3/19/10

Kids : Too Much TV Equals High BP

Time in front of a TV screen may be even worse for kids than paediatricians thought. According to new data, excessive screen time raises children's blood pressure - even if they're not overweight. In the study of 111 girls and boys, systolic blood pressure (the maximum pressure in the ateries) was six to seven points higher in kids who watched TV three or more hours a day than in those who clocked only about ten minutes daily. That's enough to affect long-term health, says researcher Joe Eisenmann, PhD, at Michigan State University. For your kids' heart health, he says, limit daily screen time to two hours and aim for an hour of heart-pumping, off-the-couch activity.

Beth Howard
RDAsia March 2010.

regards, taniafdi ^_^

3/18/10

All UTI Management Strategies May Achieve Similar Symptom Control

News Author: Laurie Barclay, MD

February 24, 2010 — All management strategies for urinary tract infections (UTIs) achieve similar symptom control, according to the results of a randomized controlled trial reported in the February 5 issue of the BMJ.

"Previous studies have documented that delayed antibiotic prescribing in respiratory infections results in good symptom control, reduced belief in the effectiveness of antibiotics, and fewer repeat consultations," write P. Little, from University of Southampton, United Kingdom, and colleagues. "We hypothesised that, compared with an immediate antibiotic prescription, other management strategies would result in worse symptom control, particularly in women asked to delay antibiotics empirically or while waiting for the result of midstream urine analysis. We aimed to assess the effectiveness of management using dipstick or clinical algorithms compared with the alternative management strategies (empirical antibiotic treatment, delayed prescribing, and targeted prescribing based on midstream urine results)."

In a primary care setting, 309 nonpregnant women aged 18 to 70 years seen for suspected UTI were randomly assigned to 1 of 5 different management approaches. These were empiric antibiotics; empiric antibiotics delayed by 48 hours; or targeted antibiotics based on a symptom score (at least 2 of the following features: urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result positive for nitrites or for both leukocytes and blood, or a positive result on midstream urinalysis.

For each group, self-help advice was controlled. Primary study endpoints were symptom severity on days 2 to 4, symptom duration, and antibiotic use.

Women who immediately took antibiotics had 3.5 days of moderately severe symptoms. The 5 groups did not differ significantly in duration or severity of symptoms. Mean frequency of symptoms on a scale of 0 to 6 was 2.15 for immediate antibiotics, 2.08 for midstream urinalysis, 1.74 for dipstick, 1.77 for symptom score, and 2.11 for delayed antibiotics (likelihood ratio test for the 5 groups: P = .177).

However, the percentage of patients using antibiotics differed among the groups (97% in the immediate antibiotic group, 81% in the midstream urine group, 80% in the dipstick group, 90% in the symptom score group, and 77% in the delayed antibiotics group [P = .011]), as did the percentage of patients sending midstream urine samples (immediate antibiotics, 23%; midstream urine, 89%; dipstick, 36%; symptom score, 33%; and delayed antibiotics, 15%; P < .001).

Compared with patients taking immediate antibiotics, those who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.36 - 0.89; P = .014) but, on average, had symptoms for 37% longer (incidence rate ratio, 1.37; 95% CI, 1.11 - 1.68; P = .003). This was especially true for the midstream urine group (73% longer; 95% CI, 22% - 140%), whereas duration was not more than 22% longer in any of the other groups.

Limitations of this study include possible type I error for the subgroup analyses; slight but not significant difference among groups in frequency symptoms at baseline; and some group differentiation in dipstick use, midstream urinalysis, and the willingness of women to delay the use of antibiotics.

"All management strategies achieve similar symptom control," the study authors write. "There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use."

This study was funded by the Health Technology Programme of UK NHS Research and Development. One of the study authors reports having been paid to attend consultancy workshops by Bayer and is currently working in collaboration with Bayer in an unpaid capacity.
 
BMJ. 2010;340:c199.

source : http://cme.medscape.com/viewarticle/717506?src=cmemp&uac=97984HK


regards, taniafdi ^_^

Metformin Extended Release May Be Helpful for Adolescent Obesity

News Author: Laurie Barclay, MD

March 1, 2010 — Metformin hydrochloride extended release (XR) with lifestyle intervention may be helpful for the treatment of adolescent obesity, according to the results of a multicenter, randomized controlled trial reported in the February issue of the Archives of Pediatrics & Adolescent Medicine.

"Metformin has been proffered as a therapy for adolescent obesity, although long-term controlled studies have not been reported," write Darrell M. Wilson, MD, from Lucile Salter Packard Children's Hospital, Stanford University School of Medicine in Stanford, California, and colleagues from the Glaser Pediatric Research Network Obesity Study Group. "Therefore, we conducted a 48-week randomized, double-blind, placebo-controlled trial of...XR metformin therapy in nondiabetic obese adolescents, followed by a 48-week monitoring period after completion of treatment."

Metformin’s Small, but Significant, Effect on BMI
 
The goal of the study was to test the hypothesis that 48 weeks of daily metformin XR treatment would reduce body mass index (BMI) in obese adolescents vs placebo.

From October 2003 to August 2007 at the 6 centers of the Glaser Pediatric Research Network, 78 obese adolescents following a lifestyle intervention program underwent a 1-month run-in period and were then randomly assigned 1:1 to receive 48 weeks of treatment with metformin hydrochloride XR, 2000 mg once daily or an identical placebo. At baseline, BMI was at least in the 95th percentile, and age range was 13 to 18 years. The main study endpoint was change in BMI, after adjustment for site, sex, race, ethnicity, and age, and group assignment.

Mean adjusted BMI increased by 0.2 ± 0.5 in the placebo group and decreased by 0.9 ± 0.5 in the metformin XR group (P = .03) after 48 weeks of treatment, and this difference persisted for 12 to 24 weeks after cessation of treatment. There were no significant effects of metformin on body composition, abdominal fat, or insulin indices.

