paru adalah small cell lung cancer carcinoma (SCLC) dan non-small cell lung cancer carcinoma (NSCLC). NSCLC mencakup 75-80% dari semua kasus kanker paru dan terdiri dari adeno-karsinoma, sel skuamosa dan large cell. Adenokarsinoma merupakan jenis kanker paru yang tersering dan yang paling ban-yak memiliki mutasi EGFR. Membedakan jenis ini sangat penting karena terapi yang

10 March 2012 Indonesia FocusPertemuan Ilmiah Pulmonologi dan Ilmu Kedokteran Respirasi (PIPKRA) ke-10, Februari 9-10, 2012, Jakarta

diberikan berbeda. Hampir 70% kasus NSCLC terdiagno-

sis pada stadium lanjut pada saat kanker sudah menyebar. Pada tahap ini, sekitar 15-35% pasien akan hidup hingga satu tahun, dan hanya 2% pasien yang dapat bertahan hidup hingga lima tahun. Rerata angka harapan hidup pasien NSCLC sta-dium lanjut hanya sekitar 4 bulan.

“Kanker paru perlu perhatian khusus. Bila tidak dibedakan stadium dan jenisnya, overall survival (5 years survival) sesuai dengan angka dunia, mencapai 13%,” lan-jut dr. Hudoyo. Sebenarnya kanker paru ini bisa dicegah yaitu dengan tidak merokok. Sekitar 20% kanker paru tidak dihubung-kan dengan kebiasaan merokok, namun ada faktor-faktor lainnya.

Prevalensi perokok di Indonesia sekitar 69%. Perokok pemula mengalami pen-ingkatan terutama remaja perempuan. Perokok pasif memiliki risiko terkena kanker paru sebesar 2 kali lipat dengan

suami non perokok. Bila pasangannya mer-okok, perokok pasif memiliki peningkatan risiko terkena kanker paru 25%. Sedangkan orang yang terpapar asap rokok di lingkun-gan kerja, risiko meningkat 17%.

Untuk bebas risiko kanker diperlukan 15 tahun setelah stop merokok dan pada yang sudah berhenti merokok ini, kemungkinan terkena kanker hampir sama dengan yang tidak merokok.

Perkembangan PIPKRASelaku Ketua PIPKRA 2012, Prof. dr. Wiwin H Wiyono, PhD, SpP(K), memaparkan perkem-bangan terbaru pada PIPKRA tahun ini ada-lah pada Penyakit Paru Obstruksi Kronik (PPOK) yang didiagnosis tidak hanya ber-dasarkan dari hasil spirometri, namun dili-hat juga faktor esksaserbasi dan risiko tinggi eksaserbasi. Sedangkan pada kanker paru, bila ditemukan mutasi EGFR maka terapi target dapat digunakan sebagai lini pertama pengobatan kanker paru.

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11 March 2012 Indonesia FocusJenjang subspesialisasi dalam RUU Dikdok

Hardini Arivianti

Sekitar awal Februari 2012 lalu, dalam sebuah diskusi “RUU Pendidikan Kedokteran”, Pengurus Besar Persatuan Ahli Penyakit Dalam Indonesia (PB PAPDI) menyoroti upaya penghapusan pendidi-kan dokter jenjang subspesialis (konsultan) di Indonesia dalam Rancangan Undang-Undang Pendidikan Kedokteran (RUU Dikdok) yang saat ini tengah dibahas di DPR.

“Jika pendidikan jenjang subspesia-lis tidak disebutkan dalam RUU Dikdok, maka yang akan terjadi adalah pendidikan kedokteran hanya akan sebatas sampai spesialis saja (magister). Efek sampingnya, masyarakat tidak akan mendapatkan dokter subspesialis yang kompeten,” tukas Dr dr Aru Sudoyo, SpPD-KHOM. Oleh karena itu memang selayaknya pendidikan subspesia-lis termasuk yang disebut di dalam Undang-Undang Pendidikan Kedokteran.

“Jika kita tidak mempersiapkan dokter subspesialis dengan baik melalui proses yang terstruktur, maka kita akan kekurangan dokter konsultan yang baik sehingga rumah sakit akan diisi oleh para tenaga subspesia-lis atau konsultan kesehatan asing,” tukas Ketua PB PAPDI ini lebih lanjut.

Selanjutnya, Ketua Bidang Advokasi PB PAPDI, Dr. dr. Ari Fahrial Syam, SpPD-KGEH menjelaskan, dalam pasal 26 RUU tersebut di-terangkan jika hanya ada dua jenjang pendidikan kedokteran. Yaitu program pen-didikan akademik dan program pendidikan profesi. Untuk program pendidikan profesi, terdiri dari dokter umum, dokter gigi, dok-ter spesialis, dan dokter gigi spesialis.

“RUU Dikdok ini sangat berkepentingan

terhadap kelanjutan pendidikan dokter di tanah air, dan dikhawatirkan dengan tidak dicantumkannya pendidikan dokter konsultan atau sub spesialis dalam RUU dapat membuat regenerasi dokter konsul-tan terputus dan jumlahnya akan semakin berkurang.”

Lebih jauh ia menjelaskan, program pen-didikan kedokteran subspesialis memiliki tujuan untuk menyediakan tenaga dokter dan konsultan yang kompeten. Sejalan de-ngan itu, program pendidikan ini juga untuk memenuhi kebutuhan dokter subspesia-lis di rumah sakit tersier atau rumah sakit rujukan.

Menurut dr. Sukman Tulus Putra SpA(K), ada beberapa pihak yang keberatan den-gan masuknya pendidikan sub spesialis ke dalam UU. Salah satunya, sebagian dokter spesialis sendiri merasa bahwa masalah ini belum mendesak. Namun jika pendidikan sub spesialis tidak ada dalam UU, maka sama level kompetensinya tidak akan diakui pemerintah maupun masyarakat.

“Memang saat ini UU Dikdok masih berupa rancangan tetapi pembahasannya sudah tahap finalisasi dan diperkirakan akan disahkan dalam dua bulan mendatang,” jelas Ketua Program Studi Sub Spesialis Jantung Anak FKUI-RSCM ini

13 March 2012 Indonesia Focus1st National Congress of ISHMO/PERHOMPEDIN 2012, Jakarta, 2-5 February 2012

Tantangan pengobatan kankerHardini Arivianti

Untuk mempermudah pasien kanker mendapatkan penanganan yang lebih

mudah, Perhimpunan Dokter Hematologi Onkologi Medik Penyakit Dalam Indonesia (PERHOMPEDIN) mengupayakan pe-ningkatan peran dokter penyakit dalam (internis) agar dapat bekerja sebagai mitra dokter KHOM dalam menangani pasien kanker. Hal ini menjadi salah topik utama pada Kongres Nasional PERHOMPEDIN tanggal 2-5 Februari lalu dengan topik ‘The Role of Internist in Cancer Management’.

Penanganan pasien kanker memerlukan serangkaian terapi yang memerlukan pen-dekatan multidisiplin, yang berbeda den-gan penanganan pasien dengan penyakit tidak menular lainnya. Penanganan pasien kanker secara profesional adalah dengan memberikan informasi secara kompre-hensif, skrining, diagnosis, pembedahan, radiasi, terapi sistemik, pengelolaan efek samping dan mengedepankan keselama-tan dan keamanan pasien. Untuk terapi sistemik seperti di negara-negara maju lainnya, disiplin keahlian dengan kompe-tensi tertinggi adalah Onkologi Medik.

Namun rasio jumlah dokter yang memi-liki kompetensi tersebut dengan pasien kanker, tidak berbanding secara propor-sional. “Itu sebabnya kami melakukan pelatihan internis di Jakarta dan sejumlah daerah lainnya secara bertahap,” tukas Prof. Dr. dr. A Harryanto Reksodiputro, SpPD-KHOM. Tujuan pelatihan ini untuk memberikan akses penanganan terapi sis-temik kanker secara tepat dan profesional,

khususnya bagi pasien di daerah-daerah di luar jangkuan dokter keilmuan onkologi.

Kini pengobatan kanker mengalami kemajuan pesat dan hal luar biasa ini bisa dicapai berkat kemajuan dalam peng-gunaan obat sitostatika. Namun obat tersebut memiliki keterbatasan sehingga menimbulkan tantangan tertentu pada dokter. “Untuk itu dokter tersebut harus memiliki kompetensi yang dibantu oleh kolega-kolega lainnya sehingga bisa men-gombinasikan beberapa jenis obat atau bekerjasama dengan divisi lain serta para ahli bedah sehingga dapat memberikan pelayanan terpadu dan efisien,” jelas Ketua PERHOMPEDIN ini lebih lanjut.

