MedicallyMe

L U P I R K A

2013-12-13T11:43:00.000+07:00

Asslm Wr Wb

Untuk teman-teman sejawat yang ingin mengetahui jadwal event-event simposium di tahun 2014, teman-teman bisa melihat di web ini, web ini cukup lengkap dan update dalam menginformasikan event-event simposium/seminar kedokteran. Semoga bermanfaat.

LUPIRKA : http://www.lupirka.com/lain-lain/43-lain-lain/693-kegiatan-farmasi-tahun-2014

regards, taniafdi ^_^

Museum Dirgantara Yogyakarta

2013-12-13T11:31:00.001+07:00

Asslm wr wb.

Liburan akhir pekan di Yogyakarta kali ini saya isi dengan berpelesir ke Museum Dirgantara dengan anak dan suami. Nama museum ini tepatnya "Dirgantara Mandala". Museum ini diresmikan tanggal 4 April 1969, awalnya museum ini berdomisili di Jakarta, namun karena sesuatu hal di pindahkan ke Yogyakarta pada 29 Juli 1978. Untuk koleksi nya sendiri, menurut saya cukup banyak dan variatif. Walaupun jujur saja, saya juga tidak mengerti benar tentang dunia kedirgantaraan. Anda dapat menemukan berbagai macam bentuk pesawat terbang yang dipakai bangsa Indonesia di jaman perang dulu. Kemudian ada diorama-diorama dan aneka baju seragam TNI AU. Selain itu, anda juga bisa berfoto dengan menggunakan seragam TNI AU sambil duduk di belakang kemudi pesawat (ceritanya jadi pilot dadakan gitu lho... ^_^). Museum ini buka dari jam 08.30-15.00 setiap hari. Untuk harga tiketnya sangat-sangat bersahabat, cukup 3000 per orang. Lokasinya sendiri bertempat di Lanud Adi Sucipto Yogyakarta.

Hormat...graaakkk!!!

Museum Dirgantara Mandala

My son and my husband.

Hal ihwal kenapa saya akhirnya memilih museum ini sebagai tempat berekreasi adalah berdasarkan pengalaman saya waktu kecil dulu. Yup, dulu sekitar tahun 90-an (jamannya saya masih SD), saya pernah mengunjungi museum ini. Kebetulan paman saya memang seorang TNI AU, dan saat itu bertugas di Yogyakarta. Dan sekarang ketika saya sudah berkeluarga, saya ingin sekali anak saya ikut mengecap pengalaman ibunya waktu itu (agak melow-melow gitu ya). Rasanya jenuh juga kalau mengajak anak jalan-jalan ke tempat yang sama berulang-ulang. ^_^. Dan yang paling penting Alhamdulillah bangeeett, anak saya benar-benar menikmati jalan-jalannya kesini, banyak request naik pesawat ini itu, dan banyak pertanyaan-pertanyaan yang terlontar dari anak saya. Jadinya belajar sambil bermain. ^_^

regards, taniafdi ^_^

Duo Jagoan ku..

2013-12-02T23:13:00.001+07:00

Asslm Wr Wb....

Seneng banget kalo liat foto yang satu ini..., anak bapak bener-bener ketawanya lucu...

Senyuuummmmmm......

regards, taniafdi ^_^

It's been so looonnnnggg....

2013-12-02T22:40:00.002+07:00

Asslm wr wb...,
Tak disangka sudah lama rupanya saya tidak mengutak atik blog ini. Awalnya kebingungan karena sistem one account for all-nya Google. Tapi akhirnya saya bisa menyelesaikan masalah ke gaptek-an saya ini. Untuk selanjutnya saya akan melanjutkan postingan-postingan saya. Mudah-mudah an selalu bermanfaat...

regards, taniafdi ^_^

Journals

2012-02-15T08:13:00.003+07:00

Antenatal Thyroid Screening and Childhood Cognitive Function.

The Perpetual Challenge of Infectious Diseases.

Tai Chi and Postural Stability in Patients with Parkinson's Disease.

Negative and competitive social interactions are related to heightened proinflammatory cytokine activity.

Bone-Density Testing Interval and Transition to Osteoporosis in Older Women.

regards, taniafdi ^_^

Event Simposium Medis 2012

2012-02-15T07:39:00.002+07:00

regards, TaniaAfdi ^_^

Adult Immunization Schedule for 2012 Issued

2012-02-14T23:20:00.003+07:00

Clinical Context

The Advisory Committee on Immunization Practices (ACIP) has adopted an evidence-based process modeled after GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) guidelines to evaluate the quality of evidence, harms, benefits and values, and preferences of affected populations in its recommendations for adult and pediatric immunization schedules. The preliminary recommendations are considered provisional until published in the Morbidity and Mortality Weekly Report Recommendations and Reports. Vaccine coverage mandated through the Affordable Healthcare Act should increase access to vaccines, but budget issues could delay incorporation of recommendations, especially in the private sector.

This is a summary of changes in the ACIP immunization recommendations for 2012.

Study Synopsis and Perspective

The US Centers for Disease Control (CDC)'s ACIP has issued the 2012 adult immunization schedule, published onlineJanuary 31 in the Annals of Internal Medicine. The schedule was also published simultaneously in the CDC'sMorbidity and Mortality Weekly Report Recommendations and Reports.

The new recommendations include broader recommendations for human papillomavirus (HPV) and hepatitis B virus (HBV) vaccination. In addition, the adult schedule and the child and adolescent schedules are now designed to be combined and used together.

Since October 2010, the annual ACIP review of the CDC's Recommended Adult Immunization Schedule has used an evidence-based process considering the quality of evidence, the benefits and harms, the values and preferences of affected populations, and the economic effects of the immunizations. The ACIP intends the updated schedule to reflect current clinical recommendations for licensed vaccines, and to offer guidance to healthcare practitioners regarding the appropriate vaccines for their adult patients.

Specific changes from the 2011 recommendations include the following:

Boys aged 11 to 12 years should receive routine vaccination with quadrivalent human papillomavirus (HPV4), with catch-up vaccination for boys and men aged 13 to 21 years.
Adults younger than 60 years who have diabetes should receive HBV vaccination as soon as possible after the diagnosis of diabetes.
Adults aged at least 60 years who have diabetes should receive HBV vaccination based on their need for assisted blood glucose monitoring, risk for acquiring hepatitis B infection, and likelihood of immune response to HBV vaccination.
Pregnant women should receive the tetanus, diphtheria, and acellular pertussis (Tdap) booster, preferably after 20 weeks of gestation, to protect infants from pertussis by transfer of protective maternal antibodies.
Adults should continue to receive influenza vaccination, even if they are allergic to eggs. However, adults with egg allergy should receive inactivated influenza vaccination, because safety data are available for this vaccination in this population.
A new footnote adds links for the full ACIP vaccine recommendations and the specific vaccine recommendations for travelers.
A new table summarizes precautions and contraindications for vaccines.
The influenza vaccination footnote now states that all persons at least 6 months of age can receive trivalent inactivated influenza vaccine (TIV), and that healthcare personnel (HCP) who care for persons requiring a protected environment should receive TIV. HCP younger than 50 years who have no contraindications may receive either the live attenuated influenza vaccine or TIV. This footnote also includes age indications for 2 recently licensed formulations of TIV.
The HPV vaccination footnote now explains that HPV vaccination is not specifically recommended for HCP, but that they should receive the vaccine if they are in the recommended age group. Men aged 22 to 26 years also may be vaccinated with HPV4 vaccine.
The zoster vaccination footnote now indicates that zoster vaccination is not specifically recommended for HCP, but that they should receive the vaccine if they are in the recommended age group. Although the FDA has approved this vaccine for use in persons at least 50 years of age, ACIP continues to recommend that vaccination begin at 60 years of age.
The measles, mumps, rubella (MMR) vaccination footnote refers readers to the ACIP MMR recommendations, as well as to the ACIP recommendations for the immunization of HCP regarding the use of MMR vaccine in outbreak settings.
The pneumococcal polysaccharide vaccine (PPSV) vaccination footnote now includes additional examples of functional and anatomic asplenia.
A footnote regarding revaccination with PPSV clarifies recommendations for persons at least 65 years of age who had been vaccinated with PPSV23 at least 5 years previously.
The meningococcal vaccination footnote now includes military recruits in the group recommended to receive a single dose of meningococcal vaccine. It also indicates that first-year college students through 21 years of age who are living in residence halls should be vaccinated if they have not received a dose on or after their 16th birthday.

An accompanying editorial by Sandra Adamson Fryhofer, MD, from Emory University in Atlanta, Georgia, describes the rationale behind the 2012 changes and notes that the American College of Physicians has established its first Adult Immunization Technical Advisory Committee.

"The College has representation at all ACIP meetings and on many ACIP vaccine working groups," Dr. Fryhofer writes. "Vaccines are vital to ensuring our nation's health. The newly released fourth edition of the ACP Guide to Adult Immunization can help physicians incorporate and improve vaccination strategies in their own practices."

Relevant financial relationships of the ACIP and Dr. Fryhofer can be viewed on the ACP Web site.

Ann Intern Med. 2012;156:211-217, 243-245. Article full text, Editorial full text

http://www.medscape.org/viewarticle/758089?src=cmemp

regards, taniafdi ^_^

Differences in Estrogen Metabolism May Influence Breast Cancer Risk

2012-01-25T19:28:00.005+07:00

The way a woman’s body processes, or metabolizes, the hormone estrogen may influence her risk ofpostmenopausal breast cancer, according to new data from NCI’s Division of Cancer Epidemiology and Genetics(DCEG) published online January 9 in the Journal of the National Cancer Institute.

In postmenopausal women, higher levels of estrogen are known to be associated with an increased risk of breast cancer. Laboratory work, however, has suggested that how estrogen is metabolized may also be important for risk. Two major hypotheses for the role of estrogen metabolites have dominated the field: one, that specific metabolites stimulate tumor growth and progression; and two, that specific metabolites function as mutagensand initiate DNA damage that can turn a normal cell into a cancerous one. This study confirms that estrogen metabolism is important and lends credence to both hypotheses.

“Those are the results we’re most excited about and also the most cautious about, because it’s the first time that we’ve been able to measure the relevant metabolites in blood in an epidemiologic setting,” said Dr. Barbara Fuhrman, a postdoctoral fellow with DCEG and lead author of the study. She and her colleagues used a novel liquid chromatography/mass spectrometry assay that allowed them to measure 15 different parent estrogens and estrogen metabolites accurately at the very low concentrations present in postmenopausal women.

They performed their analyses on blood samples taken from women enrolled in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Researchers compared the blood samples of 277 postmenopausal women who later developed breast cancer and 423 matched women without the disease. None of the women were taking menopausal hormone therapy at the time of blood collection.

Apart from the expected strong relationship with estradiol, the researchers found no clear relationships between individual hormone and metabolite concentrations and cancer risk. When they considered relationships among the three major estrogen metabolic pathways and their components, the clearest patterns emerged when they compared the pathways to one another and to the total pool of parent estrogens available for metabolism. Two metabolic patterns seemed to influence breast cancer risk in a statistically significant manner independent of circulating estradiol. One pattern was associated with an increased risk of breast cancer, whereas the other was associated with a decreased risk. When the researchers included a measure of each of these patterns in an established risk prediction model for breast cancer, the calculated risk for a considerable number of the women changed substantially.

“Although these findings are of great research interest, they need to be replicated and there are no immediate clinical implications,” said Dr. Regina Ziegler, also of DCEG and the senior author on the study. “We are still at the beginning of our understanding of the complex role of estrogen in the etiology of breast cancer. By improving our knowledge of the role of estrogen metabolism, we may uncover novel strategies for chemoprevention and treatment and be better able to predict an individual’s risk of breast cancer.”

http://www.cancer.gov/ncicancerbulletin/012412/page3#c
regards, taniafdi ^_^

Happy New Year

2012-01-25T19:26:00.001+07:00

regards, taniafdi ^_^

Koran by Heart

2011-11-01T20:16:00.002+07:00

A great documentary movie from HBO. So inspiring...

regards, taniafdi ^_^

Ballarat : Sovereign Hill

2011-11-01T18:53:00.002+07:00

What a great trip.^_^

@ Sovereign Hill

Yuupp.., i'm gold digger..., bring it on.. :D

cute kiddos..

my parents, n "old" lady...

regards, taniafdi ^_^

Management of Psoriatic Arthritis From the View of the Dermatologist

2011-11-01T15:57:00.002+07:00

Caroline A. Chang, MD; Alice B. Gottlieb, MD, PhD; Paul F. Lizzul, MD, PhD, MPH, MBA

CME Released: 09/13/2011; Valid for credit through 09/13/2012

Abstract

Psoriatic arthritis (PsA) is an inflammatory seronegative spondyloarthropathy associated with psoriasis. Although the main assessment measures for PsA are borrowed from the standard criteria used to assess rheumatoid arthritis, a number of new criteria such as the PsAJAI and CPDAI are being developed specifically for PsA. Long-term consequences of untreated PsA include persistent inflammation, progressive joint damage and, in many cases, substantial functional limitations, pain and disability. Moreover, patients with PsA have an increased mortality risk and an increased risk of developing cardiovascular disease and metabolic syndrome. Both GRAPPA and the AAD have developed treatment guidelines, which are discussed here. Psoriasis commonly precedes arthritic symptoms; thus, dermatologists are ideally placed to make the initial diagnosis of PsA and treat it appropriately, affording the opportunity to slow disease progression, improve physical function and enhance quality of life. This Review explores the management of patients with PsA, with a particular emphasis on assessment tools, long-term consequences and treatment issues from the viewpoint of the dermatologist.

