Free Medical Update

Evaluation of Hypertension

2008-09-21T22:21:00.000+07:00

Hypertension significantly increases the risk of developing coronary disease, heart failure, renal failure, and stroke. Risk further increases dramatically in the presence of smoking, glucose intolerance, hyperlipidemia, left ventricular hypertrophy (LVH), male gender, African American race, or increasing age. Treatment of hypertension greatly reduces its morbidity and mortality risks
The definition of hypertension is somewhat arbitrary because actuarial data show that morbidity and mortality related to complications of hypertension increase almost linearly with increasing levels of either systolic blood pressure (SBP) or diastolic blood pressure (DBP).

Classification
The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC), a national consensus group, has issued several reports that include recommendations of the classification of hypertension. they designate three stages:
• Prehypertension: DBP 80 to 89 mm Hg, SBP 120 to 139 mm Hg
• Stage 1: DBP 90 to 99 mm Hg, SBP 140 to 159 mm Hg
• Stage 2: DBP 100 mm Hg or greater, SBP 160 mm Hg or greater.
Establishing the Diagnosis
1. Measurement of Blood Pressure
Blood pressure is properly measured in both arms while the patient is seated comfortably, with feet on the floor, and after resting for 5 minutes. Coffee intake and smoking should be halted at least 30 minutes before taking the pressure
2. Number of Blood Pressure Determinations and Settings
Use of proper technique for measurement of the blood pressure is essential (see Chapter 14 and later discussion). Except in patients with severely elevated blood pressure, the diagnosis of hypertension should almost always be based on multiple determinations of blood pressure, preferably not only on different visits, but also by different personnel and in different settings. As noted earlier, there is a tendency for blood pressures to be higher when taken by a physician than when taken by a nurse or other medical worker
3. Home and Office Determinations
Teaching the patient to check his or her pressure at home and at work can greatly facilitate diagnosis and management, but home determinations should be viewed as an adjunct, not as a replacement for office-based measurements. Home determinations are diagnostically useful when there is concern the office reading might represent white-coat hypertension caused by patient anxiety. Home determinations are usually lower than those obtained in the office
4. Ambulatory Blood Pressure Monitoring
When there is a marked discrepancy between home and office pressures or a wide variation in pressures obtained throughout the day, 24-hour ambulatory monitoring may be useful, though usually it is unnecessary and quite expensive
Recomendation
• On encountering blood pressure elevation, confirm the diagnosis, but do not test for underlying pathophysiology (except in cases of suspected secondary hypertension) because such testing is not yet sufficiently accurate to aid in clinical decision making.
• Check for and rule out any clinically suggested secondary causes.
• Assess the severity of the blood pressure elevation.
• Identify any target-organ (end-organ) damage.
• Identify any and all concurrent cardiovascular risk factors, including clinically overt cardiovascular disease.
• Combine these risk determinations into an overall estimate of cardiovascular risk

Treatment strategies in GERD

2007-12-20T23:52:00.001+07:00

The goals of treatment of GERD are to :

Relieve symtoms
Heal oesophagitis
Maintain remmision
Improve quality of life
Prevent complications

Medication the have been used to relive GERD include antacids, prokinetic agent, histamine 2 resceptor antagonist (H2RA) and PPIs. PPIs are the most effective treatment for control of symptoms and healing of oesohagitis and erosive GERD.
While antacids are use for treatment of GERD, ther is only one out of three studies that shows evidence of antacid efficacy in relieving GERD symtoms. H2RA are mos effective than placebo for relieving mild to moderate GERD symtoms with a response rate between 60% to 70%.
Short term trials using PPIs have shown faster healing raes and more complete heart burn relief than H2RA of prokinetics in patiens with erosive GERD. Amongst the PPIs, standar doses have resulted in comparable helaing and remission rates in erosive oesophagitis. For NERDthe PPIs are also significantly superior to prokinetic agents in heartburn remission and to H2RA in overall symptom improvement. However they have a lower efficacy (10% - 30% less) in NERD patients than in patients with erosive GERD.