Mengingat jumlah KHOM yang masih

14 March 2012 Indonesia Focuskurang, langkah pertama yang perlu dibuat adalah membuat sistem rujukan khusus kanker antara KHOM di rumah sakit den-gan para internis yang ada di sekitarnya. Program ini adalah ‘Internis Plus’, dengan cara KHOM di rumah sakit tertentu akan mencari internis di sekitarnya. “Dengan pelatihan ini internis memiliki dasar hukum saat memberikan pengobatan dan kini lebih terprogram dengan adanya kuri-kulum dan sertifikat untuk waktu tertentu saja agar pengobatan lebih efisien dan efektif.” Wewenang internis setelah mengi-kuti progam ini, disesuaikan dengan ujian dan sertifikasinya. Ada yang hanya boleh memberikan pengobatan dasar saja dan ada yang tidak boleh melebihi protokoler pengobatan kanker tertentu.

Mengenai pelatihan internis ini, Dr. dr. Aru Sudoyo, SpPD-KHOM menjelaskan, kemitraan ini dapat membantu merin-gankan kendala pasien secara fisik dan ekonomi dalam upayanya mencapai tujuan terapi. “Salah satu kriteria pro-gram internis plus ini harus dalam jarak

jangkauan propinsi agar dapat berkomu-nikasi dan disupervisi oleh propinsi,” tam-bah Ketua PAPDI ini. Para internis yang sudah ‘comitted’ tersebut akan menda-patkan pelatihan cara pemberian sito-statika dan menjadi pelaksana. Sistem yang berlaku, tetap berkonsultasi den-gan KHOM. Program ini sudah dimulai di Jogjakarta dengan kursus kemoterapi (selama 20 minggu) dan jumlah peserta pelatihan ini mencapai 20 orang.

Biaya terapi kanker secara menyeluruh tidak murah, yang mungkin masih ditambah pula dengan biaya perjalanan pasien dan keluarga untuk menemui dokter dan men-jalani terapi. Padahal mayoritas masyarakat tidak memiliki perlindungan keuangan. Mengenai hal ini, Prof. dr. Hasbullah Thabrany, MPH menjelaskan, pemerintah sedang mempersiapkan sebuah sistem jaminan agar pasien kanker dapat berobat secara komprehensif. Namun masyarakat perlu tahu siapa yang perlu mereka temui untuk berobat agar dapat mencapai tujuan pengobatan

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15 March 2012 Indonesia Focus7th International Symposium and 10th International Course on Metabolism and Clinical Nutrition, February 18-19 2012, Jakarta

Pentingnya peran nutrisi pada penyakit kronikHardini Arivianti

Sesuai dengan data Riset Kesehatan Dasar (RISKESDAS) tahun 2007, kema-

tian karena penyakit menular terutama dis-ebabkan oleh tuberkulosis, penyakit hati, pneumonia dan diare. Sedangkan kematian karena penyakit tidak menular disebabkan oleh stroke, hipertensi, diabetes, tumor dan iskemik. Hal ini diungkapkan oleh Dr. Minarto, MPS, selaku selaku Direktur Bina Gizi Masyarakat, Ditjen Bina Kesehatan Masyarakat, Departemen Kesehatan pada presentasinya yang berjudul ‘Early Life Nutrition: Fetal Programming for Chronic Diseases in Adult’.

Topik tersebut diangkat dalam ple-nary lecture pada ‘7th International Symposium and 10th International Course on Metabolism and Clinical Nutrition’ (ISCMCN) tanggal 18-19 Februari 2012 lalu. Tahun ini, ISCMCN bertemakan ‘Nutrition in Chronic Disease: from Bench, Bedside, Epidemiology toward Healthier Life’ dan bekerjasama dengan dua universitas dari Perancis yaitu Universite Joseph Fourier dan Universite d’Auvergne.

Mengenai kondisi nutrisi sesuai data RISKESDAS 2010, Dr. Minarto mengungka-pkan status gizi di Indonesia, dengan prev-alensinya, stunting (35,6%), kurus (13,3%) dan obesitas (14,2%). “Kita sudah berhasil menurunkan prevalensi gizi kurang namun kita dihadapkan dengan isu stunting, gizi kurang dan kegemukan pada saat yang bersamaan dan ini merupakan tantangan kita bersama, baik pemerintah dan institusi

pendidikan lainnya.” Intervensi utama pembangunan gizi

memiliki 3 poin utama, yaitu 1. peruba-han perilaku (ASI eksklusif, MP-ASI, cuci tangan dengan sabun), 2. pemberian zat gizi mikro dan kecacingan, dan 3. makanan pendamping dan makanan pemulihan gizi buruk. Untuk poin ke-2, meliputi: zat gizi mikro bagi anak, seperti vitamin A, zink dan bubuk tabur gizi dan pemberian obat cacing; suplementasi gizi bagi ibu hamil seperti zat besi dan kapsul yodium (jika diperlukan); dan fortifikasi bagi masyarakat seperti garam beryodium dan fortifikasi besi pada bahan pangan pokok.

Nutrisi pada kankerHal yang harus diperhatikan pada pasien kanker umumnya adalah penurunan berat badan dan malnutrisi akibat anoreksia dan rendahnya asupan makanan.

Anoreksia, bila tidak diatasi dan ditan-gani dengan tepat akan menimbulkan kondisi yang lebih berat lagi, yaitu can-cer cachexia, yang merupakan salah satu faktor penting penyebab kematian pada pasien kanker.

Kebutuhan nutrisi pada pasien kanker harus disesuaikan dengan status nutrisi dan terapi pasien. Pada umumnya dianjur-kan meningkatkan asupan energi hingga 35 kkal/kg, protein 1,5-2,5 g/kg dan lemak kurang dari 30% dari total energi. Dan pasien kanker memerlukan suplementasi vitamin dan mineral. Hal ini dikemukakan oleh dr. Sri Sukmaniah, MSc, pada presentasinya berjudul ‘Specific Nutrients for Cancer’.

16 March 2012 Indonesia FocusNutrisi pada PPOK‘Nutrition in COPD’ menjadi topik beri-kutnya yang dipresentasikan Prof. dr. Wiwien H Wiyono, SpP(K). Masalah nutrisi perlu diperhitungkan menjadi sebagai salah satu komponen penatalaksanaan Penyakit Paru Obstruksi Kronik (PPOK) karena insiden malnutrisi sejalan dengan beratnya penyakit. Semakin berat malnu-trisi pada pasien maka semakin berat dera-jat penyakitnya.

“Malnutrisi menjadi salah satu faktor prog-nostik pada PPOK sehingga PPOK yang diser-tai dengan malnutrisi dan low free fat mass akan dapat meningkatkan mortalitas.”

Mekanisme malnutrisi pada PPOK, menu-rut Prof. Wiwien, adanya interaksi ketidakseim-bangan energi disertai dengan perubahan metabolisme, meningkatnya sitokin (akibat inflamasi sistemik), adanya hipoksia jaringan dan penggunaan kortikosteroid.

Malnutrisi yang terjadi bisa dipahami karena pasien mengalami gangguan dalam proses asupan makanan akibat sesak yang dialami. Sebaliknya kebutuhan energi dalam keadaan istirahat ternyata lebih tinggi

dibandingkan dengan orang normal dengan usia dan jenis kelamin yang sama. Malnutrisi ini dapat menimbulkan perubahan pada komposisi tubuh, sel parenkim paru, kapasi-tas fisik dan meningkatkan angka kesakitan dan kematian.

Bagaimana menyikapi malnutrisi ini? Dokter perlu mengukur indeks massa tubuh. Berkurangnya berat badan 10% dalam 6 bulan atau 5% dalam 1 bulan, hal ini menandakan terjadinya malnutrisi. Dengan menggunakan resting energy expenditure (REE) kebutuhan energi pasien lebih tinggi dan ditambahkan sekitar 10%. Dianjurkan dikalikan dengan 1,3 (REE x 1,3) yang digabung dengan pemberian tinggi protein dan karbohidrat. “Dengan ini, diharapkan dapat meningkatkan berat badan, kekuatan otot lengan atas dan meningkat-kan aktivitas fisik yang nantinya dapat men-ingkatkan kualitas hidup pasien,” tukas Prof. Wiwien. Rekomendasi pemberian kalori ter-diri dari karbohidrat (20%), lemak tak jenuh (20-40%), dan protein (40%) serta diberikan dalam porsi kecil namun sering. Selain itu, omega-3 dikatakan dapat menurunkan infla-masi dan produksi sitokin.