Introduction

Current figures suggest that 1-3% of the world population has been diagnosed with psoriasis; psoriatic arthritis (PsA) is an inflammatory, seronegative spondyloarthropathy associated with this condition.^[1]Among patients with psoriasis, the overall prevalence of PsA has been estimated to range from ~11%^[2] to 24%.^[3] In the USA, PsA affects around 520,000 patients, with an overall prevalence of 0.25%.^[2] No gender difference exists in the risk for PsA—although it might occur earlier in women than in men—and PsA can develop at any time during the course of psoriasis.^[4] Symptoms of PsA generally develop after the skin manifestations of psoriasis, with just one in seven patients complaining of arthritis before the onset of cutaneous disease. In many cases, PsA occurs 7-12 years after the initial diagnosis of psoriasis;^[4] for example, skin disease was reported to precede joint disease by a mean of 12 years in 84% of patients with PsA.^[5] Furthermore, the likelihood of developing PsA correlates with duration of clinical psoriasis.^[6,7] Despite these findings, about 14-20% of patients with PsA present with joint manifestations before skin disease.^[8-10] In the absence of a thorough family history, such patients are often classified as having an undifferentiated spondyloarthritis. Given that joint disease can precede cutaneous involvement in some patients with PsA, a diagnosis of 'PsA sine psoriasis' may occur. Characteristic joint findings in conjunction with HLA-Cw6 positivity and a family history of psoriasis might suggest this diagnosis.^[11]Therefore, the physician must include a complete family history —including family members with psoriasis—in the physical examination of the patient in order to diagnose and treat PsA.

The prevalence of PsA varies with the extent and location of skin involvement. In one study, PsA was observed in 6% of patients with minimal psoriasis, 18% of patients with 3-10% body surface area psoriasis and 56% of patients with >10% body surface area psoriasis.^[2]Importantly, however, the extent of skin disease does not correlate with the severity of joint disease.^[12] Nail dystrophy, scalp lesions, and intergluteal and/or perianal location of psoriatic lesions are associated with an increased likelihood of PsA.^[13] The anatomical relationship between the nail and enthesis is hypothesized to account for the association between PsA and nail disease.^[14]Another study showed a positive association between small joint disease in patients with PsA and onycholysis.^[15]

If left untreated, a substantial number of patients with PsA develop persistent inflammation, progressive joint damage and, in many cases, marked functional limitations, pain and disability.^[16] Rapid diagnosis and therapeutic intervention is, therefore, of paramount consideration. This Review explores the clinical management of PsA from a dermatologist's perspective. Here, we discuss assessment tools, long-term consequences and treatment options for PsA, with a focus on medications familiar to the dermatologist and rheumatologist alike.

Assessment of PsA

The Outcome Measures in Rheumatology (OMERACT) initiative and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) consortium developed a set of six core domains that should be included in all clinical trials for PsA. The fields assessed are peripheral joint activity, skin activity, patient global assessment, pain assessment, physical function and health-related quality of life.^[17]

Quality of Life Tools

The Stanford Health Assessment Questionnaire (HAQ) is easily administered and widely used to predict productivity, morbidity, healthcare utilization, healthcare costs and death associated with rheumatic diseases;^[18] however, this questionnaire has limited relevance for patients with PsA as it does not assess the dermatologic effect of psoriasis. As a consequence, the HAQ-Skin (HAQ-SK) was developed as a PsA-specific tool. HAQ-SK is a short questionnaire that addresses the functional, but not the social or psychological, aspects of psoriasis.^[19]The Psoriatic Arthritis Quality of Life (PsAQoL) tool was later developed to determine the impact of PsA on functional, social, psychological and vocational needs.^[17,20]PsAQoL is an easily administered test in which patients provide 'true' or 'false' answers to a set of 20 questions. Although PsAQoL has demonstrated good reliability, more studies are needed to determine its correlation with treatment effects.^[21]

Treatment Efficacy Tools

Tools to assess treatment efficacy in PsA rely heavily on the standard criteria used to assess rheumatoid arthritis (RA).

ACR20. According to the American College of Rheumatology (ACR) criteria for 20% improvement (ACR20), an improvement of at least 20% in swollen and tender joint count and in three of five other measures (erythrocyte sedimentation rate or C-reactive protein level; physician global assessment of disease activity; patient global assessment of disease activity; patient pain assessment; disability) is indicative of treatment efficacy in patients with PsA.^[22]

DAS28. The Disease Activity Score (DAS)-28 includes the assessment of 28 joints and was originally developed for patients with RA.^[23] DAS28 comprises the following measures: tender joint count; swollen joint count; patient's assessment of pain; patient's and physician's global assessments of disease activity; patient's assessment of physical function; and laboratory evaluation of one acute-phase reactant. However, the joints usually involved in PsA, such as the distal interphalangeal joints of the hands, are not included in the DAS28 assessment. As a consequence, disease activity might be missed with these criteria. In addition, the inclusion of a square root in the DAS28 formula necessitates the use of a calculator in the clinic. Whereas most rheumatologists have access to a hand-held tool that easily calculates the DAS28 score, dermatologists do not have access to or use such a device.

PsARC. The Psoriatic Arthritis Response Criteria (PsARC) were created for a study of sulfasalazine in patients with PsA.^[24]PsARC response is defined by improvement in joint swelling or tenderness in association with improvement in any of four other measures (patient global assessment of articular disease; physician global assessment of articular disease; joint pain or tenderness; joint swelling).^[24,25]Nonetheless, PsARC determines only relative changes from baseline, overestimates the number of responders, has not been formally validated, and is not widely used.

EULAR. The European League Against Rheumatism (EULAR) criteria defines a good response to treatment based on DAS or DAS28 score. Response is measured as improvement in DAS or DAS28 >1.2 and reaching DAS <2.4 or DAS28 <3.2. A study that compared the efficacy of response criteria found that the EULAR criteria were better than ACR20 or PsARC for distinguishing the effects of a TNF inhibitor from placebo in patients with PsA.^[26] However, all three criteria showed improvement in the treatment group and are probably most relevant for PsA patients with active polyarticular disease.

DAPSA. The Disease Activity Index for Psoriatic Arthritis (DAPSA) is derived from the Disease Activity Index for Reactive Arthritis (DAREA) assessment tool; it measures the number of swollen and tender joints, the patient's pain and global assessment, and levels of C-reactive protein. This tool is a useful measure of disease activity for PsA.^[27]

PsAJAI. The PsA Joint Activity Index (PsAJAI) is a simplified score based on ACR30, which involves the weighted sum of 30% improvement in several core measures. This tool is useful as an outcome measure for assessing the response of joint disease in PsA clinical trials.^[28]

CPDAI. The Composite Psoriatic Disease Activity Index (CPDAI) assesses five domains (peripheral arthritis; skin disease; enthesitis; dactylitis; and spinal disease) on a scale of mild (1 point), moderate (2 points) or severe (3 points) in an attempt to create a single composite score for both skin and joint disease. Definitions of what constitutes mild, moderate and severe disease have been defined by the authors and are not universally accepted. CPDAI can distinguish between patients who require a change in treatment regimen and those who do not.^[29]

Joint Progression

The course of PsA varies, with some patients having long-term, mild disease and others experiencing severe, rapid destruction of the joints.^[30] A cohort of 100 patients with PsA was identified and followed prospectively for 5 years.^[31] By study end, 87 patients survived; 18 patients displayed an increased number of joints involved, six had a decrease in joint involvement and one changed from an oligoarticular pattern to predominant spondylitis. Among patients with polyarticular disease at baseline, the majority (73%) had an increase in the number of joints involved, with a median rate of joint progression of 0.42 peripheral joints per year (range 0-7.2).^[31]In a second study, patients were followed prospectively at 6-12 month intervals for >20 years.^[2] Overall, 39% of patients with PsA classified the condition as "a large problem" with everyday life, and an additional 38% rated it "a problem" in everyday life.^[2] These issues stem, in part, from the considerable functional limitations imposed by PsA. A comparison of PsA with RA—which is widely recognized as severely disabling for many patients —showed that, whereas peripheral joint damage is markedly greater in RA than in PsA after equivalent disease duration, function and quality of life scores are nearly identical in the two groups.^[32] These data suggest that PsA should not be viewed as a mild arthropathy. Instead, patients with PsA should be appropriately treated in order to slow progressive structural damage, delay functional limitations and improve quality of life.

Cardiovascular and Metabolic Risk

Patients with PsA have an increased risk of developing cardiovascular disease and metabolic syndrome. In one study, the prevalence of metabolic syndrome in patients with PsA was 58.1% compared with 35.2% of the general population reported by the National Health and Nutrition Examination Survey III.^[33] Metabolic syndrome predisposes patients to diabetes mellitus and atherosclerotic cardiovascular disease. Furthermore, a retrospective database study of patients with PsA in the UK found that cardiovascular disease was the leading cause of death in this group.^[34]

Mortality

RA confers an increased mortality risk, primarily as a result of an increased risk of cardiovascular disease.^[35]However, what is less appreciated is that PsA also confers a considerable incremental increase in mortality risk. Studies conducted in the 1970s and 1980s suggested that patients with PsA had a 1.8-fold increased risk of death compared with the general population.^[36] By contrast, a 1998 study of mortality among 680 patients with PsA found that the risk had dropped to 1.36-fold.^[37] Furthermore, patients with PsA lost 3 years of life on average compared with the general population. Of particular note, radiographic changes observed at presentation are associated with increased mortality risk in patients with PsA.^[37]

Major causes of death among patients with psoriasis include myocardial infarction, respiratory causes, pneumonia, chronic obstructive pulmonary disease and cancer. Patients with PsA have a 5-fold greater risk of death from respiratory disease, compared with a 1.3-fold increased risk of death from cardiovascular disease. The pathophysiological factors underlying the increased risk of pulmonary disease in patients with PsA remain unknown, although data suggest that patients with psoriasis are more likely to smoke than the general population. The link between cardiovascular mortality and PsA might involve metabolic syndrome, a complex constellation of metabolic abnormalities, including diabetes mellitus, hypertension and central obesity, as well as through inflammatory mediators such as TNF.^[36]

Treatment of RA with biologic agents reduces mortality risk and cardiovascular complications,^[38-40] but the effect of such treatment in patients with PsA has not yet been determined. A study of veterans with psoriasis or RA showed that methotrexate decreased the incidence of vascular disease.^[41] Similar treatment of PsA could, therefore, decrease cardiovascular complications of this disease. Long-term, controlled studies with large numbers of patients are needed to demonstrate whether control of inflammation decreases cardiovascular events and mortality in patients with PsA.

Psychological Impairment

Skin and debilitating joint disease both have a profound psychosocial impact on patients with PsA. A positive correlation exists between psoriasis-related disability and the level of alcohol consumption and cigarette smoking and use of psychiatric medications (tranquilizers, sleeping medications and antidepressants).^[42] The severity of both peripheral and axial PsA correlates with poor mental functioning.^[43] In addition, mental health, emotional health and social functioning are decreased in patients with PsA.^[44] Indeed, the reduced quality of life observed with PsA is similar to that seen with other chronic and life-threatening diseases, including cancer, diabetes mellitus and depression.^[45-47] Moreover, 5-20% of patients with psoriasis have contemplated suicide.^[48,49]

General Issues in the Treatment of PsA

Given the many long-term consequences of untreated PsA, early intervention is imperative. Dermatologists and rheumatologists can each play a critical part in the management of patients with PsA by treating upon diagnosis to alleviate signs and symptoms, inhibit structural damage and improve overall quality of life.^[1] However, as cutaneous disease can precede arthritic symptoms by 12 years,^[9]dermatologists may be the first to detect PsA and are, therefore, ideally placed to prevent disability by initiating treatment early.

GRAPPA devised guidelines that categorized each treatment according to categories of evidence (1A-4) and strength of recommendations (grade A to D).^[50]Treatment outcomes emphasize signs and symptoms of disease, quality of life and toxicity. Strength of evidence was delineated for peripheral arthritis, psoriasis, nail involvement, axial disease, enthesitis and dactylitis. A general pathway for the treatment of patients with PsA on the basis of current GRAPPA guidelines is illustrated in Figure 1.^[51]Discussion of treatment is divided into those patients with mild PsA and those with moderate-to-severe disease (Table 1 ).

Figure 1.

Comparison of GRAPPA⁵¹ and AAD⁵² Treatment Guidelines for Control of Joint Symptoms in PsA. Boxes in orange denote GRAPPA recommendations and those in red denote the AAD guidelines. *Not routinely used by dermatologists secondary to psoriasis flares upon cessation. *Based on EULAR guidelines. §Not FDA-approved for the treatment of PsA. Abbreviations: AAD, American Academy of Dermatology; EULAR, European League Against Rheumatism; GRAPPA, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis; PsA, psoriatic arthritis.

The American Academy of Dermatology (AAD) guidelines for PsA differ from those of GRAPPA.^[52] According to the current AAD guidelines, mild PsA should be managed first with NSAIDs alone. If no response is noted after 2-3 months, then methotrexate should be considered. For patients with moderate-to-severe PsA and concurrent psoriasis, treatment with methotrexate, TNF blockade or a combination of these therapies is the first-line option. Ustekinumab with or without methotrexate can be considered as a second-line treatment.^[52]These differences are highlighted in Figure 1.

Drugs used for the treatment of PsA—although generally effective—are subject to a number of warnings, precautions and adverse effects, and must be used with caution. The following discussion should be considered a broad outline of potential safety issues; manufacturer recommendations and the literature must be thoroughly evaluated before initiating therapy with any of these agents.

Treatment of Mild PsA

Mild PsA is generally treated symptomatically with physical therapy, patient education and medication, including NSAIDs and intra-articular injections of corticosteroids.^[1]Neither of these drug classes modifies the course of disease, nor do they inhibit the development of structural joint damage. Dermatologists do not, however, routinely use systemic corticosteroids secondary to the risk of psoriasis flares upon drug cessation.

NSAIDs

Mechanism. NSAIDs reduce inflammation via nonselective inhibition of the cyclooxygenase enzymes COX1 and COX2. This inhibition prevents the formation of prostaglandins and leukotrienes, which contribute to the inflammatory process.

Safety. NSAIDs should not be considered benign drugs. Clinically important NSAID-related events, such as bleeding, result in over 100,000 hospitalizations and 16,500 deaths each year in the USA alone; endoscopic studies indicate that gastric or duodenal ulcers develop in 15-30% of patients who regularly take NSAIDs.^[53]Moreover, these agents are associated with a variable risk of cardiovascular events and might attenuate the efficacy of anti-hypertensive agents, particularly those that act on the renin-angiotensin-aldosterone system.^[54,55]Depending on the patient's level of gastrointestinal risk, nonselective agents may be administered with concomitant proton pump inhibitors. All NSAIDs should be administered with caution to patients with cardiovascular risk factors, and patients should be followed for changes in blood pressure and cardiovascular risk profile. Worsening of psoriasis is rarely observed in patients taking NSAIDs.^[1]

Prednisone

Mechanism. Prednisone is an anti-inflammatory agent that acts through modification of gene transcription via the glucocorticoid receptor. Prednisone is converted in the liver to its active form, prednisolone. The mechanism of blocking inflammation is multifactorial and includes inhibition of COX2, cytokines, cell adhesion molecules, leukocyte infiltration and nitric oxide synthetase.