On the basis of these findings, the investigators concluded that metformin XR caused a small but statistically significant decrease in BMI when added to a lifestyle intervention program and was safe and well tolerated.

Independent Commentator Responds to Findings
 
"The relevance of a small amount of weight reduction without clear evidence of metabolic benefit is uncertain," Kathleen M. Hoeger, MD, MPH, associate professor of obstetrics and gynecology and director of the Reproductive Endocrine Division, University of Rochester Medical Center in New York, told Medscape Pediatrics when asked for independent comment.

"There did not appear to be an interactive effect of the lifestyle program, which did not appear effective," said Dr. Hoeger, who has recently published the effect of metformin on polycystic ovary syndrome in obese adolescent women (J Clin Endocrinol Metab. 2008;93:4299-4306. Epub 2008 Aug 26). "On the positive side, there did not appear to be significant side effects to use of relatively high doses of metformin (2000 mg daily) in this population."

Study Strengths and Limitations
 
When asked about strengths and limitations of this study, Dr. Hoeger noted that it had "a robust protocol with appropriate randomization and placebo control that is lacking from many studies involving metformin in adolescents.

The study is limited by the relatively high dropout rate of 50%, which is common in lifestyle modification long-term studies; however, the authors attempted to assess this impact with projection of last weight forward, which did not change the study conclusions. Nonetheless, the number of subjects completing the trial was smaller than anticipated in the power calculations, which assumed only a 20% attrition rate, reducing the power of the study."

The study authors acknowledge that the study was not specifically powered to evaluate the effect of metformin on insulin and lipid indices. Dr. Hoeger also pointed out that this study had a mixed population that did not account for the possible effect of pubertal stage, or possible polycystic ovary syndrome in the female subjects, both of which may affect insulin resistance, and could potentially affect response to metformin. However, controlling for age and insulin measures did not affect the findings.

"Finally, the study did find significant reduction in BMI in the metformin group during treatment, but this was overall <3% of BMI and disappeared after discontinuation of the metformin," Dr. Hoeger said. "The program for lifestyle intervention did not appear to be very effective in the initial assessment. However, the placebo group did continue to have modest weight reduction in the long-term assessment at 100 weeks, whereas the metformin group regained a significant amount of weight lost."

The investigators note that although metformin may have an important role in the treatment of adolescent obesity, longer-term studies will be needed to clarify the effects of metformin treatment on obesity-related disease risk in these patients.

"It would be helpful to have a larger trial with a more effective lifestyle intervention program that may allow for more careful study of subgroups, which may be more likely to have an impact from metformin intervention," Dr. Hoeger concluded.

"Clearly, that is challenging in this age group, as few studies have been able to demonstrate long-term management of weight with lifestyle interventions alone. Additional weight loss medications may be more appropriate management if lifestyle modifications fail; however, careful study must be done in these age groups to assess not just weight loss but significant overall health improvement."

Bristol-Myers Squibb provided active drug (GlucophageXR) and placebos. The Glaser Pediatric Research Network is funded by the Elizabeth Glaser Pediatric Research Foundation, a program of the Elizabeth Glaser Pediatric AIDS Foundation. The study was supported by the Elizabeth Glaser Pediatric Research Foundation and the National Institutes of Health–supported Clinical Research Centers. 
 
Dr. Hoeger has disclosed no financial relationships.
Arch Pediatr Adolesc Med. 2010;164:116-123.

source : http://cme.medscape.com/viewarticle/717702?src=cmemp&uac=97984HK
regards, taniafdi ^_^

Journal of The Day 3

Experimental Drug Benefits Patients with Advanced Prostate Cancer.

Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus.

 regards, taniafdi ^_^

Brain Fitness Games Improve Delayed Memory in Elderly Adults

by Pam Harrison

March 8, 2010 (Savannah, Georgia) — Elderly adults who play brain fitness games that exercise global aspects of memory show improvements in the domain of delayed memory at 6 months compared with a slight decline in active controls, according to preliminary findings presented here at the American Association for Geriatric Psychiatry 2010 Annual Meeting.

Karen Miller, PhD, University of California at Los Angeles, reported that significant differences were observed at 6 months after randomization between the intervention group who were assigned to the Dakim BrainFitness computerized memory program vs active controls, even though after 2 months of training, "controls” were also given the same training as the intervention group.

Assessed by 4 different memory tests, the group who played the BrainFitness game for the full 6 months gained almost 2 points on memory scores, increasing from 10.4 at baseline to 12.1 at follow-up.

This is in contrast to controls, who, having played the same BrainFitness game from month 2 to month 6, had the same memory scores decrease slightly from 10.2 at baseline to 10.1 at follow-up (P = .001). A total of 38 elderly subjects completed the 6-month trial, 22 at an average age of 82 years in the intervention group and 16 at an average age of 83 years in the control group.

"By month 6, the intervention group had played more than double the number of sessions at 93 compared with only about 40 sessions played by active controls, so it’s the long-term use that improves overall memory. The maximum benefit comes when you keep on playing," Dr. Miller told Medscape Psychiatry.
 
Pilot Study
 
Before launching the clinical trial, Dr. Miller and colleagues carried out a pilot study involving 22 elderly subjects, with an average age of 74 years, who were assigned to the Dakim BrainFitness computerized game or to an active control group.

Participants played the game 5 times a week, each session lasting 30 minutes, for 2 months. At the end of the 2-month pilot study, a modest effect size was seen on 1 memory test.

Realizing that this particular version of the BrainFitness game did not exercise traditional aspects of memory training, including encoding and long-term memory, UCLA investigators helped Dakim redesign the game. The version used in their latest clinical trial now exercises short-term memory, critical thinking, visual spatial skills, long-term memory, calculations, and language.

"There is also a variety of 300 to 400 games or events that cycles through each time a senior plays so they are not going through the same format each time," Dr. Miller said.