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17 March 2012 Indonesia Focus

Kursus Penyegar dan Penambah Ilmu Kedokteran (KPPIK)Jakarta, 17-18 Maret 2012Hotel Grand Sahid Jaya, JakartaSekr : Fakultas Kedokteran Universitas Indonesia Lt. 2, Jl. Salemba Raya No.6, JakartaTel : 021-3106737Fax : 021-3106443Email : kppik2012.cmefkui@ gmail.comWebsite : http://cmefkui.com, http://cme.fk.ui.ac.id

Post Satelite Meeting International Symposium On Atherosclerosis 2012 ’Atherosclerosis & Metabolic Syndrome in Managemernt of Cardiocerebrovasculer Disease’Bali, 30-31 Maret 2012Sanur Paradise Plaza Hotel, BaliSekr : Indonesia Cardiocerebrovascular SocietyTel : 021-31934636Fax : 021-3161467Email : [email protected] : www.postisa2012- bali.com

The 21st Annual Scientific Meeting of the Indonesian Heart Association (21st ASMIHA)Jakarta, 6-8 April 2012Hotel Ritz Carlton, JakartaSekr : PP PERKI, Wisma Harapan Kita Lt.2, Jl. Letjen S Parman Kav 87, JakartaTel : 021-5681149, 5684093 ext 1441 & 1440Fax : 021-5684220Email : [email protected]

Website : www.asmiha.org

7th SIOP Asia CongressYogyakarta, 21-24 April 2012Sekr : Subdivisi Hematologi dan Onkologi, Departemen Ilmu Kesehatan Anak, Fakultas Kedokteran, Universitas Gadjah Mada / Dr. Sardjito General Hospital Kesehatan St., Yogyakarta 55284, IndonesiaTel : 0274-553142Fax : 0274-583745E-mail : localcommittee@ siopasia2012.com, siopasia2012@yahoo. co.idwebsite : www.siopasia2012.com

Jakarta Antimicrobial Update 2012 (JADE 2012)Jakarta, 27-29 April 2012Hotel Sahid, JakartaSekr : Divisi Tropical dan infectious Disease, FKUI , RSCM, Jl. Salemba Raya No.6, JakartaTel : 021-3920185, 39801573, 925491, 3929106Fax : 021-3911873, 39921 06Email : [email protected]. dide, [email protected], loemni [email protected]

3rd National Symposium Cardiovascular AnesthesiaSemarang, 9-12 Mei 2012Hotel Gumaya Tower, SemarangSekr : PT. Ginong Prati Dina, Jl. Kebalen V No.24 A Kebayoran Baru, JakSel


Tel : 021-70602664,7246720, 7254424Fax : 021-7396261Email : gpd@gpdindonesia. com

PIR PDPIBandung, 11-13 Mei 2012Hotel Aston Primera Pasteur, BandungSekr : PT TrendMICE Jl Veteran No.40 BandungTel : 022-4215427Fax : 022-4215422Email : sekretariat.pdpijabar@ yahoo.com , trendmice@ cbn.net.id

American Thoracic Society International Conference 2012 (ATS 2012)San Fransisco, USA, 18-23 May 2012Tel : 212- 315 8652Email : conference@thoracic. orgWebsite : www.thoracic.org/go/ international-conference

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 & Clinical Respiratory Disease, Department of internal medicine, Department of pulmonology & respirastory medicine , Faculty of medicine, University of asanudin, 2nd Fl, Infection Center Bldg, RS dr. Wahidin Sudirohusodo, Jl. Perintis Kemerdekaan km.11 , Tamalanrea, Makassar 902145Tel / Fax : 0411-582002Email : konasperparimakasaar@ gmail.com

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 : konaspdpixiiisurabaya@ yahoo.co.idWebsite : 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_ [email protected]

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20 March 2012 NewsNon-drug approaches help alleviate cancer pain Elvira Manzano

Non-pharmacological, psychosocial interventions are a valid and effective

option for the treatment of pain in patients with cancer, according to a recently pub-lished meta-analysis.

“Pain is one of the most common, bur-densome and feared symptoms experi-enced by patients with cancer,” said Dr. Paul B. Jacobsen, lead study author and associate director for Moffit’s Division of Population Science, Tampa, Florida, US. “The positive findings from this meta-anal-ysis considerably advance support for the importance of psychosocial interventions in reducing pain in cancer patients.”

Jacobsen and colleagues analyzed 37 randomized controlled studies of psy-chosocial interventions involving a total of 4,199 adult patients with cancer. The studies were published between 1966 and 2010. [J Clin Oncol 2012. Jan 23. Epub ahead of print]

Across the studies, psychosocial interven-tions were found to provide weighted aver-aged effect sizes of 0.34 (95% CI 0.23-0.46; P<0.001) for pain severity and 0.40 (95% CI 0.21-0.60; P<0.001) for pain interference.

In interpreting their results, the authors concluded that such interventions pro-vided medium-sized effects in statistical terms, in terms of reducing pain severity and the degree to which pain related to cancer and its treatment interfered with patients’ lives.

They also revealed that skill-based approaches, for example relaxation and hypnosis, tended to be more effective

at reducing pain severity compared with educational approaches, such as teaching patients how to use their medications.

“Psychosocial interventions on the whole do work,” said Professor Cynthia Goh, senior consultant, department of pal-liative medicine, National Cancer Center Singapore. “The findings are relevant because the article looks at how good the evidence is for psychosocial interventions to alleviate cancer pain,” she said. “It is very important for patients to understand their pain and learn how to control it with the help of their doctors and therapists.”

Sometimes, a simple explanation repeated as necessary is enough to help a patient learn how to take their medicines for pain and for treatment of side effects, or how to avoid certain situations which

Relaxation and hypnosis reduce pain incancer patients.

21 March 2012 Newsmake the pain worse so they can feel they are in control, Goh explained. “But in some chronic pain situations, patients need more than explanations given at a medi-cal consultation. Sometimes, they need to go through certain kinds of training to help them think about their pain in a different way, or change their behavior which makes the pain worse.”

She said these kinds of training may be done in a group, or individually. “I have seen patients who have undergone cognitive behavior therapy and benefited from it.”

Other interventions include more con-tact with a nurse or a therapist for follow-up and education about their pain.

Goh said the study has been carefully

done and the information it provides is val-uable and adds to existing knowledge. “I think it is important that any interventions be properly evaluated through randomized controlled trials, and meta-analyses of such trials. But it is particularly important when it comes to psychosocial interventions, as there is less standardization of such inter-ventions, and many medical doctors, who are more used to prescribing drugs or doing operative procedures, are less con-vinced of their efficacy.”

Up to one-third of cancer patients suf-fer from moderate to severe pain which interferes with sleep, daily life activi-ties, enjoyment of life, work ability andsocial interactions.

Endometriosis increases risk of IBDRadha Chitale

An analysis of over 37,000 Danish women showed that inflamma-

tory bowel disease (IBD) is 50 percent more common among women with endometriosis.

Prior to this study, the potential risk relationship between IBD, which

encompasses Crohn’s disease [CD] and ulcerative colitis, and the inflammatory gynecological disorder had not been explored.

Researchers suggested that evident shared symptoms and localization may point to possible prognostic value.

Importantly, endometriosis and IBD

are sometimes used as differential diag-noses which could lead to a missed diagnosis.

“The two diseases (IBS, endometrio-sis) have been discussed as potentially differential diagnoses and have there-fore been described in case reports of one disease mimicking the other,” the researchers said. “An initial diagnostic

mistake between endometriosis and IBD is possible… However, the differential diagnostic problem [between atypical CD and endometriosis] does not explain the observed increased risk of IBD decades after a diagnosis of endometriosis.”

The analysis identified 320 women with IBD — 228 with ulcerative colitis

‘‘ Restricting analysis to women with surgically verified endometriosisresulted in even stronger risk associations

22 March 2012 News

The risk of developing IBD was 50 percent greater in women with endometriosis vs. the general population.

and 92 with CD – from a national regis-try of 37,661 Danish women hospitalized between 1977 and 2007. [Gut 2011 Dec 19. Epub ahead of print]

The women were monitored for a mean 13.1 years.

Based on these data, the risk of developing IBD was 50 percent greater in women with endometriosis com-pared to the general population. The risk of developing ulcerative colitis or CD increased 50 percent and 60 per-cent, respectively.

“Restricting analysis to women with surgically verified endometriosis resulted in even stronger risk associations,” the researchers said.

They acknowledged that the cohort was biased against women who were diagnosed in an ambulatory care setting as opposed to a hospital or outpatient clinic.