Safety. Rheumatologists may use low-dose prednisone (5-10 mg daily) for the long-term treatment of PsA.^[1]Adverse effects of this drug depend on dose, duration and frequency of administration. Short courses of prednisone are usually well tolerated; however, long-term, high doses might produce potentially serious adverse effects. Prednisone should be used cautiously in cases of psoriasis because abrupt cessation can precipitate severe psoriasis flares (some requiring hospitalization). As an immunosuppressant, this agent might increase susceptibility to infections such as tuberculosis and decrease response to vaccination. Corticosteroids impair calcium absorption and new bone formation, increasing risk of osteoporosis and subsequent fracture. Guidelines for the prevention of glucocorticoid-induced osteoporosis are available;^[56,57]therapies for preventing bone loss should be continued as long as the patient continues to receive glucocorticoids.

Treatment of Moderate-to-severe PsA

Aggressive therapy with DMARDs is warranted for patients with moderate-to-severe PsA, particularly those individuals with or at risk of progressive structural damage.

Because of lower cost, nonbiologic DMARDs should be considered before biologic agents in most cases. According to the GRAPPA guidelines, TNF inhibitors can be considered a first-line option for patients with a poor prognosis. Indicators of poor prognosis include polyarticular disease, elevated erythrocyte sedimentation rate, previous treatment failures, clinical or radiographic evidence of joint damage, loss of function and decreased quality of life.^[51] A combination of methotrexate and a TNF inhibitor can also be used to treat moderate to severe PsA.^[1]

Nonbiologic DMARDs

Methotrexate. Methotrexate antagonizes the activity of dihydrofolate reductase, which leads to cytoxicity in rapidly dividing cells. Although several nonbiologic DMARDs are available, only methotrexate is currently FDA-approved for the treatment of PsA (despite a lack of evidence for clinical benefit from randomized, controlled clinical trials). By contrast, methotrexate is not approved for the treatment of PsA by the European Medicines Agency (EMA). Data supporting the use of methotrexate as monotherapy in PsA come from two small randomized, placebo-controlled studies.^[58,59] Nonetheless, the low cost of methotrexate usually drives the decision to use it as first-line therapy before TNF inhibitors. Usual dosing for methotrexate in patients with PsA is up to 25 mg per week; concomitant folic acid (1 mg daily) should be given to inhibit methotrexate-induced gastrointestinal effects and reduce the risk of pancytopenia. Methotrexate may be used alone or in combination with biologic agents. Early aggressive therapy with methotrexate at high doses was associated with mild inhibition of joint damage progression in a longitudinal cohort study.^[60] In addition, treatment with methotrexate improved health-related quality of life in patients with PsA.^[61]

The use of methotrexate is contraindicated in pregnant women, alcoholics and noncompliant individuals, as well as in patients with renal impairment, hepatitis or cirrhosis, leukemia or thrombocytopenia.^[62] Drug interactions are frequent and must be accounted for before starting therapy. Bone-marrow suppression, especially with concomitant use of trimethoprim and/or sulfamethoxazole or NSAIDs, is a particularly serious concern. Methotrexate can induce pneumonitis. In addition, it is also a teratogen, an abortifacient, and it decreases sperm count. Indeed, methotrexate is classed as 'pregnancy category X', which implies an increased risk of fetal abnormalities. Methotrexate can cause hepatotoxicity; however, many rheumatologists believe that liver biopsy is not necessary in healthy patients. By contrast, dermatology guidelines divide patients with psoriasis into low-risk and high-risk categories. Individuals at low risk of liver injury should follow the current ACR criteria for methotrexate monitoring: liver biopsy should be considered after a total cumulative dose of 3.5-4.0 g. However, in patients with risk factors for liver disease, such as obesity or diabetes mellitus, or in those with pre-existing liver disease, the dermatology literature recommends monitoring and a liver biopsy after a 1.5 g cumulative dose of methotrexate.^[63]

Sulfasalazine. In a small randomized, controlled trial, administration of 2 g sulfasalazine daily provided a modest benefit in terms of PsARC criteria (57.8% versus 44.6% with placebo).^[24]However, this drug is not yet approved by the FDA or EMA for treatment of PsA.

Sulfasalazine is contraindicated in patients with porphyria, intestinal or urinary obstruction and hyper-sensitivity to sulfasalazine, its metabolites or salicylates.^[64]Sulfasalazine should be used with caution in patients with severe allergies or bronchial asthma, hepatic or renal damage or blood dyscrasias. Adequate fluid intake must be maintained to prevent crystalluria and stone formation. Gastrointestinal upset is a frequent occurrence and can be a limiting factor in dosing. Complete blood analysis, including differential white cell count and liver function tests, should be performed before starting sulfasalazine and monthly for the first 3 months of treatment. Thereafter, monitoring should be performed every 6 months. Urinalysis and an assessment of renal function should also be done periodically during treatment. Sulfasalazine is classified as 'pregnancy category B, which implies low risk of fetal abnormalities.

Leflunomide. Leflunomide is an immunomodulatory drug that inhibits dihydroorotate dehydrogenase, affecting de novo synthesis of uridine monophosphate. In a small study, a benefit of leflunomide was demonstrated in patients with PsA, with a PsARC response observed in 58.9% of treated patients compared with 29.7% of those who received placebo at an oral dosing regimen of 100 mg per day for 3 days followed by 20 mg per day thereafter.^[65]Leflunomide is approved in Europe (but not in the USA) for treatment of PsA.

Leflunomide is a pregnancy category X drug and is absolutely contraindicated in pregnant women and in patients who plan to become pregnant within 2 years of stopping the drug, unless a regimen of cholestyramine (8 g three times daily for 11 days) is completed and drug concentrations of leflunomide in the blood are below 0.02 mg/l.^[66]Caution should be used in patients with chronic renal insufficiency and those with hepatic insufficiency. Rare cases of severe liver injury, including fatalities, have been reported during treatment with leflunomide.^[66] This drug is not recommended in patients with severe immunodeficiency, bone marrow dysplasia or severe, uncontrolled infections.^[66] Platelet, white blood cell count, hemoglobin or hematocrit and liver function tests should be conducted in accordance with the recommendations of the manufacturer.^[66]

Established Biologic DMARDs

Four TNF inhibitors—adalimumab, etanercept, infliximab and golimumab—are currently the only FDA-approved biologic agents for the treatment of PsA. Administration of adalimumab, infliximab, etanercept or golimumab enables patients to achieve an ACR20 response ( Table 2 ). These drugs also exhibit efficacy in terms of improvements in Psoriasis Area and Severity Index (PASI), which is the gold standard tool for assessing the severity of psoriasis. PASI places an objective number on a patient's psoriasis by evaluating the features of the psoriatic plaque (redness, scaling and thickness) and the extent of involvement. In clinical studies, PASI scores are listed as the percentage of patients who experienced a reduction in their baseline score; for example, a PASI 75 of 50% implies that 50% of study patients achieved a 75% reduction in PASI score from their baseline. When used as monotherapy in patients with psoriasis, both adalimumab and infliximab produce PASI 75 response rates in 71-80% of patients, whereas the response rate with etanercept is somewhat lower ( Table 2 ). For patients with PsA receiving combination therapy, 58-68% of patients receiving either adalimumab, infliximab or golimumab achieved PASI 75, whereas etanercept exhibited a lower response ( Table 2 ). A summary of administration recommendations for approved biologic DMARDs can be found in Box 1 .

Other biologic agents for the treatment of PsA are also in the pipeline. For example, ustekinumab, a human monoclonal antibody directed against IL-12 and IL-23, is approved for the treatment of psoriasis but also shows promise in PsA.^[67]

TNF Inhibitors: General Efficacy Considerations. Adalimumab, etanercept and infliximab are FDA-approved and EMA-approved to control signs and symptoms, inhibit radiographic progression and improve quality of life in patients with PsA. Golimumab is currently FDA-approved and EMA-approved for only control of signs and symptoms, in PsA but not psoriasis.

Loss of efficacy over time has been observed with all TNF inhibitors, a phenomenon potentially related to the development of antibodies against the biologic drug. Some dermatologists, therefore, prescribe concomitant low-dose methotrexate, with the goal of limiting antibody formation and maintaining efficacy over time.^[68] Limited data in psoriasis,^[69] PsA,^[70] RA^[71] and inflammatory bowel disease^[72] suggest that switching from one TNF inhibitor to another following therapeutic failure or intolerance to the first agent can result in substantial clinical efficacy. Moreover, adding low-dose methotrexate to biologic treatments might reduce the immunogenicity associated with monoclonal antibody TNF inhibitors.^[73,74]

Adalimumab. Adalimumab is derived from a fully human anti-TNF monoclonal antibody that is effective in a number of inflammatory conditions, including psoriasis and RA, when used alone or in combination with methotrexate.^[75]Adalimumab currently carries a guideline 1A recommendation (highest strength of recommendation, high level of evidence) for the treatment of PsA.^[1]

The efficacy of adalimumab in patients with PsA was initially assessed in a double-blind, randomized, controlled trial that enrolled adults with moderate to severe disease (defined as at least three swollen joints and three tender or painful joints), in association with active psoriatic skin lesions or a documented history of psoriasis.^[76]Participants received either adalimumab (40 mg given subcutaneously every other week for 24 weeks) or placebo. Patients who received adalimumab had an appreciably higher ACR20 response rate than those who received placebo at all time points assessed (58% versus 14% at week 12). ACR50 and ACR70 response rates were also markedly higher among patients who received adalimumab.^[76] An open-label extension of this trial demonstrated that efficacy is maintained, with ACR20, ACR50, and ACR70 response rates of 56%, 44%, and 30%, respectively, at week 24. Sustained improvements in the Disability Index of the HAQ, and stabilization in changes in radiographic parameters were also observed with adalimumab;^[77] inhibition of radiographic progression and improvements in joint disease were maintained in most patients at 2 years.^[78]

Etanercept. Etanercept is a fusion protein engineered to link soluble TNF receptor to the Fc component of human IgG that is administered subcutaneously, either as a single 50 mg weekly dose or as two 25 mg doses given on the same day or 3-4 days apart.^[79] This drug is approved for the treatment of both psoriasis and PsA, and carries a 1A guideline recommendation for the treatment of PsA.^[1]

Etanercept was evaluated in a double-blind, randomized, controlled trial of 205 patients with PsA who received placebo or 25 mg etanercept for 24 weeks, with an optional 24-week open-label extension.^[80] Compared with placebo, etanercept was associated with a significant reduction in the signs and symptoms of PsA. At 12 weeks, ACR20 criteria were met by 59% of the etanercept groups, compared with 15% of the placebo group, with efficacy maintained at 24 and 48 weeks.^[80] Radiographic disease progression was inhibited among patients who received etanercept, with an annualized rate of change in the modified total Sharp score of -0.03 units, compared with +1.00 units in the placebo group. The benefit of etanercept was maintained at 2 years.

The Experience Diagnosing, Understanding Care, and Treatment with Etanercept (EDUCATE) trial showed that 50 mg subcutaneous etanercept once a week improved patient global assessment of joint pain and joint disease at weeks 12 and 24 in patients with active PsA treated in a dermatology clinic.^[9] In addition, PsA was newly diagnosed in 23% of psoriasis patients seen in dermatology clinics.^[5] Moreover, in the PRESTA (Psoriasis Randomized Etanerept Study in Subjects with Psoriatic Arthritis) study, three in four patients showed joint improvement, as measured by PsARC, at 12 weeks that was maintained at 24 weeks in both arms of the trial, which compared twice-weekly with once-weekly dosing of etanercept.^[81]

Infliximab. Infliximab is a chimeric (mouse-human) monoclonal antibody directed against TNF, and has a 1A guideline recommendation for the treatment of PsA.^[1] Unlike adalimumab and etanercept, which are subcutaneously administered, 5 mg/kg infliximab is infused over a 2-h period at treatment start and after 2 and 6 weeks, and every 8 weeks thereafter.^[82]

The efficacy of infliximab in treating PsA has been evaluated in multiple trials. In the IMPACT 2 (Infliximab Multinational Psoriatic Arthritis Controlled Trial) study, 200 patients with PsA, who were unresponsive to previous treatment, were randomly allocated to receive infliximab or placebo.^[83] A week 14 ACR20 response was achieved by 58% of the infliximab-treated patients and 11% of patients who received placebo; this response was maintained throughout the 24-week duration of the trial. Similar patterns were observed for ACR50 and ACR70 response. When compared with the placebo group, fewer patients in the infliximab group had dactylis (18% versus 30%; P = 0.025) or active enthesopathy (22% versus 34%, P = 0.016). Of note, 1-year analyses of the results of the IMPACT and IMPACT 2 trials showed that infliximab markedly inhibited radiographic progression of PsA.^[84,85]

Golimumab. Golimumab, the newest entrant in the anti-TNF class, is a human monoclonal antibody with a half-life of around 2 weeks, which allows it to be administered less frequently than currently approved drugs for PsA.^[86] A 2009 study evaluated golimumab in the treatment of PsA. Adults with active psoriasis plus at least three swollen joints and three tender joints were randomly allocated to receive placebo, 50 mg golimumab or 100 mg golimumab every 4 weeks for 20 weeks.^[86] At week 14, 48% of all patients who received golimumab (51% of those administered the 50 mg dose and 45% of those receiving the 100 mg dose) achieved an ACR20 response, compared with only 9% of patients who received placebo; similar patterns were observed for ACR50 and ACR70 responses. Marked improvements in quality of life were also observed.