"There are also 5 levels which can be preselected so this machine allows seniors to move up and down between levels, depending on how well they perform on different aspects of memory," she added.
Dr. Miller also stressed that to see a training effect on memory, it is likely subjects will need to commit to regular memory training exercises, much in the same way people need to commit to other lifestyle behaviors, such as exercise and stress reduction.

She also believes computerized training will only be helpful in preventing memory decline in people whose memory is still relatively healthy.

Memory training devices, such as the program modified and used by the UCLA group, are also likely to benefit subjects with amnestic memory impairment and not those with impairment in multiple domains.
Dr. Miller noted that, in her experience, subjects with impairment in multiple domains continue to deteriorate relatively quickly even when they used the BrainFitness device on a regular basis.

"The longer a person is exposed to the BrainFitness program, the more likely they are to improve in verbal and visual memory. Even if you have no computer skills, you are able to use it," said Dr. Miller.

Preliminary Results
 
Gary Small, MD, University of California at Los Angeles, told Medscape Psychiatry that these preliminary results are "encouraging" and that the Dakim BrainFitness program is a popular device in centers where it is been tested. "It is very much tailored to the older generation, with an easy-to-use touch screen, so seniors are enjoying it," he added.

On the other hand, companies manufacturing these brain fitness games need to make sure the games are more than just fun and engaging and that they exercise all domains of memory, such as the Dakim BrainFitness program appears to do.

"The issue really is will these devices improve cognitive skills?" Dr. Small added that it is certainly feasible to incorporate the kinds of games and techniques into brain games that improve cognitive skills, as he himself has done it with training programs — companies just need the will to do so.

Dr. Miller and Dr. Small disclose a financial conflict of interest with Dakim. Dr. Small has received consulting and speaker's fees from a number of pharmaceutical companies not relevant to his research with Dakim. 
 
American Association for Geriatric Psychiatry's (AAGP) 2010 Annual Meeting: Session 212. Presented March 6, 2010.

source : http://www.medscape.com/viewarticle/718101?src=mp&spon=25&uac=97984HKregards, taniafdi ^_^

Once – Symphony Yang Indah

Alun sebuah symphony
Kata hati disadari
Merasuk sukma kalbuku
Dalam hati ada satu
Manis lembut bisikanmu
Merdu lirih suaramu
Bagai pelita hidupku

Berkilauan bintang malam
Semilir angin pun sejuk
Seakan hidup mendatang
Dapat ku tempuh denganmu

Berpadunya dua insan
Symphony dan keindahan
Melahirkan kedamaian
Melahirkan kedamaian

Syair dan melodi
Kau bagai aroma penghapus pilu
Gelora di hati
Bak mentari kau sejukkan hatiku

Burung-burung pun bernyanyi
Bunga-bunga pun tersenyum
Melihat kau hibur hatiku
Hatiku mekar kembali
Terhibur symphony
Pasti hidupku ‘kan bahagia

video : http://www.youtube.com/watch?v=mTTiehavcbY

regards, taniafdi ^_^

Hiponatremia dapat Meningkatkan Risiko Fraktur

Studi terbaru menunjukkan bahwa hiponatremia ringan dapat meningkatkan risiko independen fraktur pada osteoporosis, karena hiponatremia ringan menyebabkan kelainan keseimbangan dan gaya berjalan, serta meningkatkan risiko terjatuh.
Dr. Joseph A. Estace dkk. dari Cork University Hospital melakukan studi retrospektif untuk memastikan hubungan hiponatremia dengan timbulnya fraktur.

Studi ini mencakup 1408 perempuan yang menjalani pemeriksaan densitas mineral tulang dan pemeriksaan laboratorium lainnya pada September 2006 - April 2007. Laporan mandiri terjadinya fraktur dikonfirmasi dengan hasil radiologi dan/atau laporan klinik fraktur.

Kadar natrium serum rata-rata adalah 14,6 mmol/l. Secara keseluruhan, sebanyak 59 subyek (4,2%) mengalami hiponatremia (natrium < 135 mmol/l), 634 (45%) mengalami osteoporosis, dan 254 (18,0%) mengalami minimal 1 fraktur.

Insidensi hiponatremia adalah 8,7% pada perempuan dengan fraktur, dibanding 3,2% tanpa fraktur (p<0,001). Pada analisis multivariat, hiponatremia secara bermakna dan secara independen berhubungan dengan terjadinya fraktur (rasio risiko 2,25; p<0,01).

Meskipun hiponatremia ringan cukup sering ditemukan pada orang tua, tetapi sering diabaikan. Jika hasil studi ini dapat dikonfirmasi, maka diperlukan perhatian lebih besar untuk mendeteksi dan mengobati hiponatremia terutama pada individu dengan risiko tinggi terjatuh.

Selain itu, karena hiponatremia seringkali iatrogenik dan berhubungan dengan penggunaan diuretik tiazid atau SSRI (Selective Serotonin Reuptake Inhibitors), hal ini harus secara aktif dilakukan skrining untuk memulai terapi, dan jika terdeteksi maka rasio "manfaat-risiko" untuk melanjutkan pengobatan pada indivisu bersangkutan, perlu direevaluasi.

Source : Clinical Journal of The American Society of Nephrology 2010; doi:10.2215/CJN.06120809).


regards, taniafdi ^_^

Pertumbuhan Bakteri Usus pada Pemakaian PPI Jangka Panjang

Studi yang dilakukan oleh tim peneliti Italia menunjukkan bahwa pada pasien GERD (Gastroesophageal Reflux Disease), maka penggunaan obat PPI (Proton Pump Inhibitor) jangka panjang dapat menyebabkan pertumbuhan bakteri secara berlebihan dalam usus kecil. Hal ini dapat menimbulkan gejala kembung, diare, dll.