Pancreatoblastoma

2007-12-20T23:49:00.000+07:00

DEFINITION
Pancreatoblastoma is a primary malignant tumor of the pancreas consisting of an epithelial component showing acinar differentiation, nests of squamoid cells (or squamoid corpuscles), and occasional endocrine cells. There may be a mesenchymal component in some tumors. Although the tumor has a predilection for children, it has also been reported in adults. Synonyms for this tumor include pancreaticoblastoma and carcinoma of the pancreas, infantile type
GROSS PATHOLOGY
Pancreatoblastoma presents as a solitary mass that can arise in any location in the pancreas. The tumor tends to be relatively large, ranging from 7 to 18 cm, and on cross section it has been described as being tan-yellow with incomplete lobulations. The consistency may vary from soft and fleshy to focally fibrous, and there may be areas of necrosis and hemorrhage. Cystic change may be present, and on rare occasion a gritty texture has been described due to abundant calcification.
MICROSCOPIC PATHOLOGY
Pancreatoblastoma may have a partial fibrous pseudocapsule, but there is often invasion into adjacent pancreas, duodenum, or soft tissues. The first case of pancreatoblastoma was illustrated in 1959 by Frantz , and it was the same case reported by Becker in 1957 as the first pancreatic tumor in a child (a 15-month-old boy) treated by pancreaticoduodenectomy.

Bental procedure

2007-12-11T11:04:00.000+07:00

Bental procedure on aortic valve disesase and ascending aortic root aneurysm
Aortic valve sparing operation in patien with ascending aorta and/or aortic root aneurysm have been performed and become an increasingly popular alternative for replacement of the ascending aortic root aneurysm with aortic valve disease. Implantation of a prosthetic valve conduit (Bentall procedure) and modified be protrusion to LVOT, mild aortic stenosis, ascending aortic root aneurysm and coronay artery disease corrected by benttal procedure.
A 64 years old man was diagnosed to have severe aortic regurgitation and heart failure functional class II. CT thorax showed ascending aortic root aneurysm. Multiple vessel disease was shown by coronary arteriography indicated to CABG. Echocardiogram showed RCC protrusion to LVOT, mild AV stenosis, mild but morphologically normal mitral regurgitation, severe LV dilatation (LVIDD 84 mm) decrease LV systolic function by simpson’s rule (EF 38%) , global hypokinesia and mild secondary pulmonary hypertension (estimated PASP 49 mmHg). Bental procedure with bioprothesa graft conduit to replaced aortic valve and ascending aortic root after CABG can be performed successfully. Transthoracic-two dimensional echocardiograpy second day post procedure revealed normal AV function.
By : Mulslim I, Adipranoto JD, Spratt P
Departement of cardiology and vascular medicine airlangga university

Pheochromocytoma

2007-12-10T11:13:00.000+07:00

Clinical presentation of pheochromocytoma

Pheochromocytoma is uncommon tumor arising form pheochormocytes, the predominant cells of adrenal medulla. The pheochoromocytes constitute the chromaffin system. Pheochromocytoma is most common in the fourth through sixth decades of life. Women and man ara affected with similar frequency. Pheochromocytoma has been called “the 10% tumor” because aproximetaly 10% are bilateral, 10% malignant, 10% occur in children and 10% are extraadrenal/ the extra adrenal lesions are also referad to as paragangliomas.

The presence of pheochromocytoma may provoke fatal hypertensive crises during anesthesia and other stresses.pheochromocytoa are often unrecognized, if 20% of the adult population is hypertensive, only abaout five pheochromocytomas would be expected to be found among 100.000 hypertensives each year. However, about 10% of all pheochromocytomas are found incidentally and out 5% of all incidentalomas are pheochromocytomas. We report a case of a patient presenting with cardiogenic shock due to pheochromocytoma crisis. Treatment of choice is total left adrenalectomy.
Hendari SD, Lefi A
Departement of cardiology and vascular medicine airlangga university

Update in Unstable Angina

2007-10-20T01:35:00.000+07:00

From Basic To Clinical Practice and Ther Role of Molecular Weigh Heparin

unstable angina is currentyl one of teh leading causes of hospital admission for coronary arterial disease (CAD). It is described as heterogeneous disease refering to a wide spectrum of clinical manifestation from stable angina to myocardial infarction (MI). This angina attac is a clinical manifestation of an imbalece between myocardial oxygendemand and supply. Unstable angina and myocardial infarction are closely related with respect to theri etiology and pathogenesis.