TNF Inhibitors: General Safety Considerations. General safety recommendations for TNF inhibitors are briefly summarized in Box 2 .^[68] Although the occurrence is infrequent, TNF inhibitors are associated with an increased risk of bacterial, viral, invasive fungal and mycobacterial infections, making careful monitoring and early evaluation critical.^[68] These agents should be avoided in patients with chronic, serious or recurring infections; notably, reactivation of hepatitis B virus infection has been observed in some patients taking TNF inhibitors. Risk of peripheral and central demyelinating disease, including multiple sclerosis, might be increased in patients receiving TNF inhibitors; these agents have been shown to worsen existing demyelinating disease in some cases. Moreover, new-onset psoriasis has been reported in patients administered TNF inhibitors for other diseases.^[87]

Increased incidence of lymphomas and other malignancies have also been reported among patients taking TNF inhibitors. About half of the malignancies reported in children were lymphomas.^[75,79,82] In addition, there are rare reports of aggressive hepatosplenic T-cell lymphoma in adolescents being treated with TNF inhibitors (concomitant with other immunosuppressants) for Crohn disease or ulcerative colitis.^[75,82] Periodic skin examinations are recommended for patients taking TNF inhibitors, as melanoma and nonmelanoma skin cancers have been reported. Merkel cell carcinoma has infrequently been reported in patients treated with etanercept.^[79]Thus, the decision to use a TNF inhibitor should be carefully considered in children and patients with a history of malignancy.

The use of TNF inhibitors should be avoided, if possible, in patients with severe congestive heart failure (New York Heart Association class III or IV), and withdrawn in patients with milder congestive heart failure who exhibit new symptoms or worsening of disease.^[68] Patients administered TNF inhibitors might develop increased levels of circulating antinuclear antibodies, potentially resulting in a drug-induced lupus-like syndrome. Elevated levels of liver enzymes have been observed in patients receiving infliximab, but not adalimumab or etanercept. TNF inhibitors are pregnancy category B.

Novel Biologic DMARDs

Ustekinumab. Ustekinumab, a human monoclonal antibody against the p40 subunits of IL-12 and IL-23, represents an entirely new therapeutic approach for the treatment of PsA that could be useful in patients who do not respond to standard pharmacotherapy. This drug is FDA-approved for use in patients with psoriasis; however, it is not yet approved for the treatment of PsA. Ustekinumab is administered subcutaneously and under the supervision of a physician.

In a double-blind, randomized, controlled study, patients with active PsA received 63 or 90 mg ustekinumab every week for 4 weeks, followed by placebo at weeks 12 and 16; a second group of patients received placebo for 4 weeks and 63 mg ustekinumab at weeks 12 and 16.^[67] The primary end point was ACR20 response at week 12; however, clinical response was followed to week 36. ACR responses were achieved more frequently among patients who received ustekinumab than among those who received placebo during the first 12 weeks of the trial: ACR20 (42% versus 14%; P = 0.0002), ACR50 (25% versus 7%; P = 0.0038) and ACR70 (11% versus 0%; P = 0.0055). Roughly three in four patients initially treated with ustekinumab maintained ACR20 responses at week 36 with no additional treatment received after week 3. Moreover, fewer patients who received ustekinumab experienced enthesopathy (23% versus 42% with placebo; P = 0.0163).

Some important differences exist in the patient populations enrolled in the TNF blocker and ustekinumab trials. The ustekinumab trial recruited patients from dermatology practices and participants had to have active plaque psoriasis. Up to 31% of patients were previously exposed to biologic agents, only 20% of patients were concomitantly taking methotrexate, 51% of patients received NSAIDS and no patients were concurrently taking oral corticosteroids. Finally, patients had only moderately elevated acute-phase reactant response, as measured by C-reactive protein levels. There were fewer patients with polyarticular joint disease in this study compared with those studying infliximab, adalimumab and etanercept.

Ustekinumab might increase the risk of new infections and reactivation of latent infections.^[88] As such, it should not be given in patients with any clinically important active infection. Of note, patients genetically deficient in IL-12 and/or IL-23 are particularly vulnerable to disseminated infections from mycobacteria and Bacillus Calmette-Guerin vaccinations, although whether ustekinumab has a similar effect is unknown. Nonetheless, patients should be evaluated for tuberculosis infection before initiating treatment and ustekinumab should not be administered with a live vaccine or to patients in close contact with individuals who have been administered a live vaccine. As with other immunosuppressive agents, ustekinumab might increase malignancy risk.

Abatacept. Abatacept is a fully human CTLA-4-IgG1 fusion protein that selectively binds to CD80 or CD86, which blocks T-cell interaction with CD28, the co-stimulatory signal for T-cell activation. Abatacept is not currently approved by the FDA or EMA for the treatment of PsA, although some promising results have been reported. In a phase II trial in patients with PsA and psoriasis who had failed previous therapy with a DMARD, participants were randomly allocated to receive placebo or one of three different doses of abatacept on days 1, 15, and 29 of the study, and then every 28 days thereafter.^[89] ACR20 responses were achieved in 33%, 48%, and 42% of the treatment groups (3 mg/kg, 10 mg/kg or 30 mg/kg intravenous for two doses followed by 10 mg/kg intravenous, respectively) compared with 19% in the placebo group. Further studies are needed, however, to fully assess the efficacy of this drug in the treatment of PsA.

Abatacept inhibits T-cell activation and, therefore, suppresses host response to infections and malignancies. Abatacept increases risk of infection, particularly among patients receiving concomitant TNF inhibitor therapy. Patients with a history of recurrent infections or underlying conditions that might predispose to infection should use caution when taking abatacept. Screening for tuberculosis and hepatitis B should be performed before initiating treatment. In addition, live vaccines should not be given while a patient is taking abatacept. Increased risk of lung cancer and lymphoma has been observed in patients treated with abatacept, and respiratory disorders were seen more frequently in patients with chronic obstructive pulmonary disease. Infusion-related events include dizziness, headache and hypertension. Abatacept is a 'pregnancy category C' drug, which implies that risk to the fetus is unknown or unclear.

Conclusions

A number of treatments are available for PsA, ranging from agents that primarily provide symptomatic relief (NSAIDs and intra-articular corticosteroids) to non-biologic and biologic DMARDs (methotrexate, TNF inhibitors, ustekinumab and abatacept). Limited clinical trial evidence supports the use of methotrexate in patients with PsA, and there are no compelling data to demonstrate that it has a disease-modifying effect in PsA. Nevertheless, methotrexate is used before biologic agents due to its lower cost. In contrast to methotrexate, substantial evidence exists that TNF inhibitors are effective in slowing progressive joint damage specifically in patients with PsA. Novel agents (as yet not approved for PsA), such as ustekinumab and abatacept, may broaden the spectrum of treatments available to patients with PsA.

When left untreated, a substantial proportion of patients with PsA will develop persistent inflammation, which leads to progressive joint damage and—ultimately—to pain, severe functional limitations and disability. Given the long-term functional consequences of unchecked PsA—and the potential benefits of early treatment— dermatologists are strongly encouraged to assess patients for the signs and symptoms of PsA at each visit. Moreover, rheumatologists should be included early in the assessment of patients thought to have PsA. Early detection and treatment can prevent the disability that is associated with untreated PsA.

Key Points

Dermatologists are ideally placed to diagnose and treat psoriatic arthritis (PsA), as most patients present with skin symptoms before onset of arthritis
PsA is a potentially debilitating and destructive disease that should be treated as soon as possible after diagnosis to prevent irreversible damage
Patients with mild PsA can be managed with NSAIDs; however, systemic corticosteroids should be used cautiously in such cases
Moderate-to-severe cases of PsA can be managed by DMARDs or TNF inhibitors, administered either alone or in combination
Promising new drugs for the treatment of PsA include ustekinumab and abatacept

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Chandran, V., Schentag, C. T. & Gladman, D. D. Reappraisal of the effectiveness of methotrexate in psoriatic arthritis: results from a longitudinal observational cohort. J. Rheumatol. 35, 469-471 (2008).
Lie, E. et al. Effectiveness and retention rates of methotrexate in psoriatic arthritis in comparison with methotrexate-treated patients with rheumatoid arthritis. Ann. Rheum. Dis. 69, 671-676 (2010).
Menter, A. et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J. Am. Acad. Dermatol. 58, 826-850 (2008) .
Kalb, R. E., Strober, B., Weinstein, G. & Lebwohl, M. Methotrexate and psoriasis: 2009 National Psoriasis Foundation Consensus Conference. J.Am. Acad. Dermatol. 60, 824-837 (2009).
Pfizer. Azulfidine prescribing information [online], http://labeling.pfizer.com/ShowLabeling.aspx?id=524 (2009).
Nash, P., Thagi, D., Behrens, F., Falk, F. & Kaltwasser, J. P. Leflunomide improves psoriasis in patients with psoriatic arthritis: an in-depth analysis of data from the TOPAS study. Dermatology 212, 238-249 (2006).
Sanofi-Aventis. Arava prescribing information [online], http://products.sanofi.us/arava/arava.html (2010).
Gottlieb, A. et al. Ustekinumab, a human interleukin 12/23 monoclonal antibody, for psoriatic arthritis: randomised, double-blind, placebo-controlled, crossover trial. Lancet 373, 633-640 (2009).
Menter, A. et al. A randomized comparison of continuous vs. intermittent infliximab maintenance regimens over 1 year in the treatment of moderate-to-severe plaque psoriasis. J. Am. Acad. Dermatol. 56, 31.e1-31.e15 (2007).
Pitarch, G., Sanchez-Carazo, J. L., Mahiques, L. & Oliver, V. Efficacy of etanercept in psoriatic patients previously treated with infliximab. Dermatology 216, 312-316 (2008).
Haberhauer, G., Strehblow, C. & Fasching, P. Observational study of switching anti-TNF agents in ankylosing spondylitis and psoriatic arthritis versus rheumatoid arthritis. Wien. Med. Wochenschr. 160, 220-224 (2010).
Haraoui, B. et al. Clinical outcomes of patients with rheumatoid arthritis after switching from infliximab to etanercept. J. Rheumatol. 31, 2356-2359 (2004).
Sandborn, W. J. et al. Adalimumab induction therapy for Crohn disease previously treated with infliximab: a randomized trial. Ann. Intern.Med. 146, 829-838 (2007).
Maini, R. N. et al. Therapeutic efficacy of multiple intravenous infusions of anti-tumor necrosis factor alpha monoclonal antibody combined with low-dose weekly methotrexate in rheumatoid arthritis. Arthritis Rheum. 41,1552-1563 (1998).
Atzeni, F. & Sarzi-Puttini, P. Autoantibody production in patients treated with anti-TNF-alpha. Expert Rev. Clin. Immunol. 4, 275-280 (2008).
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Mease, P. J. et al. Adalimumab for the treatment of patients with moderately to severely active psoriatic arthritis: results of a double-blind, randomized, placebo-controlled trial. ArthritisRheum. 52, 3279-3289 (2005).
Gladman, D. D. et al. Adalimumab for long-term treatment of psoriatic arthritis: forty-eight week data from the adalimumab effectiveness in psoriatic arthritis trial. Arthritis Rheum. 56, 476-488 (2007).
Mease, P. J. et al. Adalimumab for long-term treatment of psoriatic arthritis: 2-year data from the Adalimumab Effectiveness in Psoriatic Arthritis Trial (ADEPT). Ann. Rheum. Dis. 68, 702-709 (2009).
Amgen and Pfizer. Enbrel prescribing information [online], http://pi.amgen.com/united states/enbrel/derm/enbrel pi.pdf (2011).
Mease, P. J. et al. Etanercept treatment of psoriatic arthritis: safety, efficacy, and effect on disease progression.Arthritis Rheum. 50, 2264-2272 (2004).
Sterry, W. et al. Comparison of two etanercept regimens for treatment of psoriasis and psoriatic arthritis: PRESTA randomised double blind multicentre trial. BMJ 340, c147 (2010).
Centocor Ortho Biotech. Remicade prescribing information [online],http://www.remicade.com/remicade/assets/hcp ppi.pdf (2011).
Antoni, C. et al. Infliximab improves signs and symptoms of psoriatic arthritis: results of the IMPACT 2 trial. Ann. Rheum. Dis. 64, 1150-1157 (2005).
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van der Heijde, D. et al. Infliximab inhibits progression of radiographic damage in patients with active psoriatic arthritis through one year of treatment: Results from the induction and maintenance psoriatic arthritis clinical trial 2. Arthritis Rheum. 56, 2698-2707 (2007).
Kavanaugh, A. et al. Golimumab, a new human tumor necrosis factor alpha antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: Twenty-four-week efficacy and safety results of a randomized, placebo-controlled study. ArthritisRheum. 60, 976-986 (2009).
Ko, J. M., Gottlieb, A. B. & Kerbleski, J. F Induction and exacerbation of psoriasis with TNF-blockade therapy: a review and analysis of 127 cases. J. Dermatolog. Treat. 20, 100-108 (2009).
Centocor Ortho Biotech. Stelara prescribing information [online],http://www.stelarainfo.com/pdf/PrescribingInformation.pdf (2010).
Mease, P. et al. Abatacept in the treatment of patients with psoriatic arthritis: results of a six-month, multicenter, randomized, double-blind, placebo-controlled, phase II trial. ArthritisRheum. 63, 939-948 (2011).
Menter. A. et al. Adalimumab therapy for moderate to severe psoriasis: A randomized, controlled phase III trial.J.Am. Acad. Dermatol. 58, 106-115 (2008).
Leonardi, C. L. et al. Etanercept as monotherapy in patients with psoriasis. N. Engl. J. Med. 349, 2014-2022 (2003).
Gottlieb, A. B. et al. A randomized trial of etanercept as monotherapy for psoriasis. Arch.Derm. 139, 1627-1632 (2003).
Chaudhari, U. et al. Efficacy and safety of infliximab monotherapy for plaque-type psoriasis: a randomised trial.Lancet 357, 1842-1847 (2001).
Reich, K. et al. Infliximab induction and maintenance therapy for moderate-to-severe psoriasis: a phase III, multicentre, double-blind trial. Lancet 366, 1367-1374 (2005).
Gottlieb, A. B. et al. Infliximab induction therapy for patients with severe plaque-type psoriasis: a randomized, double-blind, placebo-controlled trial. J.Am. Acad. Dermatol. 51, 534-542 (2004).
Antoni, C. E. et al. Sustained benefits of infliximab therapy for dermatologic and articular manifestations of psoriatic arthritis: results from the infliximab multinational psoriatic arthritis controlled trial (IMPACT). Arthritis Rheum. 52, 1227-1236 (2005).

http://www.medscape.org/viewarticle/749147_8
regards, taniafdi ^_^

Continuous Glucose Monitoring: Guidelines

2011-11-01T15:44:00.003+07:00

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

CME/CE Released: 10/17/2011; Valid for credit through 10/17/2012

Clinical Context

People with diabetes mellitus (DM) face daily challenges in monitoring their glucose levels to prevent severe hypoglycemia or hyperglycemia. Continuous glucose monitoring (CGM) is a strategy to help patients maintain good glycemic control. CGM can be used to prevent hypoglycemia and to maintain optimal HbA1c levels.

