Jejak Petualang

Satu posting singkat, untuk memperkenalkan Dokter Hippie, dengan sebuah blog:

Dokter Hippie Travels, di http://dokterhippie.bigbig.com

Salam,

RNT

Dokter Muda/ Coass di RS Pendidikan: Aset atau Liabilitas?

Sebuah artikel di koran lokal beberapa hari yang lalu  (Radar Semarang) memuat judul “Dilematika Dokter Coass: Dinilai Repotkan Pasien, Demi Regenerasi Dokter”. Pada intinya artikel tersebut memuat keluhan pasien tentang dokter muda di rumah sakit pendidikan, “saya ogah dijadikan bahan praktik”.

Kemudian muncul pertanyaan setelah keluhan ini; dokter muda/ coass merupakan aset atau justru liabilitas sebuah rumah sakit?

Tentu saja sebagai seorang dokter yang telah menyelesaikan pendidikan, saya menyadari betapa pentingnya kegiatan belajar di fakultas kedokteran. 3,5 tahun di bangku kuliah, dilanjutkan dengan setengah tahun berlatih di laboratorium skill, sebelum akhirnya memulai kegiatan kepaniteraan klinik di rumah sakit selama hampir 2 tahun sebagai dokter muda atau coass. Untuk yang tidak familier dengan pendidikan dokter, kepaniteraan klinik adalah pendidikan profesi, sehingga semua dokter muda yang menjalani kepaniteraan klinik semuanya adalah sarjana lulusan S1. Selain itu, di Fakultas Kedokteran Universitas Diponegoro kami juga masih menjalani pendidikan tambahan selama 2 bulan di RS Daerah dan Puskesmas di wilayah Jawa Tengah sebelum lulus sebagai dokter.

Di rumah sakit pendidikan tidak ada keputusan medis yang dibuat dan dijalankan sendiri oleh dokter muda/coass. Semua tindakan yang dilakukan oleh dokter muda telah sepengetahuan dan pengawasan dokter yang berwenang, dan telah dilakukan atas persetujuan pasien.

Memang dokter muda secara umum hanya “melakukan tugas sederhana”, seperti memeriksa pasien, belajar mengawasi pasien, memasang tensi dan mengukur suhu pasien. Namun selain tugas sederhana tersebut ada banyak kompetensi yang harus dipelajari dokter muda selama kepaniteraan klinik di rumah sakit.

Tentu saja semua dokter pernah merasakan betapa melelahkannya tugas-tugas ini saat pendidikan. Namun menyebut bahwa dokter muda melakukan hanya “tugas sederhana” di atas sepertinya pernyataan yang terlalu menyederhanakan realita. Dokter masa kini paham betul, bahwa saat lulus kita harus memiliki kompetensi yang memadai sebagaimana yang ditetapkan oleh Konsil Kedokteran Indonesia. Diantara “tugas sederhana” yang wajib kita kerjakan siang, malam, dini hari dalam keadaan lelah, mengantuk dan lapar, diantara kegiatan belajar, mempersiapkan ujian, dan mengerjakan tugas-tugas teori, kita memiliki kewajiban untuk mempelajari dan menguasai keterampilan klinis sesuai standar kompetensi dokter umum. Selalu diantara “tugas sederhana” ini dokter muda masih harus belajar untuk memiliki keterampilan klinis misalnya kegiatan bedah minor seperti menjahit luka, memasang infus, menyuntik obat, memasang pembalut luka, melakukan tindakan untuk keadaan-keadaan emergency.