“However, surgically verified endome-triosis represents the most valid diagno-sis, and such cases were all included in this study,” the researchers said.

Endometriosis involves endometrial cells implanting outside the uterus with-out being cleared by the immune sys-tem. The condition can affect up to 10 percent of reproductive-age women and often presents as raised cytokine levels, decreased cell death and B- and T-cell abnormalities similar to those observed in autoimmune diseases.

Endometriosis is caused by retrograde menstruation, which is thought to be more common in women with impaired immune systems.

In addition to underlying autoimmuno-logical similarities between endometrio-sis and IBD, the researchers suggested

that oral contraceptives used to treat endometriosis may increase the risk of developing IBD.

One possibility would be to treat endometriosis as an autoimmune dis-ease similar to the way in which IBD and rheumatoid arthritis are already treated, to avoid further disease progression with oral contraceptives in women with both diseases.

“It is also of both immunological and clinical interest to know whether patients with IBD with endometriosis have a dif-ferent prognosis from that of other IBD patients,” which warrants further study, the researchers concluded.

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24 March 2012 NewsCoffee may reduce fibrosis risk in patients with NASHElvira Manzano

Increased intake of coffee may hold the key to decreasing the risk of advanced

fibrosis – scarring – in people with fatty liver disease, research suggests.

In a study of 306 patients with nonal-coholic steatohepatitis (NASH), high con-sumption of coffee significantly decreased the formation of excess fibrous connec-tive tissue in their liver. [Hepatology 2012; 55(2):429-36. doi: 10.1002/hep.24731]

“Our study is the first to demonstrate a histopathologic correlation between fatty liver disease and estimated coffee intake,” said study author Dr. Stephen Harrison, lieutenant colonel in the US Army based at Brooke Army Medical Center in Fort Sam Houston, Texas, US. “Moderate coffee con-sumption may be a benign adjunct to the comprehensive management of patients with NASH.”

Harrison and his team studied the cof-fee consumption of participants from a previous non-alcoholic fatty liver disease (NAFLD) study and NASH patients treated at the center’s clinic and categorized them into four groups – patients with no sign of fibrosis (controls), steatosis, NASH stage 0-1, and NASH stage 2-4.

There was a significant difference in the caffeine consumption of patients with stea-tosis compared to patients with NASH stage 0-1 (P=0.005). Additionally, coffee consump-tion was significantly greater in patients with NASH stage 0-1 than with NASH stage 2-4 (58 percent versus 36 percent of caf-feine intake from regular coffee, P=0.016).

“There was a stepwise decrease in cof-fee consumption as fibrosis increase,” Harrison explained. “This would suggest that other properties of coffee beyond caffeine may affect disease progression in NASH patients.”

Caffeine intake has long been associated with a reduced risk of hepatocellular car-cinoma, and reduced fibrosis and cirrhosis in patients with chronic liver diseases such as hepatitis C. [Hepatology 2009;50:1360; Hepatology 2010;51:201]

It has also recently been suggested that coffee may protect against diabetes and endometrial cancer.

“Knowing the beneficial effects of coffee intake on liver diseases, future prospec-tive research should examine the amount of coffee intake on clinical outcomes,” Harrison concluded.

Commenting on the study, Dr. Vincent Wong, professor, department of medicine and therapeutics director, Center for Liver Health, The Chinese University of Hong Kong said the current paper “adds to the existing literature showing that the same phenom-enon is observed in NAFLD patients.

“The study has a relatively large sample size. The existing literature is rather con-sistent on the association between coffee intake and liver injury. However, limited by the nature of observational studies, causal relationship is difficult to estab-lish,” he said. “For example, instead of direct causal effect, coffee intake may be associated with less liver fibrosis through differences in smoking, alcohol use and physical activity.”

Elvira Manzano

Frequent intake of dairy food – an important step to building strong bones and

preventing osteoporosis – also enhances cognitive functioning, recent research has shown.

A cross-sectional meta-analy-sis of the dietary habits and men-tal functioning of 972 adults in the US has found that individuals who

consumed dairy products once a day had significantly higher scores in memory and other cog-nitive tests compared with those who never or rarely consumed dairy food. Individuals with high milk consumption were also five times less likely to fail the tests compared with non-milk drinkers. [International Dairy Journal 2011.DOI:10.1016/j.idairyj.2011.08.001]

While little is known about the

underlying mechanisms of dairy’s benefits on cognitive functioning, the authors said its unique nutri-ent content might play a role.

“Dairy foods contain a num-ber of important nutrients such as calcium, whey protein, vitamin D, magnesium and phosphorus,” said lead researcher Ms Georgina Crichton, from the Nutritional Physiology Research Centre, Uni-versity of South Australia, Ad-

elaide, Australia. Adult subjects aged 23 to 98

who were included in a commu-nity-based study of cardiovas-cular disease (CVD) risk factors and cognitive functioning were put through a series of brain and cognitive challenges to assess their visual-spatial, verbal and working memory, scanning track-ing and executive function. Those who scored the highest across all

tests consumed the most milk and dairy products, the study found.

Cognitive performance scores increased linearly across increas-ing categorical levels of dairy food intake for 7 out of 8 outcome mea-sures. Milk drinkers also main-tained healthier diets overall com-pared to non-drinkers.

“Frequent dairy food intake was associated with better cogni-tive performance across a range of cognitive domains in this de-mentia-free, community dwelling population,” the authors said. The association between greater dairy food intake and better cognitive performance remained significant even after adjusting for several cardiovascular risk factors such as CVD prevalence, hypertension and wait circumference.

While the authors said the study has a number of strengths, including large community sam-ple, longitudinal studies are still needed to improve understanding of the association between dairy intake and cognitive function.

“As brain disorders are most likely to impact upon more than a single cognitive ability or behav-ior, cognitive function needs to be assessed with a thorough neuro-psychological test measuring a range of cognitive abilities.”

Frequent intake of dairy prod-ucts such as milk, cheese and yoghurt has also been shown to help reduce weight and control blood pressure and diabetes, all of which are risk factors for CVD that increase the likelihood of cog-nitive dysfunction.

Dairy foods

contain a number

of important

nutrients such as

calcium, whey

protein, vitamin D,

magnesium

and phosphorus

‘‘

Daily milk boosts brain power

Subjects who consumed dairy products every day scored better in cognitive tests.

NewsMarch 201208

26 March 2012 NewsTai chi improves balance, reduces falls in Parkinson’sRadha Chitale

Tai chi exercises proved better at improv-ing balance and reducing the risk of

falls among adults with Parkinson’s disease compared with strength training or simple stretching, according to a study.

“Physical activity has been shown to retard the deterioration of motor functions and to prolong functional independence,” the study authors said.

Patients with the neurodegenerative disease are left with impaired balance, less stability, gait dysfunction, poorer quality of life due to reduced functional abilities and an increased risk of falls.

These symptoms are largely unaffected by drug therapy and exercise is recom-mended. However, the researchers note that resistance training, which has been shown to address balance and strength def-icits, requires monitoring and equipment.

“We hypothesized that tai chi would be more effective in improving postural stabil-ity in limits-of-stability tasks than a resist-ance-based exercise regime or low impact stretching,” they said.

A group of 195 patients with mild-to-moderate Parkinson’s disease were ran-domly assigned to receive twice-weekly 60-minute sessions of tai chi, resistance training or stretching (control) for 24 weeks. [N Engl J Med 2012;366:511-9]

The tai chi protocol was designed to tax balance and gait by focusing on symmetric and diagonal movement, weight shifting, controlled center of gravity displacement, ankle sways, and anterior-posterior and

lateral stepping. Resistance training focused on the mus-

cles important for posture, balance and gait, including squats, lunges and heel and toe raises, using weighted vests and ankle weights.

Seated and standing stretches for the upper body and legs provided a low inten-sity control group.

Tai chi patients performed better than the resistance and stretching groups in the primary outcome measures testing the limits-of-stability, which assesses how far patients can lean in a number of directions without falling, and at directional control, which measures movement accuracy.

There were 381 falls in 76 patients overall but the incidence rate was 67 per-cent lower for the tai chi group compared with the stretching group (0.22 vs 0.33, P=0.005). Tai chi patients experienced marginally fewer falls than the resistance training group, whose incidence rate was 0.47, but this was not significant (P=0.05).

Tai chi patients performed better in all secondary outcome measures compared with the stretching group, including gait, knee movement, functional reach, and time to stand from sitting. They performed better than the resistance group at stride length and functional reach.

The effects were maintained 3 months after completing intervention.

The trial did not measure the net gain of tai chi exercise but only as compared to low intensity, low impact stretching regimes.