Dr. Lucio Lombardo dkk. dari Maurizano U.I Hospital, Torino, menggunakan tes glukosa hidrogen napas untuk meneliti pertumbuhan berlebihan bakteri intestinal pada 450 pasien, yang dibagi atas 3 kelompok. Kelompok pertama terdiri atas 200 pasien GERD yang diobati PPI dengan median waktu 36 bulan, kelompok kedua mencakup 200 pasien IBS (Irritable Bowel Syndrome) yang diberi PPI selama 36 bulan, dan kelompok terakhir mencakup 50 pasien kontrol yang tidak menggunakan PPI 10 tahun terakhir.

Semua subyek yang mengalami pertumbuhan bakteri intestinal berlebihan diberi rifamixin dosis tinggi selama 2 minggu. Pengobatan  ini berhasil pada 87% kasus kelompok PPI dan 91% kasus kelompokIBS.

Dikatakan bahwa meskipun uji glukosa hidrogen nafas tidak secara langsung mendeteksi kelainan ini, tetapi uji ini bersifat non-invasif dan mudah diulang, yang berlawanan dengan anjuran standar yang ada saat ini yaitu melakukan aspirasi isi duodenum-jejunum untuk kultur. Ditambahkan bahwa standar emas untuk diagnosis pertumbuhan bakteri intestinal secara berlebihan belum tersedia saat ini.

 Source : Clinical Gastroenterology and Hepatology 2010; DOI: 10.1016/j.cgh.2009.12.022

regards, taniafdi ^_^

3/17/10

Molekul Penyebab Respon Alergik

Studi terbaru yang dilakukan pada sel-sel manusia telah menemukan adanya suatu molekul yang secara spesifik mengatur sel-sel imun untuk mengembangkan kemampuannya dalam hal memproduksi respon alergik. Molekul-molekul sinyal yang disebut sebagai TSLP (Thymic Stromal Lymphopoietin) ini, merupakan kunci timbulnya penyakit alergi, misalnya asma, dermatitis atopik, dan alergi makanan. 
Studi ini berhasil mengidentifikasi TSLP sebagai pemicu yang menyebabkan berkembangnya respon alergik pada manusia, dan menunjukkan bahwa molekul ini mempunyai potensi sebagai sasaran terapi dan pencegahan penyakit alergi.

Source : Science Signaling 2010; DOI: 10.1126/scisignal.2000567

regards, taniafdi ^_^

Antitrombotik dan Operasi

Lebih dari 90% pasien yang menjalani operasi mayor menghadapi ririko VTE (Venous Thromboembolism), tetapi ternyata hanya sekitar sepertiganya mendapat profilaksis VTE. Selain itu, terapi profilaksis yang diberikan tergantung jenis operasinya. Pasien operasi ortopedik paling sering menjalani terapi profilaksis (100%) untuk subyek berisiko VTE, sedang pada pasien berisiko tinggi besarnya 86%. Sedangkan operasi urologik/ginekologik menerima terapi profilaksis sebesar 88,4% untuk subyek berisiko VTE dan 53,8% untuk subyek dengan risiko.
Dr. Ajay K. Kakkar dkk, dari Barts and The London School od Medicine and Dentistry, London, melakukan studi pada 18.461 pasien dewasa yang berasal dari survei ENDORSE di 32 negara. Saat ini kriteria standar panduan American College of Chest Physicians tahun 2004 digunakan untuk menentukan risiko VTE dan anjuran profilaksis.

Secara keseluruhan, sebanyak 92,5% pasien berisiko mengalami VTE dan 62,3% mendapat profilaksis. Selain adanya perbedaan dari jenis operasinya, angka risiko VTE dan jumlah pemberian profilaksis bervariasi dari negara ke negara. Dari negara satu ke negara lainnya, jumlah pasien yang berisiko VTE bervariasi dari 66,8% - 98,4%, sedangkan profilaksis yang dianjurkan diberikan pada 0,3 - 93,9% pasien.

Pada analisis multivariat, jumlah operasi ortopedik merupakan prediktor terkuat penggunaan profilaksis VTE. Secara khusus, operasi penggantian pinggul dan lutut meningkatkan risiko sebesar 6,3 dan 5,9 kali lipat. Faktor non-operatif yang merupakan prediktor terkuat penggunaan profilaksis adalah obesitas (rasio risiko 1,9).

Para peneliti menyimpulkan bahwa survei populasi bedah ENDORSE ini menegaskan adanya jarak antara prevalensi risiko VTE pada pasien yang menjalani operasi mayor dengan pemberian terapi profilaksis yang dianjurkan oleh ACCP.

source : Annals of Surgery 2010;251:330-338

regards, taniafdi ^_^

3/15/10

Pendidikan Kedokteran Berkelanjutan

Pendidikan Kedokteran Berkelanjutan
Jum'at-Minggu, 9-11 April 2010
Tempat : Hotel Horison, Jl. Pelajar Pejuang N0.121, Bandung

Kegiatan :
Plenary Hall, Symposium dan Workshop.

Symposium :
- Bleeding Management
- Osteo Arthritis
- Peptic Ulcer
- COPD Asthma
- Diabetes
- Cardio
- Rules of Vasopressor and Antibiotic in Septic Shock Patient
- Over Active Bladder
- Management Lupus
- Manajemen Sindroma Metabolik
- Manajemen TB
- etc

Workshop :
- Basic & Clinical Application of Lung Function Test
- Manajemen Asites
- Osteoporosis
- Penyakit Infeksi

Pembayaran Simposium
Dokter Spesialis : Rp.1.100.000,-
Dokter Umum : Rp. 600.000,-

Pembayaran Per Workshop
Dokter Spesialis : Rp. 600.000,-
Dokter Umum : Rp. 500.000,-

Cara Pembayaran : Tunai atau Transfer
Transfer : Bank Mandiri Cabang RSHS No. 132-00-0749208-6
                a/n PKB-P4D-IPD
Bukti transfer di fax ke 022-2040879

regards, taniafdi ^_^

3/19/10

Kids : Too Much TV Equals High BP

Time in front of a TV screen may be even worse for kids than paediatricians thought. According to new data, excessive screen time raises children's blood pressure - even if they're not overweight. In the study of 111 girls and boys, systolic blood pressure (the maximum pressure in the ateries) was six to seven points higher in kids who watched TV three or more hours a day than in those who clocked only about ten minutes daily. That's enough to affect long-term health, says researcher Joe Eisenmann, PhD, at Michigan State University. For your kids' heart health, he says, limit daily screen time to two hours and aim for an hour of heart-pumping, off-the-couch activity.