RS Pendidikan harus mendidik mahasiswa kedokteran, sebagaimana sebagai RS mereka tetap harus melayani pasien. Kembali saya ingatkan bahwa para dokter muda telah mendapat pendidikan dan persiapan sebelum memasuki jenjang kepaniteraan klinik maupun selama menjalaninya. Di Indonesia, hal ini dilakukan di beberapa lingkup tertentu RS Pendidikan tersebut sesuai kebijakan RS yang bersangkutan, dalam pengawasan dokter yang berwenang. Harap diingat, hal semacam ini dilakukan oleh semua rumah sakit pendidikan di seluruh dunia termasuk di negara barat. Tidak ada tempat bagi dokter-dokter baru lulus yang hanya merupakan produk lulusan laboratorium dengan alat-alat peraga berupa boneka. Dokter adalah profesi dengan tanggung jawab kemanusiaan yang berat, yang harus dididik dan dilatih untuk dapat bekerja mandiri menghadapi pasien, situasi klinis dan problem kesehatan yang kompleks di masyarakat. Dokter-dokter baru ini yang nantinya akan menjadi petugas kesehatan, dan bahkan sebagian akan memilih untuk menjalani kegiatan pengabdian dan ditempatkan oleh Departemen Kesehatan di daerah terpencil dan sangat terpencil di seluruh pelosok Indonesia. Meningkatnya derajat kesehatan bangsa Indonesia dan tingginya kualitas dokter tidak bisa lepas dari peran RS Pendidikan dalam mempersiapkan dokter-dokter baru.

Untuk menjawab pertanyaan di atas, maka kehadiran coass di RS Pendidikan sebagai aset dan bukannya liabilitas membutuhkan kerja sama dan usaha keras dari semua pihak, baik RS Pendidikan, fakultas kedokteran, para coass sendiri dalam hubungannya dengan penyediaan layanan terhadap pasien.

Kegiatan supervisi yang selanjutnya harus ditingkatkan agar dokter muda dapat tetap menimba keterampilan dan pengalaman agar siap terjun di masyarakat, sementara pasien tetap mendapat penanganan yang optimal dari sebuah rumah sakit. Tentu saja hal ini harus dibarengi etika dan persiapan keterampilan yang matang dari dokter muda yang melayani pasien di rumah sakit.

Dr.Rahajeng Tunjung

Choosing Medical Specialty (and more on Internal medicine, infectious disease, and academic medicine)

By: Dr. Rahajeng

I recently stumbled on a very interesting publication of Lange, The Ultimate Guide to Choosing Medical Specialty by Brian Freeman.

For many, the decision of taking up a specialty is easy, for others it’s much more complicated. The best thing is of course to be able to choose based on your interest and the kind of life you want for yourself. I realized very early on that a certain medical specialty is not just about the kind of work that you have to do, but also about the commitment you have to make to a certain lifestyle. I was lucky to have had a real life experience about the field I am going to take up, as well as to have several mentors to introduce me to it.

What is sometimes not immediately anticipated for us Indonesian young medical doctors is that choosing a medical specialty is a decision of the family (and family sometimes means the whole extended family). This means you can’t really make your own decision. There’s mum, dad, grandparents (if they’re around), and maybe others that will have a say about the decision, and for some unlucky ones, the decision is not even yours anymore. For some, they never had a say in what they like, it’s always about what they have to take.

For example, a friend of mine had been pursuing his interest in surgery for a long time during medical school. Dad is a pediatrician, and mom is an ophthalmologist. He did express his interest of surgery to his parents, but dad took over the decision-making and told him that ob-gyn was the best choice for him. He agreed to it despite the fact that he had another choice. He thought that it was what’s best for the family.

For another guy, ob-gyn is a no-question choice, as many in the family (grandpa, uncles) was ob-gyn specialist and they already establish their own private hospital and clinics. Neither a bright nor dedicated student, by circumstances that many call luck, he is to take over the family business.

My own experience is by situation a more liberated one despite the family medical legacy. Grandpa from dad’s side was an orthopedic surgery professor, uncle is also an orthopedic surgeon and his son is now an orthopedic surgery resident. My father was briefly in surgical residency but he resigned and decided that being a company’s medical manager and acupuncture was more enjoyable. He worked for 25 years in a national oil mining company as medical manager and have started and now runs the first dermatology/ aesthetic acupuncture clinic in the city. Uncle from mom’s side is a psychiatrist. I had ob-gyn and pediatrics in mind for a short period. I was finally exposed to the wonders of internal medicine and infectious disease and eventually choosing infectious disease for myself two years ago, preferably in academic setting.