The diagnosis of unstable angina implies recognation of sysmtom of myocardial ischemia like the usual pattern of chest pain. Elevation of plasma level biomarkers including CK-MB, troponin I And Troponin T are sensitive markers to differentiate between unstable angina and non ST Elevation myocardial infarction (NSTEMI). Although many episodes of unstable angina and acute MI are caused by plaque disruption, coronary vasoconstriction plays also an important role as a response of dysfuntional endothelium. In unstable angina, a releatively small erosion of atherosclerotic plaque may lead to reduction in coronary blood flow resulting in exacerbation of angina.
the target of medical management in unstable angina and NSTEMI are control symtoms of myocardial ischemia and prevention of MI and Death as the end poin. the involvement of platetet activation and trombus formation has been well established in patients with unstable angina and has led to teratmen strategies tat include aspirin, antiplatelet aggregation and antithrombitic. in the las Decades, some subcunaeous low moleculer weight (LMWH) ware administrered. pernaarin is a relatively new LMWH available with a high bioavaility and prolonged hal live whose efficacy and safety has already been established. The Prime care study is showing that a uniform dose of parnaparin was adequate for all the patients irrespective ther body weight.

Video Games Hone Surgical Skills

2007-10-18T16:17:00.000+07:00

Recant study has found that one or more important surgical training tools can be purchased over the counter and from the chlideren departement, no Less !

whether the choice is microsoft Xbox, Sony Playstation 3 or Nitendo Wii, joining the kids for regular gaming sessioan apperrs to increase laparoscopic surger skliss, assessed via a simulated surgery coury courese.

researcher from beth israel medical center in new york established that the top one - thrid of sugeons with superior vidwo gaming sklills ware less likely to comit errors while performing laparoscopic surgery. they were also faster than the bottom one-third. [Arch Surgery 2007;142:181-6]
surgeons with superior skills made 47% fewer errors, compliceted procedures 39% faster earned a 41 % superior overall score.
Dr. James C Rosser Jr led his colleagues on an assessment of 33 surgeons : 21 resident and 12 attending based on the rosser top gun laparoscopic sklils and auturing program.
in comprasion with non players, current players ware 24 % faster, coomiteed 32% fewer erros and had 26 % higer overall score.
Rosser Jr concluded thet video games would be a valuable teaching tool, adding "traning curicula that include video games may help thim the technical interface between sugeons and screen mediated application, such as laparoscop surgery.
Original Articel from Medical Tribune 04|2007

The Rule of ACE Inhibitor in diastolic heart failure

2007-09-26T19:45:00.000+07:00

diastolic heart failure is clinical sysndrom characterized by the symtoms and sign of heart failure, a preserved ejection fraction (EF), and abnormal diastolic function.

treatment of diastolic heart failure can be framed in 3 step :

treatement should target symtom reducion, principally by decreasing pulmanary venous presure at rest and during exertion.
treatment should target the pathological disease that caused the diastolic hearth failure.
treatment should targeet the underlying mechanisms that are altered by the disease procsess.

ACE inhibitor redue systemic vascular resistance, artial presure, LV and right ventricular end-diastolic ressures, cardiac work, and myocardial oxygen consumtion and increase cardiac output. beside that ace inhibitor also improve HF associated with normal LV ejection fraction by decreaseng afterload, lowering elevated blood pressure, decreasing LV mass and artial and arteriolar wall thicness and stiffness by improving LV relaxation and by attenuating the coronary Vasocontriction of angiotensin II.
few observatioanl data available showed ACE inhibitor improved NYHA functiooanl class, LVdiastolic function, mortality and quality of life scores in diastolic heart failure. however data form large scale, prospective, randomized, placebo controlled studied investigating the efficacy of ACE inhibitor on cardiovaskuler mortality and morbidity are needed to establish in the treatment of diastolic HF.

refrence
ASMIHA 16, articel by Idris Idham
National cardiovasculer center harapan kita - jakarta

New Treatment of Pulmonary Arterial Hypertension

2007-09-26T19:12:00.000+07:00

Ther are several treatmen of PAH (Pulmonary Arterial Hypertension) such as phospodiesterase (PDE) inhibitor eg : sildenafil ; endothelin (ET-1) receptor antagonist, eg : bosentan ; prostacyclin analogue (beraprost Sodium).