“Clinically, these changes indi-cate increased potential for effectively

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b Efficacy of this alternative regimen has been demonstrated for infections caused by S. pneumoniae (excluding MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniaeand Chlamydia pneumoniae.c Where Pseudomonas aeruginosa is a documented or presumptive pathogen, combination therapy with an antipseudomonal β-lactam is recommended.

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28 March 2012 Newsperforming daily life functions, such as reaching forward to take objects from a cabinet, transitioning from a seated to a

standing position (and from standing to seated), and walking, while reducing the probability of falls,” the researchers said.

Daily milk boosts brain powerElvira Manzano

Frequent intake of dairy food – an important step to building strong bones and prevent-

ing osteoporosis – also enhances cognitive functioning, recent research has shown.

A cross-sectional meta-analysis of the dietary habits and mental functioning of 972 adults in the US has found that indi-viduals who consumed dairy products once a day had significantly higher scores in memory and other cognitive tests com-pared with those who never or rarely con-sumed dairy food. Individuals with high milk consumption were also five times less likely to fail the tests compared with non-milk drinkers. [International Dairy Journal 2011.DOI:10.1016/j.idairyj.2011.08.001]

While little is known about the under-lying mechanisms of dairy’s benefits on cognitive functioning, the authors said its unique nutrient content might play a role.

“Dairy foods contain a number of important nutrients such as calcium, whey protein, vitamin D, magnesium and phos-phorus,” said lead researcher Ms Georgina Crichton, from the Nutritional Physiology Research Centre, University of South Australia, Adelaide, Australia.

Adult subjects aged 23 to 98 who were included in a community-based study of cardiovascular disease (CVD) risk factors and cognitive functioning were put through a series of brain and cognitive challenges to assess their visual-spatial, verbal and

working memory, scanning tracking and executive function. Those who scored the highest across all tests consumed the most milk and dairy products, the study found.

Cognitive performance scores increased linearly across increasing categorical levels of dairy food intake for 7 out of 8 outcome meas-ures. Milk drinkers also maintained healthier diets overall compared to non-drinkers.

“Frequent dairy food intake was associ-ated with better cognitive performance across a range of cognitive domains in this dementia-free, community dwelling popu-lation,” the authors said. The association between greater dairy food intake and better cognitive performance remained significant even after adjusting for several cardiovas-cular risk factors such as CVD prevalence, hypertension and wait circumference.

While the authors said the study has a num-ber of strengths, including large community sample, longitudinal studies are still needed to improve understanding of the association between dairy intake and cognitive function.

“As brain disorders are most likely to impact upon more than a single cognitive ability or behavior, cognitive function needs to be assessed with a thorough neuro-psychological test measuring a range of cognitive abilities.”

Frequent intake of dairy products such as milk, cheese and yoghurt has also been shown to help reduce weight and con-trol blood pressure and diabetes, all of which are risk factors for CVD that increase the likelihood of cognitive dysfunction.

29 March 2012 NewsMortality predictors not ready for clinical useRadha Chitale

Despite the existence of a variety of prognostic indices to determine the

risk of death among older adults, research-ers who reviewed them cited insufficient evidence for use of these tools in wide-spread clinical practice.

“By our measures, no study was com-pletely free from potential sources of bias… even if [data] quality barriers are overcome, important limitations remain,” they said.

The survey included 16 validated indi-ces that predicted the absolute risk of all-cause mortality in patients whose average age was 60 or older. The clinical settings included hospitals, nursing homes and com-munities but excluded indices estimated from cohorts in intensive care units, those that were disease specific and those that were in-hospital. [JAMA 2012;307:182-192]

The greatest challenge for such indices, the researchers noted, was the inability to account for all factors that can affect survival. Key factors such as comorbid conditions, genetics and social supports are omitted.

Less common comorbid conditions, such as Parkinson’s disease or dementia, tended not to be included in the indices.

The indices did not account for genetics in life span and did not include relevant infor-mation on parent or sibling ages of death.

Conversely, protective factors such as social supports and community involve-ment were also not considered.

The researchers said the purpose of prognostic indices is to allow clinicians to shift to more sophisticated clinical decision making when treating older adults rather

than falling to arbitrary age-based cutoffs. However, only very high or very low mortal-ity risk is likely to influence clinical decisions.

“There may be a limited role for the high-est-quality indices in the right settings,” the researchers said. “If patient character-istics align closely with those of the devel-opment or validation cohorts, clinicians may find prognostic information useful to help inform, though not replace, their clini-cal judgment. Prediction rules have been shown to outperform clinicians in terms of prognostication, whereas human predic-tion on its own is fraught with bias.”

However, only three indices predicted greater than an 80 percent risk of mortal-ity in the highest risk group.

In an accompanying editorial, Dr. Thomas Gill, of the Yale School of Medicine, New Haven, Connecticut, US, was not opti-mistic about the potential for mortality-based indices, because of the burden of meticulous data collection in order to achieve an accurate assessment. [JAMA 2012;307:199-200]

“Given the central role of prognosis in clinical decision making, waiting for the ideal index to be developed, validated, and rigor-ously tested would not be prudent,” he said.

The best predictors of mortality in older people are comorbidities and func-tional status.

Instead of mortality, Gill suggested focus-ing on predicting life expectancy.

“A preferred alternative is a single [devel-oped and validated] prognostic index (or perhaps a small number of indices) based on estimated life expectancy, a metric that is familiar to both physicians and patients.”

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31 March 2012 NewsPhysical activity lowers CV risk, better in moderation? Elvira Manzano

Mild-to-moderate levels of exercise may be more beneficial than strenu-

ous exercise when it comes to preventing heart attack in the long term, according to a recent study.

Researchers analyzed data from INTERHEART – a long-running case-control study on heart attacks involving 24,000 patients from 52 countries in Asia, Europe, the Middle East, Africa, Australia and North and South America – and found that only mild-to-moderate physical activity at work was protective against MI. [Eur Heart J 2012; DOI:10.1093/eurheartj/ehr432]

However, all levels of intensity of exer-cise during leisure time reduced the risk of heart attack. The odds of acute MI were lower with mild exercise (OR 0.87) and moderate to strenuous exercise (OR 0.76). The risk was even lower in patients who exercised 30 minutes or less a week. Surprisingly, no further risk reduction was seen in patients who exercised more than 60 minutes a week.

“Given previous reports indicating a dose-response protective effect of exercise duration, this result was somewhat unex-pected,” said lead author Dr. Claes Held from Uppsala Clinical Research Center, in Uppsala, Sweden.

For occupational activity, both light and moderate activities were associated with decreased odds of acute MI compared with being sedentary (ORs 0.78 and 0.89, respectively). However, heavy physical labor (OR 1.02) did not lower the risk of

heart attack. Held and colleagues included in the

study 10,043 individuals who had an MI and 14,217 controls. Compared to controls, individuals who had an acute MI were more likely to be sedentary during leisure time and at work (P<0.001 for both). Sedentary lifestyle was associated with greater risk of MI after adjusting for age, sex, country level income, smoking, alcohol, education, hypertension, diabetes and other factors.

Interestingly, people who owned a car and a television were at greater risk of MI than those who had none of these machines (P=0.054). While Held acknowl-edged that a TV and a car increase physi-cal inactivity, he said a prospective trial is needed to validate their study.

The authors said their findings highlight the protective effect of physical activity across all country income levels in addition to the known benefits of modifying tradi-tional risk factors.

“It’s an interesting finding that goes with the theme… Daily moderate physi-cal activity should be encouraged for both men and women of all ages as a protec-tive act against cardiovascular disease,” the authors said. “Walking and bicycling is recommended as a method to promote physical activity.”

They attributed the increase in seden-tary lifestyle to increasing urbanization, mechanization at work, motorized trans-portation, easy access to activity-limiting devices (cars, escalators, elevators) and appliances (TV, computers), which all pro-mote sedentary behavior.

33 March 2012 Conference Coverage53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011,San Diego, California, US

Optimizing treatment for H. pylori infectionsLeonard Yap

Selecting better antibiotic therapy strat-egies for Helicobacter pylori infections

and educating patients about compliance with their medications is the best way to avoid antibiotic resistance, says an expert.

Using a combination of antibiotics with the right duration of therapy, in addi-tion to improving patient compliance to these medications, will prevent H. pylori resistance to antibiotics, said Dr. Francis Megraud, professor of bacteriology, University Victor Segalen Bordeaux 2 and head of the National Reference Center for Helicobacters, France. Currently, clarithromycin is a commonly used anti-biotic for H. pylori infections, but “the burden of clarithromycin resistance is steadily increasing.”