Back to the book, it also offers looking to MBTI personality types to see if you cut-out to be in certain specialty although for internal medicine, it is very flexible on who it is most suited for (Introverted–Intuitive–Feeling– Judging INFJ, Extroverted–Sensing–Feeling– Judging ESFJ, Introverted–Intuitive–Thinking– Judging INTJ, Extroverted–Intuitive–Thinking– Judging ENTJ). It doesn’t really matter I guess, as long as you have good access to yourself, knowing what you like and what you can be passionate about. I happen to be an ENFJ (sorry, you gotta find out what that is yourself).

I started thinking about these 4 years ago when I was still doing my preclinical years (naturally, without having a book to guide my thinking):

• What do you want to get out of your medical career? (intellectual and spiritual satisfaction)

• For whom do you want to work? (international academic institutions)

• Do you want to be a leader in your specialty? (i’d like that very much, so yes)

• How much time do you want to devote to research, teaching, or administrative work? (research and teaching: a lot of time. Administrative: naaah, not really into it)

And knowing that I’ve explored answers to these questions has definitely made me confident in the choices I make.

I have a vision of what career I want for myself, as well as very personal reasons of why I choose a certain path. But the thing is I always know what I like, not just the science but also the lifestyle. I like international travel, I like discussions, I like challenges of pursuing knowledge of the unknown. I like reading, writing and facing cerebral challenges. And I definitely like giving presentations in front of international audience, preferably about something I know a lot about. Those reasons above are part of the things that shape my choices.

And surprise surprise, my Keirsey profiling ended up being “teacher”.

*

These are selected excerpt from the book “The Ultimate Guide to Choosing Medical Specialty” by Brian Freeman

TO SUBSPECIALIZE OR NOT: THE FELLOWSHIP DECISION

Before considering their practice options, residents in every specialty have to decide whether or not to subspecialize. The additional time spent in fellowship training gives them advanced knowledge and skills—both of which are essential for practicing as an expert in a focused variety of specialty medicine.

Residents who become inspired by a particular organ system or a complex problem within their specialty should seriously consider pursuing a fellowship. The training provides sophisticated knowledge and skills, making you an expert to whom colleagues look for advice and teaching. Knowing one narrow area very well can enhance your career satisfaction and build your professional confidence. With an emphasis on research and scholarly endeavors, fellowships are also great preparation for careers in academic medicine.

Are there any disadvantages to pursuing a fellowship? Just one—the temporary financial sacrifice. You will have to wait several more years before paying off all those big educational debts hanging over your head.

Private Practice: Delivering the Best Patient Care

Most of you will enter private practice after completing residency or fellowship. In the private sector, physicians either work by themselves or with others, providing high-quality medical care to all types of patients. Because they are not tied strictly to the large academic medical centers, private practitioners have the flexibility to set up shop anywhere in the country—urban, suburban, or rural. Depending on the specialty, you may be working in the office-clinic (dermatology, rheumatology, allergy medicine), the hospital (anesthesiology, radiology, pathology), or both (internal medicine, surgery, pediatrics). Some private practitioners also make rounds at other places, like nursing homes (geriatricians, internists), state facilities (psychiatrists), and prisons (internists, family practitioners).

Academic Medicine: Shaping the Future of Your Specialty

Medical students who want to be leaders in their specialty should consider a career in academic medicine. A much smaller percentage of physicians work at university hospitals than in the private sector. Academicians serve as medical school faculty members in their specialty’s department and also provide patient care at their affiliated teaching hospital. With less emphasis on patient volume and turnover, the pace of academic medicine is more relaxed than that of private practice. Although the job market for new faculty physicians is quite strong, the tertiary care medical centers are usually in major metropolitan areas. This limitation means that academic physicians—whether pediatricians or interventional radiologists—have less geographic flexibility than their counterparts in the private

sector.