Beth Howard
RDAsia March 2010.

regards, taniafdi ^_^

3/18/10

All UTI Management Strategies May Achieve Similar Symptom Control

News Author: Laurie Barclay, MD

February 24, 2010 — All management strategies for urinary tract infections (UTIs) achieve similar symptom control, according to the results of a randomized controlled trial reported in the February 5 issue of the BMJ.

"Previous studies have documented that delayed antibiotic prescribing in respiratory infections results in good symptom control, reduced belief in the effectiveness of antibiotics, and fewer repeat consultations," write P. Little, from University of Southampton, United Kingdom, and colleagues. "We hypothesised that, compared with an immediate antibiotic prescription, other management strategies would result in worse symptom control, particularly in women asked to delay antibiotics empirically or while waiting for the result of midstream urine analysis. We aimed to assess the effectiveness of management using dipstick or clinical algorithms compared with the alternative management strategies (empirical antibiotic treatment, delayed prescribing, and targeted prescribing based on midstream urine results)."

In a primary care setting, 309 nonpregnant women aged 18 to 70 years seen for suspected UTI were randomly assigned to 1 of 5 different management approaches. These were empiric antibiotics; empiric antibiotics delayed by 48 hours; or targeted antibiotics based on a symptom score (at least 2 of the following features: urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result positive for nitrites or for both leukocytes and blood, or a positive result on midstream urinalysis.

For each group, self-help advice was controlled. Primary study endpoints were symptom severity on days 2 to 4, symptom duration, and antibiotic use.

Women who immediately took antibiotics had 3.5 days of moderately severe symptoms. The 5 groups did not differ significantly in duration or severity of symptoms. Mean frequency of symptoms on a scale of 0 to 6 was 2.15 for immediate antibiotics, 2.08 for midstream urinalysis, 1.74 for dipstick, 1.77 for symptom score, and 2.11 for delayed antibiotics (likelihood ratio test for the 5 groups: P = .177).

However, the percentage of patients using antibiotics differed among the groups (97% in the immediate antibiotic group, 81% in the midstream urine group, 80% in the dipstick group, 90% in the symptom score group, and 77% in the delayed antibiotics group [P = .011]), as did the percentage of patients sending midstream urine samples (immediate antibiotics, 23%; midstream urine, 89%; dipstick, 36%; symptom score, 33%; and delayed antibiotics, 15%; P < .001).

Compared with patients taking immediate antibiotics, those who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.36 - 0.89; P = .014) but, on average, had symptoms for 37% longer (incidence rate ratio, 1.37; 95% CI, 1.11 - 1.68; P = .003). This was especially true for the midstream urine group (73% longer; 95% CI, 22% - 140%), whereas duration was not more than 22% longer in any of the other groups.

Limitations of this study include possible type I error for the subgroup analyses; slight but not significant difference among groups in frequency symptoms at baseline; and some group differentiation in dipstick use, midstream urinalysis, and the willingness of women to delay the use of antibiotics.

"All management strategies achieve similar symptom control," the study authors write. "There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use."

This study was funded by the Health Technology Programme of UK NHS Research and Development. One of the study authors reports having been paid to attend consultancy workshops by Bayer and is currently working in collaboration with Bayer in an unpaid capacity.
 
BMJ. 2010;340:c199.

source : http://cme.medscape.com/viewarticle/717506?src=cmemp&uac=97984HK


regards, taniafdi ^_^

Metformin Extended Release May Be Helpful for Adolescent Obesity

News Author: Laurie Barclay, MD

March 1, 2010 — Metformin hydrochloride extended release (XR) with lifestyle intervention may be helpful for the treatment of adolescent obesity, according to the results of a multicenter, randomized controlled trial reported in the February issue of the Archives of Pediatrics & Adolescent Medicine.

"Metformin has been proffered as a therapy for adolescent obesity, although long-term controlled studies have not been reported," write Darrell M. Wilson, MD, from Lucile Salter Packard Children's Hospital, Stanford University School of Medicine in Stanford, California, and colleagues from the Glaser Pediatric Research Network Obesity Study Group. "Therefore, we conducted a 48-week randomized, double-blind, placebo-controlled trial of...XR metformin therapy in nondiabetic obese adolescents, followed by a 48-week monitoring period after completion of treatment."

Metformin’s Small, but Significant, Effect on BMI
 
The goal of the study was to test the hypothesis that 48 weeks of daily metformin XR treatment would reduce body mass index (BMI) in obese adolescents vs placebo.

From October 2003 to August 2007 at the 6 centers of the Glaser Pediatric Research Network, 78 obese adolescents following a lifestyle intervention program underwent a 1-month run-in period and were then randomly assigned 1:1 to receive 48 weeks of treatment with metformin hydrochloride XR, 2000 mg once daily or an identical placebo. At baseline, BMI was at least in the 95th percentile, and age range was 13 to 18 years. The main study endpoint was change in BMI, after adjustment for site, sex, race, ethnicity, and age, and group assignment.

Mean adjusted BMI increased by 0.2 ± 0.5 in the placebo group and decreased by 0.9 ± 0.5 in the metformin XR group (P = .03) after 48 weeks of treatment, and this difference persisted for 12 to 24 weeks after cessation of treatment. There were no significant effects of metformin on body composition, abdominal fat, or insulin indices.