at present there is prostacyclin analgue for the treatmen of pulmunari artieal hypertension, wicch provide all charecteristec acton as antiplatelet action, vasodilating action and endothelial protective acton, anti inflammatton, and vascular smoot muscle cell growth inhibitor. with beraprost sodium wich can be administered orally, so it enables the teratmen of administration has been shown (4 year survival rate of 75 %). because of its caracteristic, beraprost sodium considered to be the most soitable first choice drug for PAH.

articel from Annual Scientific Meeting of the indonesia heart associaton
The Current management of pulmunary hypertension by harmani kalim
national cardiovaskuler center harapan Kita jakarta

Diabetic Foot and Vasular disease in Diabetic Patient

2007-09-24T19:44:00.000+07:00

What Physician should know

diabetic foot ulecer precede 85% of nontraumatic lower-exteremity amputation (LEAs). approximatelly 3- 4 % of individual with diabetes currentyl have foot ulcer or deep infektion. fiiteen percent develop foot ulcer during their lifetime. ther risk of LEA increases by a factor of 8 onece an ulcer develops.

etiology of diabetic foot is including peripheral neuropaty, ischemic vascular disease and immune dficiency. the primary risk factor for the developmen of diabetic foot ulcer is loss of pertectice sensation. abnormal white blood cell fungtion and the presence of peripheral vascular disease allow wounds to become cotaminated and infected by normaly nonpathogenic organism. this explains he indetifiacation of unusual bacteria form the wound of patien with diabetec.
ischemic pherpheral disesase is tehe second risk factor for developing diabetic foot ulcer and infection. this used to be considered a smal vessel disease, but curren research links the vascular pathology to the basement membrane of the artierial wall. the disease is similar to that in those with vasular disease who are not diabetic, except that the distribution is somewhat more scattered and geographic in person who are not diabetic, as opposed to progressive in a distal direction in person who ara diabetic.
the third major risk factor related to the immune deficciency seen in this patient population, glycosylated immune proteins lose efficency, and granulocytes do not perform adequately, leavieng these patients prrone to infection form organisms that not affect a healthy host. each of these potential abnormallities make the diabetic foot susceptible to abnormal mechanical stresses that can lead to a break in the normal soft tissue envelope, which can intiate a foot infection that cannot be resolved easeily
management of diabetic foot and peripheral artery disease in diabetic patient need a comprehensive treatmen consisist of an optimal control of blood glucose, wound care and treating of peripheral artery disease is crucial as well, either medication or evdovascular intervation wich leads to be better outcome in terms of preserving lims.

original article from ASMIHA 16 by Iwan Dakota
Devision of Vascular Medicine, National Cardiovascular Center Harapan Kita - Jakarta

Educational Development In Assessment And Evaluation

2007-09-24T16:51:00.000+07:00

The Implementation For Medical Education
Nurfitri Bustamam, Ssi, MKes
Department of Physiology Faculty of Medicine University of UPN “Veteren” Jakarta

Abstract

The implementation of competency based curriculum wich incorporating Student centered Problem-based, Integrated, Community-based, Elective and Systematic (SPICES) as educational strategy requires new mwthod of assesment, peer assesment, and performance assesment. The implementation of the new curriculum also requires evaluation. Evaluation is an essential part of the educational process related to quality assurance. The aim of evaluation is quality improvement. Evaluation may cover the process and/or the outcome of any aspect of education. This article also discusses the importance of evaluation in teaching and assessment for medical education.

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Development Of Educational Leadership In The Faculty Of Medicine

2007-09-24T16:48:00.000+07:00

Nurfitri Bustamam, Ssi, MKes
Department of Physiology Faculty of Medicine University of UPN “Veteren” Jakarta

Abstract

Academic vitality is dependent upon faculty member’s interest and expertise. Staff development has a critical role to play in promoting academic exellence and innovation. In the future medical schools will face many challenges in their missions of education, research, and patient care that call for effective leadership at all levels of the organization. This article provides a brief overview of methods used in identifying and developing abilities in educational leadership.

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