This is a report of the Endocrine Society Clinical Practice Guideline subcommittee, which used a task force to evaluate the evidence for the use of real-time CGM (RT-CGM) in hospital, pediatric, and outpatient settings.

Study Synopsis and Perspective

CGM assists people with diabetes in maintaining target blood glucose levels, according to an Endocrine Societyclinical practice guideline published in the October issue of the Journal of Clinical Endocrinology and Metabolism.

"There are some caveats to consider before accepting continuous monitoring of glucose as a routine measure to improve glycemic control in diabetes," guidelines task force chair David C. Klonoff, MD, from Mills-Peninsula Health Services in San Mateo, California, said in a news release. "There are still concerns about the high costs of CGM and the accuracy of the various systems available. However, the new [clinical practice guideline] shows that CGM can be a beneficial tool to help maintain target levels of glycemia and limit the risk of hypoglycemia."

CGM, using various devices, measures glucose in the interstitial fluid; the intended use is for patients with type 1 or type 2 diabetes to make decisions about food, medicines, and exercise. A task force of experts, a methodologist, and a medical writer set out to develop evidence-based practice guidelines for identifying clinical scenarios in which CGM would be most beneficial to patients with diabetes. The goals of CGM are to maintain target levels of glycemia and to limit the risk for hypoglycemia in 3 potential settings: RT-CGM in hospitalized adults, RT-CGM in children and adolescent outpatients, and RT-CGM in adult outpatients.

The strength of the recommendations and the quality of the evidence were described using the Grading of Recommendations, Assessment, Development, and Evaluation system. Consensus was established in a group meeting, conference calls, and emails. The Diabetes Technology Society and the European Society of Endocrinology also reviewed and commented on preliminary drafts of these guidelines.

Specific recommendations for CGM are as follows:

While awaiting further evidence, RT-CGM alone should not be used for glucose management of adults in the intensive care unit or operating room.
Children and adolescent outpatients with T1DM and glycosylated hemoglobin (HbA1c) levels less than 7.0% should use RT-CGM with currently approved devices.
Pediatric, adolescent, and adult outpatients with T1DM and HbA1c levels of 7.0% or more should use RT-CGM if they are able to use these devices on a nearly daily basis.
The guidelines do not recommend for or against the use of RT-CGM by children younger than 8 years with T1DM.
Patients should be given treatment guidelines so that they can safely and effectively use the information obtained from RT-CGM.
Intermittent use of CGM systems capable of short-term retrospective analysis is recommended in children and adults with diabetes and possible nocturnal hypoglycemia, dawn phenomenon, and postprandial hyperglycemia; in patients with hypoglycemic unawareness; and in patients undergoing significant changes to their diabetes regimen.
Adults with T1DM and HbA1c levels less than 7.0% should use RT-CGM devices if they can use them on a nearly daily basis.

"CGM can be beneficial in maintaining target levels of glycemia and limiting the risk of hypoglycemia," the guidelines authors write.

All Endocrine Society clinical practice guidelines are supported entirely by society funds. Some members report various financial relationships with Bayer, C8 MediSensors, Insuline, LifeScan, Medtronic Diabetes, Roche, Diabetes Technology Society, MedTronic MiniMed, LifeScan, NovoNordisk, JDRF, UnoMedical, European Society of Endocrinology. KER Unit (Mayo Clinic), Abbott Diabetes, Eli Lilly, Macrogenics, Dexcom, the Endocrine Society, and/or Insulet.

J Clin Endocrinol Metabol. 2011;96:2968-2979. Abstract

http://www.medscape.org/viewarticle/751544?src=cmemp
regards, taniafdi ^_^

Draft Guidelines Recommend Against PSA Screening: USPSTF Review

2011-11-01T15:42:00.003+07:00

News Author: Zosia Chustecka
CME Author: Charles P. Vega, MD

CME/CE Released: 10/13/2011; Valid for credit through 10/13/2012

Clinical Context

Few topics in the field of preventive medicine are contentious as prostate cancer screening. Widespread screening for prostate cancer has had a remarkable effect on the epidemiology of this tumor, as demonstrated in a study by Welch and Albertsen published in the October 7, 2009, issue of the Journal of the National Cancer Institute. Their study found that the introduction of routine prostate cancer screening led to approximately 1.3 million more men being diagnosed with prostate cancer in the United States alone. Men younger than 60 years accounted for most of this surge in cases. The authors estimated that more than 20 additional men would have to be diagnosed with prostate cancer through screening to result in a single case of reduced mortality risk from prostate cancer.

These findings are fairly pessimistic regarding the value of prostate cancer screening. The current study commissioned by the US Agency for Healthcare Research and Quality provides a more complete review of important issues in screening for prostate cancer.

Study Synopsis and Perspective

The US Preventive Services Task Force issue draft recommendations against routine screening for prostate cancer using the prostate-specific antigen (PSA) test in the United States, where it is currently used more than in any other country in the world. As a result, prostate cancer is the most commonly diagnosed cancer in American men.

The USPSTF draft recommendation against routine screening with the PSA test was to have been published October 11 in the Annals of Internal Medicine, but the entire draft paper was leaked and posted October 6 on theCancer Letter Web site, in "an egregious breach of our embargo and media policies," according to the journal. The news has since been widely disseminated on the Internet; as a result, the journal published the paper early.

The USPSTF already recommends against routine PSA screening in men older than 75 years. In the new draft recommendation, it extends this to all men. It now recommends against routine screening in men younger than 75 years, giving this a "D" rating, which means "there is moderate or high certainty that the service has no benefit or that the harms outweigh the benefits."

The news is likely to spark a furor in medical circles, not unlike the outcry that followed the USPSTF's recommendation in 2009 against routine mammography screening for breast cancer in women younger than 50 years. This provoked outrage from some breast cancer experts, patient advocates, and professional societies, with accusations that this was a move toward the "rationing" of healthcare.

Angry reactions to the latest news have already begun. The "decision of no confidence on the PSA test by the US government condemns tens of thousands of men to die," said Skip Lockwood, CEO of ZERO, the Project to End Prostate Cancer. ZERO is sponsored by many organizations with a stake in prostate cancer, such as Abbott, Beckman Coulter, Accuray, CyberKnife, Dendreon, and the American Urological Association (AUA).

Based on Reviews of Trials

The recommended change is based on a review of 5 randomized trials of screening and 3 trials and 23 cohort studies of treatments. Included in the review were the 2 largest trials of PSA screening, which reported conflicting results, the USPSTF notes. The European study found a reduction in mortality after 9 years of screening, but the American trial, which had high crossover and contamination rates, found no reduction in mortality after 10 years of screening, as previously reported by Medscape Medical News.

The review also noted that treatment for prostate cancer, such as prostatectomy and radiation, is associated with risks for problems such as erectile dysfunction, urinary incontinence, and bowel dysfunction.

The USPTSF concludes that "after about 10 years, PSA-based screening results in small or no reduction in prostate-cancer-specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary."

Delay in Announcement

This recommendation has been a long time coming, according to reports in the October 7 issue of the Cancer Letter and in the New York Times magazine. They assert that the timing of the release of this recommendation was influenced by political considerations. According to these reports, the task force first voted to recommend against routine PSA screening back in November 2009, but this "caused a violent political firestorm," and subsequent follow-up meetings were cancelled. The final vote was taken in March. After this, a paper summarizing the recommendation was submitted to the Annals of Internal Medicine, where is it expected to appear next week.

PSA Test is Not Specific

The main problems with the PSA test are that it is not specific for prostate cancer and it cannot differentiate between aggressive and indolent forms of the disease.

"It cannot distinguish cancer that will never make a difference in a man's lifetime from cancers that will make a difference," so might prompt men to undergo aggressive treatment unnecessarily, Virginia Moyer, MD, MPH, chair of the USPTSF panel that made the recommendation, stated in an interview yesterday with Bloomberg News. "So you go from being a guy who feels fine and who is potentially one of the majority who would never have known they had this disease, to being a guy who wears adult diapers," she said. Dr. Moyer is a professor of pediatrics at Baylor College of Medicine in Houston, Texas.

The PSA test is "hardly more effective than a coin toss," said Richard Ablin, PhD, research professor of pathology at the University of Arizona College of Medicine in Tucson. Dr. Ablin discovered PSA in 1970. Using this test to screen for prostate cancer in the general population has been a "hugely expensive public health disaster," he wrote in an opinion piece in the New York Times last year.

"Drug companies continue peddling the tests, and advocacy groups push 'prostate cancer awareness' by encouraging men to get screened," he wrote. "The medical community must confront reality and stop the inappropriate use of PSA screening," he stated. "Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatment."

Although PSA testing is recognized as being imperfect, it is the only test for prostate cancer that is widely available, and it does provide information that can be useful, proponents point out. One of the professional bodies that has long supported the use of the test, the AUA, emphasizes that it should not be used on its own, but needs to be combined with other information (such as family history).

The AUA issued a statement in reaction to the new USPSTF recommendations: "We are concerned that the Task Force's recommendation will ultimately do more harm than good to the many men at risk for prostate cancer, both here in the United States and around the world."

"The AUA's current clinical recommendations support use of the PSA test, and it is our feeling that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pretreatment staging or risk assessment, and posttreatment monitoring of prostate cancer patients," according to the statement.

"Not all prostate cancers require active treatment and not all prostate cancers are life-threatening," the statement points out, and the decision of whether to proceed to active treatment or whether surveillance is an option needs to be discussed in detail with the patient.

The Agency for Healthcare Research and Quality supported this study. Author disclosure information is available on the Annals of Internal Medicine Web site.

Ann Intern Med. Published online October 7, 2011.

Related Link

The American Urological Association offers a downloadable pocket guide to the interpretation and use of Prostate Specific Antigen that includes diagnostic and management algorithms.

http://www.medscape.org/viewarticle/751461?src=cmemp
regards, taniafdi ^_^

Should Doctors Be Involved With a Patient's 'Spiritual Care'?

2011-11-01T15:40:00.002+07:00

by Shelly Reese

Science and religion have always had a complicated relationship, so it's not surprising that, as interest in holistic care grows, physicians are trying to come to grips with whether they should play a role in patients' spiritual care.

"We've always talked about the limitations of the biomedical model that would reduce people to our physiology," says Carol Taylor, PhD, director of the Center for Clinical Bioethics at Georgetown University. "When we talk about holistic health, we talk about biological, psychological, and social needs and now we're talking about spiritual needs as well. They're all interrelated."

More than half of physicians believe that religion and spirituality affect patient health in some way, according to research conducted by the University of Chicago. In a survey of 2000 physicians, 56% believed that religion and spirituality have much or very much influence on health, but only 6% believed they often changed "hard" medical outcomes.^[1]Rather, respondents suggested that religion and spirituality help patients cope, give them a positive state of mind, or provide emotional and practical support via the religious community.

While doctors might believe religion and spirituality influence health, acknowledging a connection raises some fundamental and tricky questions. The American College of Physicians' ethics manual encourages physicians to explore a patient's religion and spirituality as part of an overall physical. But how are they to do that? What does it mean, and what are they to do with the information?

Stethoscope and Spiritual Care?

Spirituality, broadly defined, is what gives a person's life meaning. Religion may or may not factor into the picture. In asking about spirituality, clinicians are seeking to identify a patient's source of hope, strength, and values, not their dogma or doctrine.

Research indicates that roughly 80% of medical schools now offer spiritual care courses or integrate spirituality into their curricula, according to Christina Puchalski, MD, an internist at George Washington University and director of the George Washington Institute for Spirituality and Health. But what's included and how it's taught differs tremendously from one institution to the next. In an effort to bring consistency to the spiritual history and assessment process, various proponents have development of myriad tools represented by apropos acronyms such as FAITH, SPIRIT, and HOPE as well as the slightly less catchy FICA and FACT.

Assessing a patient's spiritual health is important, because spiritual issues can not only impact a patient's health, but they can impact a patient's medical compliance and treatment choices as well, says Puchalski.

"What if they don't want to take medicines because they believe God will heal them? What if they're very nature-centric and don't want to put medications in their body? What if they don't believe in blood transfusions?" she asks. "Physicians need to know these concerns if they're going to treat a patient."

However, not everybody believes spiritual care belongs in the examination room. Indeed, those who oppose the idea present a litany of arguments: Spirituality is a private matter. Over-zealous physicians might abuse their position and proselytize to their patients. Pragmatically, many note that in the real world of 15-minute office visits, taking the time to ask questions about spirituality would come at the expense of addressing clinical issues.

Most worrisome says Richard Sloan, professor of behavioral medicine at Columbia University Medical Center and author of Blind Faith: The Unholy Alliance of Religion and Medicine, taking a spiritual history sets a doctor up to be a spiritual guide, "which they are completely untrained and unequipped to do."

"Nobody should deny that spirituality is important to a great many people, but I don't think it's grist for the physician's mill," he says. Doctors need to know about all facets of their patients' lives, he says, but shouldn't ask more than "Is spirituality important to you?" A simple "yes" or "no" answer suffices, he says.

As for the possibility that patients' spirituality might impact their care, Sloan notes that spiritual, financial, transportation, and other potential barriers to care are more likely to surface if a doctor asks, "Is there anything that would keep you from taking this medication?"

How do patients feel about the subject? Not surprisingly, it depends. World War II Army Chaplain William T. Cummings famously declared, "there are no atheists in fox holes." Patients seem to have the same sentiment when it comes to talking to physicians about their spirituality.