On the basis of these findings, the investigators concluded that metformin XR caused a small but statistically significant decrease in BMI when added to a lifestyle intervention program and was safe and well tolerated.

Independent Commentator Responds to Findings
 
"The relevance of a small amount of weight reduction without clear evidence of metabolic benefit is uncertain," Kathleen M. Hoeger, MD, MPH, associate professor of obstetrics and gynecology and director of the Reproductive Endocrine Division, University of Rochester Medical Center in New York, told Medscape Pediatrics when asked for independent comment.

"There did not appear to be an interactive effect of the lifestyle program, which did not appear effective," said Dr. Hoeger, who has recently published the effect of metformin on polycystic ovary syndrome in obese adolescent women (J Clin Endocrinol Metab. 2008;93:4299-4306. Epub 2008 Aug 26). "On the positive side, there did not appear to be significant side effects to use of relatively high doses of metformin (2000 mg daily) in this population."

Study Strengths and Limitations
 
When asked about strengths and limitations of this study, Dr. Hoeger noted that it had "a robust protocol with appropriate randomization and placebo control that is lacking from many studies involving metformin in adolescents.

The study is limited by the relatively high dropout rate of 50%, which is common in lifestyle modification long-term studies; however, the authors attempted to assess this impact with projection of last weight forward, which did not change the study conclusions. Nonetheless, the number of subjects completing the trial was smaller than anticipated in the power calculations, which assumed only a 20% attrition rate, reducing the power of the study."

The study authors acknowledge that the study was not specifically powered to evaluate the effect of metformin on insulin and lipid indices. Dr. Hoeger also pointed out that this study had a mixed population that did not account for the possible effect of pubertal stage, or possible polycystic ovary syndrome in the female subjects, both of which may affect insulin resistance, and could potentially affect response to metformin. However, controlling for age and insulin measures did not affect the findings.

"Finally, the study did find significant reduction in BMI in the metformin group during treatment, but this was overall <3% of BMI and disappeared after discontinuation of the metformin," Dr. Hoeger said. "The program for lifestyle intervention did not appear to be very effective in the initial assessment. However, the placebo group did continue to have modest weight reduction in the long-term assessment at 100 weeks, whereas the metformin group regained a significant amount of weight lost."

The investigators note that although metformin may have an important role in the treatment of adolescent obesity, longer-term studies will be needed to clarify the effects of metformin treatment on obesity-related disease risk in these patients.

"It would be helpful to have a larger trial with a more effective lifestyle intervention program that may allow for more careful study of subgroups, which may be more likely to have an impact from metformin intervention," Dr. Hoeger concluded.

"Clearly, that is challenging in this age group, as few studies have been able to demonstrate long-term management of weight with lifestyle interventions alone. Additional weight loss medications may be more appropriate management if lifestyle modifications fail; however, careful study must be done in these age groups to assess not just weight loss but significant overall health improvement."

Bristol-Myers Squibb provided active drug (GlucophageXR) and placebos. The Glaser Pediatric Research Network is funded by the Elizabeth Glaser Pediatric Research Foundation, a program of the Elizabeth Glaser Pediatric AIDS Foundation. The study was supported by the Elizabeth Glaser Pediatric Research Foundation and the National Institutes of Health–supported Clinical Research Centers. 
 
Dr. Hoeger has disclosed no financial relationships.
Arch Pediatr Adolesc Med. 2010;164:116-123.

source : http://cme.medscape.com/viewarticle/717702?src=cmemp&uac=97984HK
regards, taniafdi ^_^

Journal of The Day 3

Experimental Drug Benefits Patients with Advanced Prostate Cancer.

Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus.

 regards, taniafdi ^_^

Brain Fitness Games Improve Delayed Memory in Elderly Adults

by Pam Harrison

March 8, 2010 (Savannah, Georgia) — Elderly adults who play brain fitness games that exercise global aspects of memory show improvements in the domain of delayed memory at 6 months compared with a slight decline in active controls, according to preliminary findings presented here at the American Association for Geriatric Psychiatry 2010 Annual Meeting.

Karen Miller, PhD, University of California at Los Angeles, reported that significant differences were observed at 6 months after randomization between the intervention group who were assigned to the Dakim BrainFitness computerized memory program vs active controls, even though after 2 months of training, "controls” were also given the same training as the intervention group.

Assessed by 4 different memory tests, the group who played the BrainFitness game for the full 6 months gained almost 2 points on memory scores, increasing from 10.4 at baseline to 12.1 at follow-up.

This is in contrast to controls, who, having played the same BrainFitness game from month 2 to month 6, had the same memory scores decrease slightly from 10.2 at baseline to 10.1 at follow-up (P = .001). A total of 38 elderly subjects completed the 6-month trial, 22 at an average age of 82 years in the intervention group and 16 at an average age of 83 years in the control group.

"By month 6, the intervention group had played more than double the number of sessions at 93 compared with only about 40 sessions played by active controls, so it’s the long-term use that improves overall memory. The maximum benefit comes when you keep on playing," Dr. Miller told Medscape Psychiatry.
 
Pilot Study
 
Before launching the clinical trial, Dr. Miller and colleagues carried out a pilot study involving 22 elderly subjects, with an average age of 74 years, who were assigned to the Dakim BrainFitness computerized game or to an active control group.

Participants played the game 5 times a week, each session lasting 30 minutes, for 2 months. At the end of the 2-month pilot study, a modest effect size was seen on 1 memory test.

Realizing that this particular version of the BrainFitness game did not exercise traditional aspects of memory training, including encoding and long-term memory, UCLA investigators helped Dakim redesign the game. The version used in their latest clinical trial now exercises short-term memory, critical thinking, visual spatial skills, long-term memory, calculations, and language.

"There is also a variety of 300 to 400 games or events that cycles through each time a senior plays so they are not going through the same format each time," Dr. Miller said.