Resistance of H. pylori to metronidazole and clarithromycin has been reported, with metronidazole resistance being very com-mon. This has an important clinical impact on dual antibiotic therapies and standard triple therapies, which include the use of a

proton pump inhibitor (PPI) and two anti-biotics. When PPI-based triple therapies with amoxicillin or clarithromycin and met-ronidazole are used, the resistance could be overcome in up to 75 percent of cases. [Gut 1998;43 (suppl 1):S61-5]

“Several factors influence eradication failure. Obviously, if you don’t take the drug, [there is] lack of compliance [result-ing in a decrease in the eradication rate], and, if you have [high] gastric acidity, especially if you are an extensive metabo-lizer of PPI, you decrease your eradication rate. It has also been shown that when you have a high bacterial load you are less likely to eliminate the bacteria – pos-sibly, the presence of intracellular bacte-ria or the impact of altered immunity [can decrease the eradication rate of H pylori],” Megraud said.

The Second Asia-Pacific Consensus Conference was convened to review cur-rent information on H. pylori management and a set of updated consensus state-ments was issued. (Box 1) [J Gastroenterol Hepatol 2009;24:1587-600].

• In Asia, the currently recommended first-line therapy for H. pylori infection is PPI, amoxi-cillin and clarithromycin for 7 days.

• There is an increasing rate of resistance to clarithromycin and metronidazole in parts of Asia. This has led to reduced efficacy of PPI-based triple therapy.

• Fourteen-day triple therapy confers limited advantage over 7-day triple therapy in H. pylori eradication rates.

Box 1: Consensus statements on H. pylori management.


• Bismuth-based quadruple therapy is an effective alternative to first-line therapy for H. pylori eradication.

• There are currently insufficient data to recommend sequential therapy as an alternative first-line for H. pylori therapy in Asia.

• Salvage therapy for H. pylori eradication includes: (i) a standard triple therapy that has not been previously used; (ii) bismuth-based quadruple therapy; (iii) levofloxacin-based triple therapy; and (iv) rifabutin-based triple therapy.

• CYP2C19 polymorphisms may affect H. pylori eradication rates in PPI-based triple ther-apy. Choice of PPI or increasing the dose is a more practical approach than CYP2C19 genotyping in the clinical setting to overcome CYP2C19 polymorphisms in the context of salvage therapy.

• Smoking adversely affects the outcome of H. pylori eradication therapy.

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Liver enzyme polymorphisms may affect drug responseLeonard Yap

Cytochrome P450 2C19 (CYP2C19) poly-morphisms may play a significant role

in the success or failure of treatments for Helicobacter pylori, say a panel of experts.

CYP2C19 polymorphisms have been known to affect the metabolism of certain types of pharmaceuticals, said Associate Professor Varocha Mahachai, Division of Gastroenterology, Chulalongkorn University, Bangkok, Thailand.

This is particularly true of proton pump inhibitors (PPI), which are commonly used to control gastric acidity in H. pylori infec-

tions. Patients who have the ‘extensive metabolizer’ polymorphism tend to have poor control of gastric acid as they metabo-lize the drug too quickly before the PPI can do its job, she said. [Aliment Pharmacol Ther 1999;13 Suppl 3:27-36]

Professor Fock Kwong-Ming, of the Faculty of Medicine, National University of Singapore and senior consultant gas-troenterologist at Changi General Hospital said, “CYP2C19 polymorphisms may affect H. pylori eradication with standard triple therapy. The way to overcome this effect is to increase the dose of the PPI or change to a PPI that is less affected by CYP2C19.

“Three studies, one from Japan, one from Taiwan and one from Korea, show that the CYP2C19 [polymorphisms] were a factor [in H. pylori eradication].”

PPIs such as omeprazole and lansopra-zole are mainly metabolized by CYP2C19 in the liver. There are three types of CYP2C19 polymorphisms: extensive, intermediate and poor metabolizer. Extensive metabo-lizers are typically less responsive as they metabolize PPIs much faster than the inter-mediate and poor metabolizer. Therefore, eradication rates for H. pylori are typically lower for extensive metabolizers. [Clin Pharmacol Ther 2001;69(3):158-68]

The Second Asia-Pacific Consensus Guidelines for H. pylori infection includes this statement: “CYP2C19 polymorphisms may affect H. pylori eradication rates in PPI-based triple therapy. Choice of PPI or increasing the dose is a more practi-cal approach than CYP2C19 genotyping in the clinical setting to overcome CYP2C19 polymorphisms in the context of sal-vage therapy*.” [J Gastroenterol Hepatol 2009;24:1587-600]

*Salvage therapy: therapy after multiple (at least two) treatment failures with different regimens.

CYP2C19 polymorphisms may affect H. pylori eradication with standard triple therapy. The way to overcome this effect is to increase the

dose of the PPI or change to a PPI that is less affected by CYP2C19‘‘

‘‘

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H. pylori eradication alters appetite hormone levels

Malvinderjit Kaur Dhillon

A change in Helicobacter pylori coloni-zation status can potentially induce

changes in ghrelin and leptin levels, thus influencing metabolic status and body weight, says an expert.

Dr. Fritz Francois, a gastroenterolo-gist at the New York University Langone Medical Centre, New York, US, said, “Our group began to look at the functional ele-ments of the gut as they relate to satiety hormones, and we focused on two in par-ticular: leptin (an anorectic peptide which signals you when you have had enough to eat and, in fact, has a very strong anorec-tic effect) and ghrelin, perhaps one of the only known orexigenic peptides, one that stimulates appetite.”

“We are looking at the issue not only from the perspective of what is going on in H. pylori positive and negative [subjects], but also the impact of eradication on a meal. Ultimately, what you really want to know is the change – when you give some-body a meal, when somebody eats, what happens to these particular hormones before and after?” he added.

The study by Fritz and his team involved a group that were primarily male and in their 60s. Blood was drawn at baseline and the subjects were fed a standardized meal. Blood was drawn an hour later and under-went eradication of H. pylori. The proce-dure was repeated after 6 weeks.

“There is a drop in ghrelin levels

post-meal, which is exactly what you would expect. After the eradication treatment, ghrelin levels are higher pre-meal com-pared to the pre-eradication group. Compared to the post-meal levels, there isn’t a drop that you would expect. As for leptin, we found an increase in leptin levels in both instances,” he said.

Fritz and his group also looked at body mass index (BMI) changes of these patients over a span of 18 months and found a positive co-relation between fasting ghre-lin and change in BMI. As ghrelin levels increased with eradication, BMI levels also increased. [BMC Gastro 2011;11:37]

Varying studies demonstrated different effectsof H. pylori eradication on preprandial andpostprandial ghrelin and leptin levels.

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SG-DEC-2011

39 March 2012 In Pract iceAdvancements in the management ofanal fistulasAnal fistula is usually the result of a chronic infection in select individuals who happen to have intra-sphincteric or extrasphincteric glands. In this article, Drs. Koh Poh Koon, Fran-cis Seow-Choen, Lim Jit Fong and Ho Kok Sun, colorectal surgeons at the Novena Colorec-tal Centre in Singapore, elucidate on the cause of this painful condition and review latest advancements in its clinical management.

IntroductionMost cases of anal fistula are a result of a chronic infection of an anal crypt gland or so called cryptoglandular infection.1-3 These infections can only occur in people with intra-sphincteric or extrasphincteric anal glands and therefore not everyone can develop anal fistula as most people only have anal glands in the intramucosal plane.4 The worldwide incidence of anal fistula is estimated to be about 9 cases per 100,000 people.5

The condition usually starts as an infec-tion or abscess at the anal region, char-acterized by a redness and swelling with throbbing pain and sometimes fever.4 When the pus drains externally, a small channel between the anal canal and the skin near the anus is formed. The exter-nal end of a fistula then appears as a hole on the skin from which pus, blood or stool may discharge.

Repeated unsuccessful attempts by the body to heal may lead to a hard nodule at the external opening that occasionally

closes up, causing debris entering the internal opening to be trapped in the tract and setting up recurrent episodes of peri-anal sepsis.5

Anal fistulae are classified as simple or complex, or according to their anat-omy— inter-sphincteric, trans-sphincteric, supra-sphincteric or extra-sphincteric. Trans-sphincteric and ‘high’ fistulas are more likely to occur in females, and in patients with pre-vious perianal sepsis or surgery for fistula. External openings close to the posterior mid-line almost always underlie simple fistulas, whereas postero-lateral external openings are predictive of complex fistulas.1

Cryptoglandular anal fistula are not associated with infection by extraordinary organisms.6 Nearly twice as common in men than in women, an anal fistula can also be caused by inflammatory bowel disease such as Crohn’s disease or specific infec-tion, for example in tuberculous fistula. People with HIV are also at increased risk of developing the condition. Other spe-cific causes include birth related injuries

Dr. Koh Dr. Seow-Choen Dr. Lim Dr. Ho

40 March 2012 In Pract icewith ano-vaginal fistula and prostatic and urethral injuries leading to ano-urethral and ano-prostatic fistulas. These fistulas are normally not considered together with cryptoglandular anal fistula.