In a survey published in 2003 in the Journal of General Internal Medicine, researchers asked 456 outpatients in North Carolina, Florida, and Vermont whether they wanted their doctor to ask them about their spirituality. Only one third of respondents interviewed in a clinic setting liked the idea, but the number climbed to 40% in a hospital setting and 70% in hospice.^[2]

"Should we do this in every primary care practice and patient interaction?" asks Drew Rosielle, MD, director of the University of Minnesota's Hospice and Palliative Medicine Fellowship. "Realistically, of course not."

But when a doctor has a little more time, such as during an annual physical, or when a patient is faced with a major diagnosis, working a question or two about spirituality into the conversation can help a physician better understand and support a patient, he says. Rosielle routinely asks a couple of questions about spirituality as part of his initial palliative care consultation with patients so he can refer them to the chaplain on his care team if necessary.

"For patients who are not interested, it's a non-issue," he says. "You just move on. I've never had a patient get offended about being asked."

But for patients with spiritual concerns, the conversation helps him connect them with the support they need. "When you get sick -- especially when you're facing a terminal illness or a life-changing situation, it affects your entire being emotionally, spiritually, existentially," he says. "Patients are hungry for any support they can get."

Puchalski sites an example from her own experience. Several years ago her father, a devout Catholic, underwent surgery for colon cancer. Prior to the procedure, the nurse asked him whether he was spiritual and what that meant to him. A retired opera singer, he responded that he couldn't live without music. Intrigued, she asked him to sing and he responded with a heart-felt aria. Afterward he felt more relaxed and uplifted. The nurse noted his love of singing on his chart. After the operation, other clinicians read her notation and encouraged her father to sing as a way of exercising his lungs.

For her father, Puchalski says, bringing music into the hospital was a profoundly positive experience, "but how would the doctors and nurses have known that if the nurse hadn't asked the question?" she asks.

Assessing Spiritual Outlook

Still, fitting spiritual assessments into practice is a hodgepodge. "From what we've seen in our research almost nobody is using those acronyms," says Farr Curlin, MD, co-director of the Program on Medicine and Religion at the University of Chicago. "It's the rare physician who uses these pneumonic tools. Rather they try to pay attention to signs from the patient and then they try to query them to bring those issues out and connect the patient with spiritual resources in the community or their organization's pastoral care department."

Taylor, says clinicians are caught in a theory-practice gap.

"The problem is we say, 'spiritual care matters,' but we haven't gotten to the point where clinicians can identify spiritual need," she says.

References

Curlin FA, Sellergren SA, Lantos JD, Chin MH. Physicians' observations and interpretations of the influence of religion and spirituality on health. Arch Intern Med. 2007;167:649-654.
MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. J Gen Intern Med. 2003;18:38-43.

http://www.medscape.com/viewarticle/750959?src=mp&spon=25
regards, taniafdi ^_^

New Jurnals

2011-11-01T15:35:00.001+07:00

Prostate-Cancer Screening — What the U.S. Preventive Services Task Force Left Out.

One Man at a Time — Resolving the PSA Controversy.

The 2010 Dietary Guidelines — The Best Recipe for Health?

Evaluating Rivaroxaban for Nonvalvular Atrial Fibrillation — Regulatory Considerations.

Small-Airway Obstruction and Emphysema in Chronic Obstructive Pulmonary Disease.

German Outbreak of Escherichia coli O104:H4 Associated with Sprouts.

Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany.

Depression during Pregnancy.

Screening for Prostate Cancer.

regards, taniafdi ^_^

Wanita yang Dirindukan Surga

2011-09-10T19:31:00.000+07:00

Karakteristik wanita yang dijanjikan surga sebagaimana dalam Al-Qur'an dan Hadits :

1. Wanita yang taat menjalankan agama.

Siapa yang tak kenal istri Fir'aun, seorang wanita yang taat berpegang teguh dengan agama AllahSWT

sekalipun dia hidup di bawah seorang suami yang kafir. AllahSWT memberi gambaran yang indah dalam firmanNya : "Dan Allah membuat istri Fir'aun perumpamaan bagi orang-orang yang beriman, ketika ia berkata, "Ya Rabbku, bangunkanlah untukku sebuah rumah di sisiMu dalam Firdaus, dan selamatkanlah aku dari kaum yang zalim" (QS at-Tahrim (66): 11).

2. Wanita yang berhias dengan amal shalih.

"Sesungguhnya laki-laki dan perempuan yang muslim, laki-laki dan perempuan yang mukmin, laki-laki dan perempuan yang tetap dalam ketaatannya, laki-laki dan perempuan yang benar, laki-laki dan perempuan yang sabar, laki-laki dan perempuan yang khusyuk, laki-laki dan perempuan yang berpuasa, laki-laki dan perempuan yang memelihara kehormatannya, laki-laki dan perempuan yang banyak menyebut (nama) Allah, Allah telah menyediakan untuk mereka ampunan dan pahala yang besar (QS al-Ahzab (33): 35).

3. Wanita yang bagus dalam mendidik anak perempuan.

AisyahRA berkata, "Ada seorang wanita yang datang menemuiku sambil membawa kedua putrinya. Dia datang untuk meminta. Saat itu aku tidak punya apapun selain sebutir kurma. Akhirnya aku tetap memberikannya kepada wanita tersebut. Lantas wanita tadi membelah sebutir kurma menjadi dua untuk diberikan kepada kedua putrinya. Wanita tersebut tidak makan sama sekali, kemudian berdiri dan pergi. Lalu NabiSAW masuk menemuiku, maka aku pun menceritakan perihal wanita tersebut, mendengar hal tersebut lantas NabiSAW bersabda : Barang siapa diuji dengan anak-anak perempuan dengan sesuatu, kemudian dia tetap berbuat baik kepada mereka, maka anak-anak perempuan tersebut bisa menjadi penghalang baginya dari api neraka"

4. Wanita yang shalat lima waktu, puasa Ramadhan, dan menjaga kehormatannya.

Jalan menuju surga bagi kaum wanita sangat terbuka lebar. Di antara amalan yang dapat mengantarkan seorang wanita ke dalam surga adalah dengan menjaga shalat lima waktu, puasa Ramadhan, menjaga kemaluan dan kesucian dirinya serta taat kepada suami. RasulullahSAW bersabda : Apabila wanita shalat lima waktu, puasa bulan Ramadhan, dia menjaga kemaluannya, menaati suaminya, maka akan dikatakan padanya, "Masuklah ke dalam surga dari pintu mana saja yang engkau kehendaki"

5. Wanita yang sabar menerima penyakit.

Menurut hadits Atha' bin Abi Rabbah RA berkata : Ibnu Abbas RA pernah bercerita kepadaku, "Maukah aku tunjukkan kepadamu wanita penghuni surga? Ada seorang wanita yang datang kepada NabiSAW dan berkata, "Wahai Nabi, aku menderita penyakit sejenis ayan, apabila penyakit itu kumat aku tidak sadar sampai membuka auratku, berdo'alah kepada Alla agar menyembuhkanku,'NabiSAW berkata, Apabila kamu mau bersabar maka bagimu surga, tetapi apabila tidak maka saya bisa mendo'akanmu kepada Allah.' Wanita tadi menjawab.' Baiklah aku bersabar, tetapi do'akan agar aku tak sampai membuka aurat.' NabiSAW pun mendo'akannya."

6. Wanita yang tidak pernah menyakiti siapapun.

Abu Hurairah ra berkata."Ada yang bertanya kepada RasulullahSAW, ' Wahai Rasulullah, ada seorang wanita yang rajin shalat malam dan puasa di siang hari serta bersedekah juga, tetapi dia menyakiti tetangganya dengan lisannya!' Maka RasulullahSAW menjawab,"Tidak ada kebaikan padanya, dia termasuk penghuni neraka!' Mereka bertanya kembali,'Di sana ada seorang wanita yang hanya shalat wajib dan bersedekah dengan sepotong keju, tetapi dia tidak pernah menyakiti siapa pun?'RasulullahSAW menjawab.'Dia penghuni surga'.

7. Wanita yang selalu mencari keridhaan suami.

RasulullahSAW bersabda : Maukah kalian aku kabari tentang para wanita penghuni surga? Yaitu wanita yang pengasih, banyak anak, dan berperilaku baik. Jika ia dizalimi (suaminya marah kepadanya), atau ia berbuat zalim (kepada suaminya) ia akan berkata, "Ini tanganku berada di tanganmu. Aku tidak bisa memejamkan mataku hingga engkau ridha".

8. Wanita yang taat kepada suami dalam hal kebaikan.

Hushain bin Muhshin ra berkata: Bibiku telah menceritakan kepadaku, "Aku pernah datang menemui RasulullahSAW untuk sebuah keperluan, RasulullahSAW berkata, 'Ada apa ini, apakah engkau punya suami?' Aku menjawab,'Ya', RasulullahSAW kembali bertanya,'Bagaimana ketaatanmu kepadanya?'Aku menjawab.'Aku tidak pernah meremehkan ketaatan dan penganbdian kepadanya, kecuali jika aku tidak mampu.'RasulullahSAW menjawab,'Lihatlah dirimu,sejauh mana kedudukanmu di mata suamimu,dia adalah surga dan neraka bagimu.'

9. Wanita yang menyayangi binatang.

Alkisah, ada seekor anjing sedang berada di sekitar sumur air. Anjing itu hampir-hampir mati karena kehausan. Tidak jauh dari sumur, ada seorang wanita pezina dari kalangan Bani Israil. Lantas, dengan sigap wanita itu pun melepas sepatunya dan mengambil air dari sumur, kemudian meminumkan air itu kepada anjing tersebut. Akhirnya, wanita tersebut diampuni AllahSWT disebabkan perbuatannya (memberi minum anjing).

10. Wanita yang amar ma'ruf nahi munkar.

AllahSWT berfirman : Dan orang-orang yang beriman, lelaki dan perempuan, sebagian mereka (adalah) menjadi penolong bagi sebagian yang lain. Mereka menyuruh (mengerjakan) yang ma'ruf, mencegah dari yang munkar, mendirikan shalat, menunaikan zakat, dan mereka taat kepada Allah dan Rasul-Nya. Mereka itu akan diberi rahmat oleh Allah. Sesungguhnya Allah Maha Perkasa lagi Maha Bijaknsana. (QS at-Taubah (9):71)

Syaikh Ibnu Utsaimin ra mengatakan, "Di dalam ayat ini terdapat dalil bahwasanya tugas amar ma'ruf nahi munkar bukan hanya khusus bagi laki-laki saja, bahkan kaum wanita juga wajib untuk memerintahkan kebaikan dan mencegah dari yang munkar. Akan tetapi, hal itu dilakukan di medannya kaum wanita, perkumpulan kaum wanita, bukan di perkumpulan kaum lelaki atau di pasar yang banyak kaum lelakinya."

Sumber : Abu Anisah Syahrul Fatwa bin Lukman. Majalah Al-Furqon, No.117. Edisi-2. Tahun ke 11. Syawal 1432 H. Sept-Okt 2011.

regards, taniafdi ^_^

Journals

2011-08-03T17:22:00.000+07:00

New Regimens to Prevent Tuberculosis in Adults with HIV Infection.

A Hemodynamic Study of Pulmonary Hypertension in Sickle Cell Disease.

Origins of the E. coli Strain Causing an Outbreak of Hemolytic–Uremic Syndrome in Germany.

Primary Isoniazid Prophylaxis against Tuberculosis in HIV-Exposed Children.

Febrile Urinary Tract Infections in Children.

The Coagulopathy of Chronic Liver Disease.

regards, taniafdi ^_^

Vegetarian Diet Reduces Risk for Bowel Disorder

2011-08-03T17:18:00.004+07:00

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

CME Released: 07/22/2011; Valid for credit through 07/22/2012

Clinical Context

Most patients in the United Kingdom do not receive the recommended daily allowance for dietary fiber, and the authors of the current study describe how this might contribute to rising rates of diverticular disease. High levels of consumption of dietary fiber are associated with more rapid bowel transit times and increased frequency of bowel movements. This leads to less water reabsorption from the stools and softer, larger stools that are easier to pass. The overall effect of these actions is less pressure on the colonic wall and, possibly, less diverticular disease.

The current study by Crowe and colleagues examines the effects of vegetarianism and the amount of dietary fiber on the risk for diverticular disease.

Study Synopsis and Perspective

Following a vegetarian diet and having a high intake of dietary fiber are associated with a lower risk for diverticular disease, according to the results of a prospective cohort study reported online July 19 in the BMJ.

"Diverticular disease has been termed a 'disease of western civilisation' because of its high prevalence in countries like the United Kingdom and United States compared with certain parts of Africa," write Francesca L. Crowe, nutritional epidemiologist at the Cancer Epidemiology Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom, and colleagues. "We examined the associations of vegetarianism and the intake of dietary fibre (defined as non-starch polysaccharides) with the risk of diverticular disease using information from hospital admission data and death certificates for England and Scotland in men and women taking part in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Oxford cohort."

The study cohort consisted of 47,033 men and women living in England or Scotland and enrolled in EPIC-Oxford, a cohort of predominantly health-conscious participants recruited throughout the United Kingdom. Of these, 15,459 (33%) reported consuming a vegetarian diet at baseline. A 130-item, validated food frequency questionnaire was used to estimate dietary fiber intake.

Linkage with hospital records and death certificates allowed identification of cases of diverticular disease. Multivariate Cox proportional hazards regression models allowed estimation of hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk for diverticular disease by diet group and quintiles of dietary fiber intake.

Of 812 cases of diverticular disease identified during follow-up (mean duration, 11.6 years), 806 were hospital admissions and 6 were deaths. Compared with meat eaters, vegetarians had a 31% lower risk for diverticular disease, after adjustment for confounding variables including smoking, alcohol use, and body mass index (relative risk, 0.69; 95% CI, 0.55 - 0.86). Meat eaters between the ages of 50 and 70 years had a 4.4% cumulative probability of hospitalization or death from diverticular disease vs 3.0% for vegetarians.