"There are also 5 levels which can be preselected so this machine allows seniors to move up and down between levels, depending on how well they perform on different aspects of memory," she added.
Dr. Miller also stressed that to see a training effect on memory, it is likely subjects will need to commit to regular memory training exercises, much in the same way people need to commit to other lifestyle behaviors, such as exercise and stress reduction.

She also believes computerized training will only be helpful in preventing memory decline in people whose memory is still relatively healthy.

Memory training devices, such as the program modified and used by the UCLA group, are also likely to benefit subjects with amnestic memory impairment and not those with impairment in multiple domains.
Dr. Miller noted that, in her experience, subjects with impairment in multiple domains continue to deteriorate relatively quickly even when they used the BrainFitness device on a regular basis.

"The longer a person is exposed to the BrainFitness program, the more likely they are to improve in verbal and visual memory. Even if you have no computer skills, you are able to use it," said Dr. Miller.

Preliminary Results
 
Gary Small, MD, University of California at Los Angeles, told Medscape Psychiatry that these preliminary results are "encouraging" and that the Dakim BrainFitness program is a popular device in centers where it is been tested. "It is very much tailored to the older generation, with an easy-to-use touch screen, so seniors are enjoying it," he added.

On the other hand, companies manufacturing these brain fitness games need to make sure the games are more than just fun and engaging and that they exercise all domains of memory, such as the Dakim BrainFitness program appears to do.

"The issue really is will these devices improve cognitive skills?" Dr. Small added that it is certainly feasible to incorporate the kinds of games and techniques into brain games that improve cognitive skills, as he himself has done it with training programs — companies just need the will to do so.

Dr. Miller and Dr. Small disclose a financial conflict of interest with Dakim. Dr. Small has received consulting and speaker's fees from a number of pharmaceutical companies not relevant to his research with Dakim. 
 
American Association for Geriatric Psychiatry's (AAGP) 2010 Annual Meeting: Session 212. Presented March 6, 2010.

source : http://www.medscape.com/viewarticle/718101?src=mp&spon=25&uac=97984HKregards, taniafdi ^_^

Once – Symphony Yang Indah

Alun sebuah symphony
Kata hati disadari
Merasuk sukma kalbuku
Dalam hati ada satu
Manis lembut bisikanmu
Merdu lirih suaramu
Bagai pelita hidupku

Berkilauan bintang malam
Semilir angin pun sejuk
Seakan hidup mendatang
Dapat ku tempuh denganmu

Berpadunya dua insan
Symphony dan keindahan
Melahirkan kedamaian
Melahirkan kedamaian

Syair dan melodi
Kau bagai aroma penghapus pilu
Gelora di hati
Bak mentari kau sejukkan hatiku

Burung-burung pun bernyanyi
Bunga-bunga pun tersenyum
Melihat kau hibur hatiku
Hatiku mekar kembali
Terhibur symphony
Pasti hidupku ‘kan bahagia

video : http://www.youtube.com/watch?v=mTTiehavcbY

regards, taniafdi ^_^

Hiponatremia dapat Meningkatkan Risiko Fraktur

Studi terbaru menunjukkan bahwa hiponatremia ringan dapat meningkatkan risiko independen fraktur pada osteoporosis, karena hiponatremia ringan menyebabkan kelainan keseimbangan dan gaya berjalan, serta meningkatkan risiko terjatuh.
Dr. Joseph A. Estace dkk. dari Cork University Hospital melakukan studi retrospektif untuk memastikan hubungan hiponatremia dengan timbulnya fraktur.

Studi ini mencakup 1408 perempuan yang menjalani pemeriksaan densitas mineral tulang dan pemeriksaan laboratorium lainnya pada September 2006 - April 2007. Laporan mandiri terjadinya fraktur dikonfirmasi dengan hasil radiologi dan/atau laporan klinik fraktur.

Kadar natrium serum rata-rata adalah 14,6 mmol/l. Secara keseluruhan, sebanyak 59 subyek (4,2%) mengalami hiponatremia (natrium < 135 mmol/l), 634 (45%) mengalami osteoporosis, dan 254 (18,0%) mengalami minimal 1 fraktur.

Insidensi hiponatremia adalah 8,7% pada perempuan dengan fraktur, dibanding 3,2% tanpa fraktur (p<0,001). Pada analisis multivariat, hiponatremia secara bermakna dan secara independen berhubungan dengan terjadinya fraktur (rasio risiko 2,25; p<0,01).

Meskipun hiponatremia ringan cukup sering ditemukan pada orang tua, tetapi sering diabaikan. Jika hasil studi ini dapat dikonfirmasi, maka diperlukan perhatian lebih besar untuk mendeteksi dan mengobati hiponatremia terutama pada individu dengan risiko tinggi terjatuh.

Selain itu, karena hiponatremia seringkali iatrogenik dan berhubungan dengan penggunaan diuretik tiazid atau SSRI (Selective Serotonin Reuptake Inhibitors), hal ini harus secara aktif dilakukan skrining untuk memulai terapi, dan jika terdeteksi maka rasio "manfaat-risiko" untuk melanjutkan pengobatan pada indivisu bersangkutan, perlu direevaluasi.

Source : Clinical Journal of The American Society of Nephrology 2010; doi:10.2215/CJN.06120809).


regards, taniafdi ^_^

Pertumbuhan Bakteri Usus pada Pemakaian PPI Jangka Panjang

Studi yang dilakukan oleh tim peneliti Italia menunjukkan bahwa pada pasien GERD (Gastroesophageal Reflux Disease), maka penggunaan obat PPI (Proton Pump Inhibitor) jangka panjang dapat menyebabkan pertumbuhan bakteri secara berlebihan dalam usus kecil. Hal ini dapat menimbulkan gejala kembung, diare, dll.