DiagnosisFor effective treatment of a cryptoglandu-lar anal fistula, the following information must be ascertained:

1. The presence of a specific cause for the fistula

2. The location of the internal opening and its relation to the dentate line

3. The morphology of the tract and the amount of anal sphincter muscles involved

4. The presence of any other secondary tracts

Treatment of specific fistulasThe exclusion of a specific cause for the anal fistula like tuberculosis is important as the specific treatment of these causa-tive factors will cure the fistula without need for surgery. Similarly ano-vaginal or ano-urethral fistula should be treated spe-cifically if healing is to ensue.

While the external opening of the chan-nel is clearly visible, finding the internal opening can be more challenging. The anatomy of a simple tract is usually easily defined by an examination under anesthe-sia and using the following instruments:

• Fistula probe — An instrument spe-cially designed to be inserted through a fistula. The most efficacious and commonly used around the world is the Lockhart-Mummery fistula probe.

State-of-the-art clinic equipped with the latest technologies for the management of patients with anal fistulas.

41 March 2012 In Pract iceThis is a series of about four probes with various angles of the probe head enabling the surgeon to probe tracts of varying complexities.

• Anoscope — To view the anal canal.• Surgeon’s digit — Many doctors for-

get that one of the best methods to determine the anatomy of any anal fistula is the well trained index finger of the surgeon. Bi-digital palpation with the thumb outside and the index inside the anus is important for accu-rate understanding of the patho-anat-omy of the fistula. The relationship of the fistula to the sphincters and the direction and presence of any second-ary tracts can be assessed as well with the well trained finger.7

For more complicated fistulae, visualiza-tion of the tract morphology can be com-plemented by the use of:

• Diluted methylene blue dye — Dye is injected into the fistula in an operat-ing room. Whilst methylene blue may be used by some surgeons, we do not normally recommend it as it some-times stains normal tissues making identification of tracts from normal tissues even more difficult.1

• Fistulography — Injection of a contrast solution into a fistula followed by an X-ray of the affected area. This sort of radiological examination is favored by some surgeons but we have not found it useful as the tracts seen on radio-graphs are not easily translated into the anatomy seen during surgery.

• Magnetic resonance imaging (MRI) — This examination is often reserved for the most complex fistulae and expert radiological interpretation can often give a good idea of the complexity of

tracts that are present. However the problem again is similar to that of translating those radiological inter-pretations into useable information at surgery.

• Endoanal ultrasound – A useful tool for surgeons who need a simple and inex-pensive method of confirming what his skilled fingers are already telling him regarding the anatomy of the complex fistulas.7 Endoanal ultrasound is also good for assessment of anal sphincter function before surgery both to deter-mine anal function adequacy and for medico-legal protection.

Treatment optionsCryptoglandular fistulas are treated surgi-cally. Specific fistulas may require specified treatment, for example tuberculous fistula or Crohn’s fistula. Simple fistulas may be treated by fistulotomy or simple lay open, but complex or high fistulas that may implicate a significant amount of sphinc-ter muscles require careful evaluation and more complex surgical procedures. In all instances, the objective should be to eradi-cate the fistula without compromising fecal continence. Important considerations include the complexity of the fistula and the strength of the anal sphincter muscle. Acute perianal abscesses should be laid open as soon as practicable and if a fistula is present this should be laid open if the internal opening is easily found.8-11

Fistulotomy is a common surgical proce-dure in which the surgeon cuts open the whole length of the fistula, from the inter-nal opening to the external opening and drains out all the contents. Curettage of all granulation tissue is important to allow the wound to heal. This then heals into a

42 March 2012 In Pract iceflat scar. Fistulotomy essentially opens a “tube” into a “ravine” which then fills up in time to heal. For simple low-lying fistu-lae, this is often all that is sufficient. Long tracts heal faster when the wound edges are marsupialized.12

For more complex fistulae or fistulae with a very high internal opening, the fol-lowing options may be employed:

A fistuloscope for video-assisted anal fistula treatment (VAAFT)

Cutting/Loose Seton Techniques: In the loose seton technique, the surgeon uses a surgical suture called a seton to help drain the fistula and further establish the tract. This seton can be left in situ as long as drain-age is good and the patient is happy with-out acute flare-ups or abscess recurrence. Cutting or tight setons are setons that are tightened around the anal muscles and inserted into fistula tracts in an attempt to force the seton to cheesewire out and result in a high tract moving progressively lower with each tightening. Setons can be difficult to manage and both tight setons and ayurvedic medicated setons can be very painful.13-16

Fibrin glue: This is a less invasive surgical option where the surgeon uses fibrin glue, made of plasma protein, to plug the cav-ity and seal the fistula. The fibrin plug then

promotes ingrowth of tissue to obliterate the tract. Whilst initial results were promis-ing, this technique has fallen out of general favor due to a very high recurrence rate.

Anal fistula plug: As the name suggests, the technique uses a collagen tissue to plug the fistula and acts as a scaffold to promote healing. Initial reports of 80 per-cent success rates have not been repeated by other investigators and this technique might be useful only in simple tracts with-out side tracts or secondary extensions.

Advancement Flap Procedure: The inter-nal opening of the tract is excised and a flap of the rectal mucosa or better still mucosa plus rectal muscle wall is elevated and used to close the internal opening. The external tract is curetted and allowed to drain through the external opening. This method is used frequently for high tracts as it results in better results than using either anal fistula plug or fibrin glue. Flaps may be advanced outwards or inwards but length should not exceed width by more than twice the distance. However failure is not infrequent and may result in a bigger defect than was present originally.

LIFT Procedure: Ligation of Inter-Sphincteric Fistula Tract (LIFT) involves the careful delineation of the anatomy of the fistula tract using injections and probes and the isolation of the tract as it traverses within the inter-sphincteric space. The por-tion of the tract within the intersphincteric space is then ligated and excised, discon-necting the tract from the internal opening. The internal opening is ligated closed and therefore does not allow further ingress of faecal matter therefore allowing healing to progress. This leaves behind the exter-nal opening to drain and gradually heal over time. However there is a significant

43 March 2012 In Pract icewound in the inter-sphincteric space that sometimes causes problems with healing although most cases heal well.

VAAFT: A new technique, video-assisted anal fistula treatment (VAAFT) is a mini-mally invasive and sphincter-saving tech-nique for treating complex fistulas. The main feature of this technique is the ability to view the fistula from the inside of the tract so that it can be eradicated under direct vision using a fistuloscope.

The procedure allows for accurate iden-tification of the internal opening and the secondary tracts or abscess cavities with formal closure of the internal opening. It obviates the need for blind probing of the tract and minimizes the risk of iatrogenic creation of false tracts. Because it affords direct visualization of the tract anatomy, there is no longer any need for expensive imaging using MRI. This technique com-prises diagnostic and operative phases and is performed as a day surgery under regional or general anaesthesia.

ConclusionAbscess management is fairly straightfor-ward with incision and drainage being the hallmark of therapy. But the management of fistula itself is much more complicated. It requires striking a balance between rates of healing and potential alteration of fecal continence. Up to 20 percent of patients may develop some level of incontinence after fistula surgery using the traditional techniques. This can potentially be vastly reduced with the use of novel VAAFT tech-nique which does not sacrifice sphincter muscle integrity.

Although no single technique is appropriate for all patients and all fistula types, appropriate selection

of patients and choice of repair tech-nique should yield higher success rates with lower associated morbidity.