The risk for diverticular disease was also inversely associated with dietary fiber intake. Compared with participants in the lowest quintile of dietary fiber intake (< 14 g/day for both women and men), those in the highest quintile (≥ 25.5 g/day for women and ≥ 26.1 g/day for men) had a 41% lower risk for diverticular disease (HR, 0.59; 95% CI, 0.46 - 0.78; P < .001 trend).

Vegetarian diet and higher fiber intake were each significantly associated with a lower risk for diverticular disease, after mutual adjustment.

"Consuming a vegetarian diet and a high intake of dietary fibre were both associated with a lower risk of admission to hospital or death from diverticular disease," the study authors write.

Limitations of this study include unmeasured confounding, possible lack of generalizability, the possibility that vegetarians would undergo fewer tests and/or that meat eaters would have more gastrointestinal tract symptoms resulting in a diagnosis of diverticular disease, and undetermined validity of a diagnosis of diverticular disease from hospital records.

In an accompanying editorial, David J. Humes and Joe West, from Nottingham University Hospital, in Nottingham, United Kingdom, note that the findings must be interpreted in the light of these limitations.

"At a population level, if the available absolute risks are converted into a number needed to treat, about 71 meat eaters would have to become vegetarians to prevent one diagnosis of diverticular disease as measured in this study," Drs. Humes and West write. "...Overall the opportunity for preventing the occurrence of diverticular disease and other conditions, such as colorectal cancer, probably lies in the modification of diet, at either a population or an individual level. However, far more evidence is needed before dietary recommendations can be made to the general public."

Cancer Research UK funded the EPIC study. One of the study authors reports being a member of the Vegan Society. Drs. Humes and West have disclosed no relevant financial relationships.

BMJ. 2011;343:d4115, d4131.

Study Highlights

Study data were drawn from the EPIC-Oxford cohort. All participants were at least 20 years old and resided in the United Kingdom.
Participants completed a questionnaire at baseline that estimated the intake of 130 different foods and beverages during the past year. Vegetarians were defined as individuals who did not eat meat or fish. Participants who did not consume meat, fish, eggs, or dairy products were considered vegans.
The questionnaire also inquired regarding demographic, health habit, and past medical data.
The main study outcome was the relationship between vegetarianism, the amount of dietary fiber, and the incidence of diverticular disease, which was ascertained from hospital admission billing or death codes for diverticulosis, diverticulitis, and diverticulum of the small or large intestine.
47,033 adults provided study information, and 76% of participants were women. The mean follow-up period was 11.6 years.
35% of men and 32% of women were vegetarians. Vegetarians were younger than nonvegetarians, and nonvegetarians had higher body mass index values.
Rates of diabetes, hypertension, or hyperlipidemia were 2 to 3 times higher among nonvegetarians vs vegetarians.
There were 812 cases of diverticular disease during the follow-up period.
Smoking was associated with a higher risk for diverticular disease, including an 86% increased risk for diverticular disease among heavy smokers vs nonsmokers.
Higher body mass index was also associated with a higher risk for diverticular disease, as was hypertension, hyperlipidemia, and the use of female hormone therapy.
The overall rates of hospitalization or death from diverticular disease were 4.4% among nonvegetarians and 3.0% among vegetarians and vegans.
Compared with nonvegetarians, vegetarians had a relative risk for 0.69 for the development of diverticular disease (95% CI, 0.55 - 0.86). Vegans had an even lower risk for diverticular disease vs nonvegetarians (relative risk, 0.28; 95% CI, 0.10 - 0.74).
The duration of vegetarianism had no significant effect on the risk for diverticular disease.
The quantity of meat consumed among nonvegetarians also failed to affect the risk for diverticular disease.
In contrast, there was a significant inverse association between the consumption of dietary fiber and the risk for diverticular disease. Participants in the highest fifth of dietary fiber consumption (at least 25.5 g/day among women and 26.1 g/day among men) had a 41% lower risk for diverticular disease (relative risk, 0.59; 95% CI, 0.46 - 0.78; P < .001 trend) vs participants in the lowest fifth of dietary fiber consumption (< 14 g/day).
The main study results were similar in subgroup analyses based on participants' sex and age.

Clinical Implications

Rates of diverticular disease have increased, as recommendations for intake of dietary fiber are not met. High levels of consumption of dietary fiber are associated with more rapid bowel transit times, less water reabsorption from the stool, and increased frequency of bowel movements.
The current study suggests that vegetarianism and higher degrees of dietary fiber intake are associated with a lower risk for diverticular disease.

From : medscape

regards, taniafdi ^_^

Milk and Soy Protein Intake Reduce Systolic BP

2011-08-03T17:10:00.000+07:00

News Author: Lisa Nainggolan
CME Author: Désirée Lie, MD, MSEd

CME Released: 07/21/2011; Valid for credit through 07/21/2012

Clinical Context

According to He and colleagues, hypertension is highly prevalent, and a 2-mm Hg reduction in systolic blood pressure (BP) could lead to a 6% reduction in stroke mortality rates, a 4% reduction in coronary artery mortality rates, and a 3% reduction in all-cause mortality rates. A diet rich in dairy products has been shown to reduce BP in clinical trials, perhaps because of the high content of potassium and calcium in these diets.

This randomized, double-blind, crossover trial compares the effect of soy protein, milk protein, and refined carbohydrates on systolic and diastolic BP in adults with prehypertension or stage I hypertension.

Study Synopsis and Perspective

Both soy protein and milk reduce systolic BP compared with carbohydrates, according to the first randomized controlled trial to directly compare the effects of these two proteins with carbohydrate [1].

The trial found that 40 g/day of soy protein and 40 g/day of milk protein both reduced systolic BP by approximately 2 mm Hg compared with 40 g/day of carbohydrate over eight weeks. While this is a small change for an individual, at a population level such a drop would translate into a 6% reduction in stroke mortality, a 4% cut in coronary heart disease deaths, and a 3% fall in all-cause mortality, say Dr Jiang He (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA) and colleagues in their paper published inCirculation.

"Our study suggests that partially replacing carbohydrate with soy or milk protein might be an important component of nutrition intervention strategies for the prevention and treatment of hypertension," He told heartwire. He added that increasing intake of low-fat milk and other low-fat dairy products, soy milk, and beans would help achieve this goal.

First Study to Show Milk Lowers BP in Pre- and Early Stage Hypertension

He, an epidemiologist, and colleagues note that prior observational epidemiologic studies that looked at the relationship between dietary protein intake and BP have reported inconsistent findings. They also note that there are very limited data from randomized controlled trials to assess the effect of dietary protein on BP, and in most of these trials, change in BP was not the primary outcome and sample sizes were small.

In their study, they compared the effect of soy protein, milk protein, and complex carbohydrate supplementation on BP in a randomized, double-blind crossover trial in 352 adults with pre- or stage 1 hypertension between 2003 and 2008.

Participants were randomized to 40 g/day of soy protein, milk protein, or carbohydrate each, taken as powder supplements dissolved in water, for eight weeks in random order, and with a three-week washout period between interventions. The supplements used were formulated in a way that ensured they had the same sodium, potassium, and calcium content, so that the changes observed were not due to changes in the intake of these minerals.

BP readings were taken three times at each of two clinic visits--two before and two after each eight-week phase--to give a net BP change for each supplement period.

Compared with carbohydrate controls, soy protein and milk protein were significantly associated with a 2.0 mm Hg (p=0.002) and 2.3 mm Hg (p=0.0007) net decrease in systolic BP, respectively.

"The present study provides further evidence that soy protein supplementation reduces BP [and] to the best of our knowledge, this is the first clinical trial to document that milk protein lowers BP in prehypertension and stage 1 hypertension," the researchers note.

Despite these encouraging findings, further long-term randomized controlled trials are needed to examine the effects of various dietary proteins on BP, and to make specific recommendations for dietary changes, they conclude.

The authors report no conflicts of interest.

References

He J, Wofford MR, Reynolds K, et al. Effect of dietary protein supplementation on blood pressure. A randomized controlled trial. Circulation 2011; doi:10.1161/circulationaha.110.009159. Available at:http://circ.ahajournals.org/

Study Highlights

The Protein and Blood Pressure study was a randomized, double-blind, placebo-controlled phase 3 clinical trial to test whether soy or milk protein supplementation would reduce BP compared with a complex carbohydrate.
A crossover design was used with 3 intervention phases.
Between 2003 and 2008, participants were allocated to either 40 g of soy protein, 40 g of milk protein, or 40 g of complex carbohydrate, each for 8 weeks, after a 2-week washout, with random sequence and 3 weeks between each intervention.
3 groups of participants received the 3 dietary interventions in 3 different orders.
Inclusion criteria were age 22 years or older, and a mean systolic BP of 120 to 159 mm Hg and a diastolic BP of 80 to 95 mm Hg at 6 readings during 2 screening visits.
Excluded were patients receiving antihypertensive medication; those with a systolic BP of 160 mm Hg or higher or a diastolic BP of 95 mm Hg or higher; those who reported kidney disease, diabetes mellitus, or cardiovascular disease; those with body mass index of more than 40 kg/m²; those who consumed more than 14 alcoholic drinks per week; or those with a current or intended pregnancy.
The participants were recruited by mass mailing, worksite, and community-based BP screenings in 2 cities.
The soy protein, milk protein, and complex carbohydrate supplements were provided by a single producer. There were comparable amounts of sodium, potassium, and calcium in each supplement.
2 baseline and 2 termination visits were made for each of the phases of intervention and 3 BP measurements at each visit.
Mean age of the participants was 47 years, 58% were men, one third were black, 45% reported alcohol intake, and 5% to 11% were current smokers.
Mean systolic/diastolic BP was 126.7/82.4 mm Hg.
18.5% of patients had hypertension.
80.7% had BP measured at the end of supplementation with soy protein, 81.3% after supplementation with milk protein, and 81.5% after carbohydrate supplementation.
On average, dietary protein intake was significantly increased in both the soy (30.5 g/day) and milk protein (32.8 g/day) groups but not in the carbohydrate group.
Carbohydrate intake was significantly decreased in the soy protein (by 30.7 g/day) and milk protein (30.6 g/day) supplementation phases but was increased in the carbohydrate phase.
Urinary excretion of urea was significantly increased during the soy and milk protein phases but not in the carbohydrate phase.
Mean systolic BP was reduced by 1.5 mm Hg from baseline during the soy protein phase and by 1.8 mm Hg during the milk protein phase but not during the carbohydrate phase.
Diastolic BP was not significantly different during the 3 phases.
Compared with the carbohydrate phase, the soy protein phase was associated with a 2.0-mm Hg reduction in systolic BP (P = .002), and the milk protein phase was associated with a 2.3-mm Hg lower systolic BP (P = .0007).
No significant difference in BP reductions were seen for the soy protein phase vs the milk protein phase.
Adverse effects were similar among the 3 phases and consisted of appetite change, nausea, and stomach pains.
The authors concluded that dietary supplementation with soy or milk protein compared with complex carbohydrates was associated with a clinically significant reduction in systolic BP in patients with prehypertension or stage I hypertension.

Clinical Implications

Supplementation with soy protein or milk protein compared with complex carbohydrates is associated with a reduction of 2 to 2.3 mm Hg in systolic BP in patients with prehypertension or stage I hypertension.
Supplementation with soy protein or milk protein compared with complex carbohydrates is not associated with a reduction in diastolic BP in patients with prehypertension or stage I hypertension.

http://www.medscape.org/viewarticle/746757?src=cmemp

regards, taniafdi ^_^

CDC Releases New Guidelines for Infection Prevention in Outpatients

2011-08-03T16:58:00.003+07:00

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

CME/CE Released: 07/20/2011; Valid for credit through 07/20/2012

Clinical Context

The majority of medicine is practiced in ambulatory settings, and the authors of the current recommendations provide a review of this care. They state that the total number of office medical visits in the United States reached 1 billion in 2007. The average person makes approximately 3 visits to a clinician's office per year. In addition, more than three quarters of all operations in the United States are performed in settings outside of the hospital.

Ambulatory care facilities may not always maintain the same rigor in infection control practices as hospitals. The current recommendations by the US Centers for Disease Control and Prevention (CDC) describe systemic and personal means to implement effective infection control in ambulatory health centers.

Study Synopsis and Perspective

Each outpatient practice should identify an infection prevention leader, according to a new concise guide and checklist issued by the CDC and reported online July 13. The new recommendations, which aim to protect patients by informing clinicians about minimal expectations of safe care, target healthcare providers in outpatient care settings.

Despite the recent dramatic rise in medical care in outpatient settings, compliance with standard infection prevention practices is often poor in these facilities, which include endoscopy clinics, surgery centers, primary care offices, pain management clinics, urgent care centers, public health clinics, imaging centers, oncology clinics, outpatient behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, and also hospital-based outpatient departments and clinics.

"Patients deserve the same basic levels of protection in a hospital or any other health care setting," said Michael Bell, MD, deputy director of CDC's Division of Healthcare Quality Promotion, in a news release. "Failure to follow standard precautions, such as correct injection practices, cannot be tolerated. Repeated outbreaks resulting from unsafe practices, along with breaches of infection control noted in ambulatory surgical centers during inspections by the Centers for Medicare and Medicaid, indicate the need for better infection prevention across our entire health care system, including outpatient settings."

In the United States, clinicians at outpatient facilities currently perform more than 75% of all surgical procedures. Between 1995 and 2007, the average number of outpatient visits to physician offices was 3 per person per year, resulting in a total of nearly 1 billion physician office visits by 2007.

Because a significant proportion of outpatients come from vulnerable patient populations, it is essential that clinicians offer care under conditions that minimize the risk for healthcare-associated infections (HAIs).

On the basis of currently available, evidence-based CDC guidelines mostly used by hospitals but applicable to a variety of healthcare settings, the easy-reference guide uses Standard Precautions as the foundation to prevent transmission of infectious agents during patient care in all healthcare settings. Accompanying materials include an Infection Prevention Checklist for Outpatient Settings and supporting materials.

Among the supporting materials is a new, no-cost, certified continuing medical education video course for clinicians in all healthcare settings, titled Unsafe Injection Practices: Outbreaks, Incidents, and Root Causes . The video course, which is offered on the Medscape Education Web site, was developed by the CDC in collaboration with the Safe Injection Practices Coalition, a partnership of healthcare-related organizations convened to facilitate safe injection practices in all US healthcare settings.