Dr. Lucio Lombardo dkk. dari Maurizano U.I Hospital, Torino, menggunakan tes glukosa hidrogen napas untuk meneliti pertumbuhan berlebihan bakteri intestinal pada 450 pasien, yang dibagi atas 3 kelompok. Kelompok pertama terdiri atas 200 pasien GERD yang diobati PPI dengan median waktu 36 bulan, kelompok kedua mencakup 200 pasien IBS (Irritable Bowel Syndrome) yang diberi PPI selama 36 bulan, dan kelompok terakhir mencakup 50 pasien kontrol yang tidak menggunakan PPI 10 tahun terakhir.

Semua subyek yang mengalami pertumbuhan bakteri intestinal berlebihan diberi rifamixin dosis tinggi selama 2 minggu. Pengobatan  ini berhasil pada 87% kasus kelompok PPI dan 91% kasus kelompokIBS.

Dikatakan bahwa meskipun uji glukosa hidrogen nafas tidak secara langsung mendeteksi kelainan ini, tetapi uji ini bersifat non-invasif dan mudah diulang, yang berlawanan dengan anjuran standar yang ada saat ini yaitu melakukan aspirasi isi duodenum-jejunum untuk kultur. Ditambahkan bahwa standar emas untuk diagnosis pertumbuhan bakteri intestinal secara berlebihan belum tersedia saat ini.

 Source : Clinical Gastroenterology and Hepatology 2010; DOI: 10.1016/j.cgh.2009.12.022

regards, taniafdi ^_^

3/17/10

Molekul Penyebab Respon Alergik

Studi terbaru yang dilakukan pada sel-sel manusia telah menemukan adanya suatu molekul yang secara spesifik mengatur sel-sel imun untuk mengembangkan kemampuannya dalam hal memproduksi respon alergik. Molekul-molekul sinyal yang disebut sebagai TSLP (Thymic Stromal Lymphopoietin) ini, merupakan kunci timbulnya penyakit alergi, misalnya asma, dermatitis atopik, dan alergi makanan. 
Studi ini berhasil mengidentifikasi TSLP sebagai pemicu yang menyebabkan berkembangnya respon alergik pada manusia, dan menunjukkan bahwa molekul ini mempunyai potensi sebagai sasaran terapi dan pencegahan penyakit alergi.

Source : Science Signaling 2010; DOI: 10.1126/scisignal.2000567

regards, taniafdi ^_^

Antitrombotik dan Operasi

Lebih dari 90% pasien yang menjalani operasi mayor menghadapi ririko VTE (Venous Thromboembolism), tetapi ternyata hanya sekitar sepertiganya mendapat profilaksis VTE. Selain itu, terapi profilaksis yang diberikan tergantung jenis operasinya. Pasien operasi ortopedik paling sering menjalani terapi profilaksis (100%) untuk subyek berisiko VTE, sedang pada pasien berisiko tinggi besarnya 86%. Sedangkan operasi urologik/ginekologik menerima terapi profilaksis sebesar 88,4% untuk subyek berisiko VTE dan 53,8% untuk subyek dengan risiko.
Dr. Ajay K. Kakkar dkk, dari Barts and The London School od Medicine and Dentistry, London, melakukan studi pada 18.461 pasien dewasa yang berasal dari survei ENDORSE di 32 negara. Saat ini kriteria standar panduan American College of Chest Physicians tahun 2004 digunakan untuk menentukan risiko VTE dan anjuran profilaksis.

Secara keseluruhan, sebanyak 92,5% pasien berisiko mengalami VTE dan 62,3% mendapat profilaksis. Selain adanya perbedaan dari jenis operasinya, angka risiko VTE dan jumlah pemberian profilaksis bervariasi dari negara ke negara. Dari negara satu ke negara lainnya, jumlah pasien yang berisiko VTE bervariasi dari 66,8% - 98,4%, sedangkan profilaksis yang dianjurkan diberikan pada 0,3 - 93,9% pasien.

Pada analisis multivariat, jumlah operasi ortopedik merupakan prediktor terkuat penggunaan profilaksis VTE. Secara khusus, operasi penggantian pinggul dan lutut meningkatkan risiko sebesar 6,3 dan 5,9 kali lipat. Faktor non-operatif yang merupakan prediktor terkuat penggunaan profilaksis adalah obesitas (rasio risiko 1,9).

Para peneliti menyimpulkan bahwa survei populasi bedah ENDORSE ini menegaskan adanya jarak antara prevalensi risiko VTE pada pasien yang menjalani operasi mayor dengan pemberian terapi profilaksis yang dianjurkan oleh ACCP.

source : Annals of Surgery 2010;251:330-338

regards, taniafdi ^_^

3/15/10

Pendidikan Kedokteran Berkelanjutan

Pendidikan Kedokteran Berkelanjutan
Jum'at-Minggu, 9-11 April 2010
Tempat : Hotel Horison, Jl. Pelajar Pejuang N0.121, Bandung

Kegiatan :
Plenary Hall, Symposium dan Workshop.

Symposium :
- Bleeding Management
- Osteo Arthritis
- Peptic Ulcer
- COPD Asthma
- Diabetes
- Cardio
- Rules of Vasopressor and Antibiotic in Septic Shock Patient
- Over Active Bladder
- Management Lupus
- Manajemen Sindroma Metabolik
- Manajemen TB
- etc

Workshop :
- Basic & Clinical Application of Lung Function Test
- Manajemen Asites
- Osteoporosis
- Penyakit Infeksi

Pembayaran Simposium
Dokter Spesialis : Rp.1.100.000,-
Dokter Umum : Rp. 600.000,-

Pembayaran Per Workshop
Dokter Spesialis : Rp. 600.000,-
Dokter Umum : Rp. 500.000,-

Cara Pembayaran : Tunai atau Transfer
Transfer : Bank Mandiri Cabang RSHS No. 132-00-0749208-6
                a/n PKB-P4D-IPD
Bukti transfer di fax ke 022-2040879

regards, taniafdi ^_^