References

1. Br J Surg 1992;79:197-205

2. Br J Surg 1993;80:1627

3. Sem Colon Rectal Surg 1999;9:157

4. Dis Colon Rectum 1994;37:1215-8

5. Chapter In: Anal Fistula. Chapman and Hall. 1996

6. Br J Surg 1992;79:27-8

7. Br J Surg 1991;78:445-7

8. Aust NZ J Surg 1993;63:485-9

9. Dis Colon Rectum 1996;39:1415-7

10. Dis Colon Rectum 1997;40:1130-31

11. Dis Colon Rectum 1997;40:1435-1438

12. Br J Surg 1997:105–107

13. Br J Surg 1994;81:1214

14. Br J Surg 1995;82:426

15. Tech Coloproctol 2001;5:137-141

16. Colorectal Disease 2003;5:373

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45 March 2012 CalendarMarch68th Annual Meeting of the American Academy of Allergy, Asthma and Immunology 2/3/2012 to 6/3/2012Location: Orlando, Florida, US Info: American Academy of Allergy, Asthma and Immunology Tel: (1) 414-272-6071Email: [email protected] Website: www.aaaai.org

2012 Highlights of ASH® in Asia3/3/2012 to 4/3/2012Location: Singapore Info: ASH Customer Relations DepartmentTel: (1) 202-776-0544Email: [email protected] Website: www.hematology.org/Meetings/Highlights/6836.aspx

20th Annual Meeting of the Asian Soci-ety for Cardiothoracic Surgery 8/3/2012 to 11/3/2012Location: Bali, Indonesia Info: Asian Society for Cardiothoracic Surgery Tel: (1) 62-21-566-5993 Email: [email protected] Website: www.ascvtsbali2012.org

61st American College of Cardiology Annual Scientific Session 24/3/2012 to 27/3/2012Location: Chicago, Illinois, US Info: American College of Cardiology Tel: (1) 202 375-6000

Email: [email protected] Website: www.acc.org

15th World Congress of Anesthesiologists 25/3/2012 to 30/3/2012Location: Buenos Aires, Argentina Info: WF SA World Congress of Anesthesiologists Email: [email protected] Website: www.wca2012.com

9th European Congress on Menopause 28/3/2012 to 31/3/2012Location: Athens, Greece Info: European Menopause and Andro-pause Society Email: [email protected] Website: www2.kenes.com/emas/pages/default.aspx

AprilWorld Congress of Cardiology Scientific Sessions18/4/2012 to 21/4/2012Location: Dubai, UAEInfo: World Congress of Cardiology Email: [email protected] Website: www.world-heart-federation.org

24th European Congress of Ultrasound in Medicine and Biology22/4/2012 to 24/4/2012Location: Madrid, Spain Tel: (34) 913 61 2600

46 March 2012 CalendarFax: (34) 913 55 9208Email: [email protected] Website: www.euroson2012.com III NWAC World Anesthesia Convention (NWAC 2012)24/4/2012 to 28/4/2012Location: Istanbul, TurkeyTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected] Website: www.nwac.org

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

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

Upcoming

2012 American Society of Clinical Oncol-ogy Annual Meeting01/6/2012 to 05/6/2012Location: Chicago, Illinois, US Tel: (571) 483 1300Email: [email protected] Website: chicago2012.asco.org

10th Royal College of Obstetricians and Gynecologists International Scientific Congress05/6/2012 to 08/6/2012Location: Kuching, Malaysia Tel: (603) 6201 1858Email: [email protected] Website: www.rcog2012.com

15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012)03/10/2012 to 06/10/2012Location: Florence, ItalyTel: (41) 22 908 0488Fax: (41) 22 906 9150Email: [email protected]: www.kenes.com/esid

42nd Annual Meeting of the International Continence Society15/10/2012 to 19/10/2012Location: Beijing, ChinaTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected]: www.kenes.com/ics

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48 March 2012 After Hours

Yen Yen Yip recounts walking among ancient Mayan monuments, lasting reminders of one of the world’s greatest lost civilizations.

The Mayans introduced chocolate, corn and squash to the world. They

also developed the mathematical con-cept of zero and were experts in astron-omy without the aid of telescopes. Their civilization, established around 1800 BC, influenced life in present day Mexico, Honduras, Guatemala and Northern El Salvador, but started to decline during 8th and 9th centuries.

The monuments of the ancient Mayans remain today as testaments to their advanced state of develop-ment. In the Mexican states of Yucatan and Quintana Roo, three archeological sites provide fascinating insights into the Mayan way of life thousands of years ago.

Chichen ItzaChichen Itza, a UNESCO World Heritage site, is often the focal point of Mayan lore, and with good rea-son. Its structures served a varied range of purposes that illustrate the complexities of ancient Mayan

Mayan ruins – remnants of a lost civilization

culture, rituals and practices. At the height of its prominence from AD 900 to 1050, Chichen Itza was the centre of economic, religious and cultural activi-ties – a regional capital for north and central Yucatan.

The crown of the monuments in Chichen Itza is El Castillo (The Castle) – an imposing, square-based pyramid that showcases Mayan knowledge of math-ematics, astronomy and architecture. About 30m high, it was built integrating



elements of the Mayan calendar: each stairway had 91 steps, which when mul-tiplied by four sides, plus the top plat-form, gave 365 (the number of days in the solar year). Each side of the pyramid had 18 terraces flanking the stairways (18 being the number of months in a Mayan religious calendar), which fea-tured a total of 52 panels (52 being the number of years it takes to converge the religious and solar calendars). Every year during the spring and fall equinox, the rays of a setting sun align the shad-ows on the northern stairway to form a gleaming diamond-backed rattlesnake slithering down the pyramid.

El Castillo was designed with acoustic effects as well: by clapping at the base of the pyramid, sound waves rebound along the steps of the pyramid in a chirp-ing echo – imitating the call of the Quetzl bird sacred to Mayans.

The peak of the pyramid provides a bird’s eye view of other buildings of Chichen Itza – the ball court, where the ancient Mesoamerican ball game was played and the captain of the winning team would have been decapitated

in an honor sacrifice; the Temple of the Warriors, where hundreds of square and round columns were built to distin-guish the achievements of generals and warriors; and the Wall of Skulls, where it was believed that the heads of sacrifi-cial victims were placed.

TulumNestled on 12-meter-high cliffs, the coastal ruins of Tulum are impassive and enduring against the glittering azure Caribbean waves. Iguanas stretch out on its ancient sun-baked craggy stone blocks,



their beady lizard eyes peering out of leathered brown faces. Palm fronds sway to winds blowing in from the seas while the camera lenses of countless tourists click away in an excited rhythm.

Tulum was first mentioned in 1518, when a contingent of Spanish con-quistadors following the coast of the Yucatan peninsula spotted the city and compared its grandeur to that of Seville in Spain. It is believed that the Spanish also introduced Old World diseases that eventually wiped out the city; the site was abandoned by the end of the 16th century.

Modern day archeological investiga-tions determined that Tulum flourished between the 13th and 15th centuries. Artifacts that were excavated suggested that the city served as an important confluence point for land and maritime trade routes, where merchants bought and sold flint and ceramics, copper rat-tles and rings, and obsidian – prod-ucts that originated from a range of cities from Central Mexico to Central America.

Religion was an impor-tant facet of Mayan life. Among the

various deities, the Descending God was a figure distinct to Tulum. Worshipped for his association to the setting sun and the planet Venus, the Descending God is always depicted upside down above the doorways of Tulum structures. His feet and legs, spread open in a U shape, point upwards, and his hands are clasped together with his head div-ing downwards. At Tulum, the Temple of the Descending God is another tes-tament to Mayan expertise in architec-ture and astronomy. During the winter and summer solstices, a porthole in the



oceanfront wall of the temple allows the dawn light to shine through and hit the corners of other structures close by in a starburst effect.

CobaAbout 45 km from Tulum lies another Mayan site – Coba. Its highlight is the temple pyramid of Nohoch Mul. At 42 meters tall, Nohoch Mul rears up like an island above the green canopy of the encroaching jungle. Tourists clamber to the peak of the pyramid on all fours like insects, stabilizing their bodies with their hands grasping for handholds as their feet balance on the lower steps. 120 steep steps later, a look down from the top delivers an alarming jolt of vertigo: the ground looks so far away. A verdant expanse stretches out into the horizon – there are no other tall buildings in sight – and what were tall trees at ground level now look like bushy green twigs. This could easily have been the view commanded by Mayan high priests performing rituals at the top of Nohoch Mul.

A significantly larger site than Tulum, Coba e n c o m p a s s e s

an area of 80 km2. It had trade relations with the coastal city, though its size sug-gests that Coba likely rivaled Chichen Itza in social and political status. Coba is esti-mated to have held about 50,000 inhab-itants at its height. Despite its present day remoteness in an area overgrown with jungle, Coba must once have been a prosperous trade center that maintained contact with other Mayan cities through road works called sacbe. Some of these ancient highways reached the Caribbean coast, and the longest traveled 100 km to the precincts of another city, Yaxuna.

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Take the opportunity to learn more about recent advances in diabetes care, obesity and management of atherosclerotic diseases.

Organizers:

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Hong Kong Atherosclerosis Society UBM Medica Pacific Limited

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