For internal evaluation, a facility or practice can use these materials, which complement ongoing CDC and Centers for Medicare and Medicaid efforts to integrate CDC recommendations into Centers for Medicare and Medicaid surveys used while inspecting ambulatory surgery centers and other outpatient settings.

One of the leading recommendations in the new guide is that all outpatient practices should designate 1 or more persons specifically trained in infection control to be on staff or regularly available. The infection control leader(s) should play an important role in developing a written policy to prevent and contain infection and should regularly communicate with the other healthcare providers regarding specifically identified issues or concerns.

Other Recommendations

Other recommendations for outpatient facilities and practices include the following:

Infection prevention and occupational health programs should be developed, implemented, and maintained.
Written infection prevention policies and procedures, based on evidence-based guidelines, regulations, or standards, should be developed to address services provided by each facility.
All healthcare personnel, including those employed by outside agencies and available by contract or on a volunteer basis to the facility, should receive job- or task-specific infection prevention education and training focusing on principles of both healthcare provider safety and patient safety.
Sufficient and appropriate supplies needed to comply with standard precautions should always be available. These precautions should include hand hygiene, use of personal protective equipment, safe injection practices, respiratory precautions, cough etiquette, and environmental cleaning and maintenance of reusable medical equipment according to the maker's instructions.
Staff's compliance with infection prevention practices should be monitored regularly with audits and competency evaluations.
To evaluate infection control practices, facilities should use CDC's infection prevention checklist for outpatient settings.
Facilities should comply with local, state, and federal requirements regarding HAI surveillance, reportable diseases, and outbreak reporting.
Healthcare personnel should always follow procedures to ensure safe handling of medical equipment that may be contaminated.
Healthcare personnel should always follow safe medical injection practices.

Additional resources, including the guide, checklist, continuing medical education course, CDC and external commentary about the guide, clinician and patient education materials, a CDC Safe Surgery feature, and other supporting materials are available in the guidelines.

"The majority of ambulatory care settings are not designed to implement all of the isolation practices and other Transmission-Based Precautions (e.g., Airborne Precautions for patients with suspected tuberculosis, measles or chicken pox) that are recommended for hospital settings," the guide states. "Nonetheless, specific syndromes involving diagnostic uncertainty (e.g., diarrhea, febrile respiratory illness, febrile rash) are routinely encountered in ambulatory settings and deserve appropriate triage. Facilities should develop and implement systems for early detection and management of potentially infectious patients at initial points of entry to the facility."

"To the extent possible, this includes prompt placement of such patients into a single-patient room and a systematic approach to transfer when appropriate," the guide concludes. "When arranging for patient transfer, facilities should inform the transporting agency and the accepting facility of the suspected infection type."

CDC. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. Published online July 13, 2011.

Study Highlights

The ambulatory facility should have access to at least 1 individual trained in infection control practices. This person should establish and communicate standards for infection control, which might vary based on the type of ambulatory practice.
The infection control administrator should also ensure compliance with safety practices such as vaccinations for healthcare workers and post-exposure prophylaxis in case of unintended injuries.
Finally, the infection control expert should coordinate and evaluate efforts to train healthcare personnel in habits to prevent the spread of infection, such as hand hygiene.
Infection control training for healthcare personnel should focus on the safety of both practitioners and patients.
Training should be repeated regularly, and all trainees should demonstrate competency in the practice of infection control germane to their responsibilities.
At a minimum, ambulatory sites should adhere to established requirements for reporting communicable diseases. Regular surveys may help to ensure compliance with recommended protocols to prevent the spread of infection.
Standard practices in infection control expected of all healthcare facilities include hand washing, use of personal protective equipment, safe injection practices, safe handling of contaminated surfaces in a patient care environment, and respiratory/cough hygiene.
Alcohol-based hand rubs should be the primary means of hand hygiene in practice, given their ease of use and efficacy against most pathogens. Hand rubs are also faster and less irritating to the hands vs hand washing with soap and water.
Nonetheless, soap and water should be used when the provider's hands are visibly soiled or after caring for a patient with a known communicable disease.
The provider should practice hand hygiene before touching a patient, even if wearing gloves, and on leaving the patient care area. Hands should also be cleansed after gloves are removed.
Vials of injected medications should ideally be assigned to only 1 patient. Similarly, fluid and infusion equipment should be used for only 1 patient.
A syringe should never be reused to enter a medication vial or solution.
The healthcare facility should attempt to control the possible transmission of infections via aerosol or droplets from the moment a patient enters that facility. Signs should alert patients to cover their mouths and noses when coughing and sneezing. Tissues should be provided, with no-touch receptacles to discard them after use.
Hand hygiene should be available in patient waiting areas, and masks should be offered to patients who cough or sneeze.
The facility may consider a separate waiting area for patients with possible infectious respiratory tract illness.

Clinical Implications

Alcohol-based hand rubs should be the primary means of hand hygiene in practice. They are faster and less irritating to the hands vs hand washing with soap and water. The provider should practice hand hygiene before touching a patient, even if wearing gloves, and on leaving the patient care area.
Means to reduce the spread of infectious respiratory tract illness in healthcare facilities include the provision of tissues, hand hygiene available in patient waiting areas, masks for patients who cough or sneeze, and a separate waiting area for patients with possible infectious respiratory tract illness.

http://www.medscape.org/viewarticle/746666?src=cmemp

regards, taniafdi ^_^

QS. Ar-Ra'd/13:26

2011-07-29T06:34:00.002+07:00

"Allah meluaskan rezki dan menyempitkannya bagi siapa yang Dia kehendaki. Mereka bergembira dengan kehidupan di dunia, padahal kehidupan dunia itu (dibanding dengan) kehidupan di akhirat, hanyalah kesenangan (yang sedikit)"

regards, taniafdi ^_^

Hematuria Jarang Berhubungan Dengan Kanker Saluran Kemih

2011-07-27T18:14:00.000+07:00

Dr. Howard Jung dari Kaiser Permanente, Los Angeles, mengatakan bahwa studi ini merupakan tantangan terhadap panduan klinik yang ada sekarang di mana mungkin merekomendasikan secara berlebih untuk dilakukan pemindaian yang mahal dan melibatkan paparan radiasi yang bermakna untuk pasien yang mempunyai bukti mikroskopik adanya darah di urinnya.

Panduan American Urological Association (AUA) menganjurkan evaluasi kanker saluran kemih pada pasien dengan mikrohematuria asimptomatik dengan menggunakan pencitraan saluran kemih bagian atas, sitologi urin dan sitoskopi. Panduan di Kanada mirip terapi terbatas pada mereka yang berusia > 40 tahun.

Untuk itu, peneliti mempelajari data 309.402 pasien yang telah menjalani urinalisis mikroskopik, di mana 156.691 menderita hematuria. setelah 3 tahun follow-up, insidensi kanker saluran kemih secara keseluruhan adalah 0,43%. Sedangkan insidensinya pada pasien hematuria adalah 0,68% dan non-hematuria adalah 0,18%. Insidensi kanker pada pasien perempuan usia < 40 tahun adalah < 0,07% dan 0,43% pada laki-laki tanpa memandang derajat hematuria. Risiko kanker meningkat dikaitkan dengan usia > 40 tahun (OR 17), hematuria (25 sel darah merah per lapangan pandang) (OR 4,0) dan laki-laki (OR 4,8).

Defenisi AUA mengenai mikrohematuria mempunyai sensitivitas 50%, spesifikasi 84%, dan nilai prediktif positif 1,3% . Menerapkan panduan dari Kanada, secara potensial menghemat 14.333 evaluasi tetapi dengan akibat kehilangan 12 kasus kanker saluran kemih.

Pendekatan alternatif yang diusulkan untuk mengevaluasi pasien dengan usia > 40 tahun adalah dengan paling sedikit 1 kali urinalisis yang menunjukkan sel darah merah >25/lapangan pandang. Dibandingkan AUA, metode ini menghemat 25.917 evaluasi dan mendeteksi 6 kasus kanker uriner lagi. Dibandingan dengan cara Kanada, akan menghemat 11.584 evauasi dan mendeteksi 16 kasus lagi.

Paparan radiasi akibat pemindaian dapat meningkatkan risiko individu untuk menderita kanker. Demikian pula, tes yang tidak perlu berkontribusi terhadap krisis perawatan kesehatan dan biaya berlebih.

Journal of Urology 2011;185:1698-1703. MedicalUpDate July 2011.

regards, taniafdi ^_^

Saxagliptin

2011-07-27T15:13:00.001+07:00

Seperti diketahui, mayoritas pasien diabetes tipe 2 akan kesulitan mencapai atau mempertahankan target glikemik mereka, sehingga akhirnya memerlukan terapi kombinasi 2 obat antidiabetes (OAD) atau lebih, terkait dengan penurunan progresif fungsi sel beta. Saat ini, beberapa studi klinis membuktikan Saxagliptin (OAD golongan baru, yaitu penghambat DPP-4), teruji efektif dan dapat ditoleransi dengan baik sebagai terapi kombinasi dengan OAD golongan terdahulu (seperti sulfonilurea, metformin, dan thiazolidinedione/TZD), untuk memperbaiki kontrol glikemik pasien-pasien diabetes tipe 2, yang kondisinya tidak terkontrol dengan monoterapi OAD saja.

Saxagliptin merupakan penghambat kuat enzim dipeptidil peptidase-4 selektif (penghambat DPP-4), yang diformulasikan untuk menghasilkan efek hambatan enzim DPP-4 yang lebih lama. Penghambatan DPP-4 akan meningkatkan kadar hormon GLP-1 (glocagon like peptide-1) dan GIP (glucose dependent insulinotropic peptide), dua jenis hormon pengatur homeostasis glukosa darah yang bekerja menstimulasi sintesis dan penglepasan insulin, serta menghambat pengosongan lambung dan sekresi glukagon. Obat-obat penghambat DPP-4 diketahui memiliki profil keamanan yang baik, termasuk resiko hipoglikemia yang rendah terkait kerjanya yang glucose-dependet dan efek terhadap berat badan yang netral.

Tiga studi klinis baru-baru ini mengungkapkan efektivitas dan keamanan terapi saxagliptin sekali sehari sebagai terapi tambahan pada sulfonilurea, metformin, dan TZD. Berikut sekilas ulasan ketiga studi klinis tersebut.

Saxagliptin sebagai terapi tambahan sulfonilurea dosis submaksimal hasilkan kontrol glikemik yang lebih baik, dibanding peningkatan dosis sulfonilurea. Hasil studi ini menunjukkan 92% pada kelompok monoterapi membutuhkan peningkatan dosis glibenklamid. Penambahan saxagliptin 2,5 dan 5 mg menghasilkan rerata penurunan signifikan pada minggu ke-24 vs peningkatan dosis glibenklamid saja. Proporsi pasien yang mampu mencapai target A1c <7% terlihat lebih besar pada kelompok saxagliptin vs monoterapi, dan juga didapatkan penurunan postprandial glucose area under the curve/PPG AUC untuk kelompok saxagliptin vs monoterapi. Sementara itu, kejadian efek samping yang terjadi (termasuk hipoglikemia) tampak serupa pada semua kelompok.

Saxagliptin sekali sehari plus metformin merupakan terapi pilihan untuk penanganan pasien-pasien diabetes tipe 2 yang tidak terkontrol hanya dengan monoterapi metformin. Hasil studi menunjukkan terapi saxagliptin (2,5; 5; dan 10 mg) plus metformin sampai dengan minggu ke-24, secara signifikan mampu menghasilkan rerata penurunan nilai A1c, glukosa plasma puasa dan PPG, bila dibandingkan dengan monoterapi metformin. Proporsi pasien dengan A1c <7% terlihat lebih besar pada kelompok saxagliptin. Fungsi sel beta dan postprandial c-peptide, insulin, dan glukagon AUC juga terlihat lebih baik pada kelompok saxagliptin. Insidensi efek samping hipoglikemia dan penurunan berat badan sebanding dengan plasebo.

Penambahan saxagliptin pada terapi TZD hasilkan perbaikan kontrol glikemis klinis penting dan dapat ditoleransi dengan baik, dibanding monoterapi TZD. hasil studi menunjukkan pada minggu ke-24, terapi saxagliptin (2,5 dan 5 mg) plus TZD menghasilkan penurunan rerata yang signifikan vs plasebo untuk nilai A1c dan glukosa plasma puasa. Proporsi pasien dengan A1c <7% lebih besar pada kelompok saxagliptin vs plasebo. PPG AUC juga dapat diturunkan secara signifikan. Saxagliptin juga diperlihatkan secara umum dapat ditoleransi dengan baik.

- Int J Clin Pract 2009;63(9):1359-1406.

- Diabetes Care 2009;32:1649-55.

- J Clin Endocrinol Metab 2009;94:4810-19.

Source : MedicalUpDate / July 2011

regards, taniafdi ^_^

Sukses Potty Dalam 7 Hari

2011-07-27T12:46:00.003+07:00

Hari ke-1 :

Ajak si kecil buang air kecil (BAK) setiap 15 menit sekali dan buang air besar (BAB) di waktu ia biasa melakukannya.

Hari ke-2 :

Berikan kesempatan kepada si kecil untuk telanjang atau tanpa popok di rumah. jadi, saat ia ingin buang air, ia akan melakukannya dengan benar.

Hari ke-3 :

Kurangi minum saat menjelang tidur malam. Sebelum tidur, ajak si kecil untuk buang air.

Hari ke-4 :

Tetap semangati si kecil walaupun ia tidak sengaja buang air di luar potty.

Hari ke-5 :

Contohkan bagaimana harus melakukan urusan buang air ini di kamar kecil. Jika anak anda laki-laki, minta suami mengajarinya melakukan BAK.

Hari ke-6 :

Ajak si kecil datang lebih pagi ke sekolahnya, bawa ia ke kamar kecil sebelum kelas dimulai. Beri juga informasi kepada guru si kecil bahwa si kecil sedang berlatih buang air sendiri.

Hari ke-7 :

Beri hadiah jika si kecil bisa menggenapi beberapa hari tantangan (yang telah anda dan si kecil sepakati) tanpa mengompol atau BAB di celana.

Mother and Baby / Agustus 2011.

regards, taniafdi ^_^