Whereas private practitioners deliver patient care to the masses, academic physicians in every specialty and subspecialty have a set of three universal—and equally important—responsibilities.

1. Teaching: Every doctor receives residency training in a teaching hospital. By staying there to practice, academic physicians instruct generation after generation of specialists. Much of this time is spent supervising and teaching fellows, residents, and medical students. Through hours of mentorship, academic physicians can make a meaningful difference in their charges’ professional lives by shaping their formative years of clinical training. These inexperienced young doctors will pepper you with lots of probing questions, keeping you sharp in your specialty. Most faculty members recruited out of residency or fellowship start teaching at the level of Assistant Professor. Promotion and tenure—just like in nonmedical fields—are directly related to your ability to teach and conduct ground-breaking research.

2. Research: Through cutting-edge clinical and basic science research, academic physicians are responsible for advancing their specialty. They generate new knowledge, develop procedures and drugs, and evaluate the efficacy of different types of treatment. For instance, a general surgeon might conduct a study looking at the best time to take out a chest tube, and an internist investigates the outcomes of treating diabetic and renal failure patients with ACE inhibitors. Academic physicians also have to teach their colleagues in private practice about the latest advances in their specialty.

They do so by writing up their findings in medical journals and giving lectures at national conferences. To carry out any research project, academic physicians have to obtain the necessary funding—by submitting grants themselves or by receiving money from their department. In the world of academia, the number of papers published and amount of federal research grants received confers prestige on a university medical center. (In a certain weekly news magazine, the formula used to rank US hospitals and medical schools gives the greatest weight to research awards from the National Institutes of Health.)

3. Patient care: In every specialty, academic physicians provide the latest and most innovative medical care. Tertiary medical centers draw a diverse mix of patients, from the indigent (most teaching hospitals are historically located in underserved city neighborhoods) to the very wealthy (e.g., Saudi princes who fly in for the most advanced treatment). Most patients receive care directly from residents and fellows, who are supervised by their attending physicians, of course. Compared to private practitioners, full-time faculty members generally take less call, devote fewer hours to patient care, and earn less money. All revenue generated from clinical practice goes directly to the medical center instead of counting as personal income. In turn, the hospital pays each faculty physician a fixed salary that is directly proportional to the type and volume of medicine he or she practices. This is why academic pediatricians earn less than an academic cardiothoracic surgeon.

Academic medicine is perfect for doctors inspired by working with some of medicine’s greatest minds the authors of well-known textbooks, the renowned researchers who develop new drugs and vaccines, the innovators who figured out how to surgically separate two newborns sharing the same brain. Because teaching hospitals are part of major referral centers, academic physicians are the ones who manage most of the rare and complicated cases. You will take care of diseases and conditions on a level that few physicians ever surpass. This career path, therefore, gives you the autonomy to become a true leader in your specialty.

The book also features profiles of every specialty. And here I will only put up what is obviously my pick: Internal medicine (and a little bit more about infectious disease).

READY TO EXERCISE YOUR BRAIN?

Internal medicine is perhaps the most cerebral of all specialties. It requires a high level of critical thinking. Many students are drawn to internal medicine for the intellectual stimulation. There are always interesting cases that require a lot of problem solving and interpretation of signs, symptoms, and other pieces of data.

Internists are very intellectually curious doctors. They always like to ask questions of themselves and others during the differential diagnosis process. Fascinated by the science of medicine, internists love exploring details—like the mechanisms of drug therapy or the pathophysiology of disease. To make the best diagnosis, internists tend to read quite a bit. Keeping abreast of the latest advances in general medicine requires a career-long commitment to reading journals such as JAMA or The New England Journal of Medicine.

Critical thinking is necessary because internists take a scientific approach to being master diagnosticians. They thrive on making a great diagnosis, analyzing a fascinating big case, and solving complex medical problems. Internists love to sit around and discuss disease. They get excited by putting together a patient’s signs, symptoms, and laboratory findings and trying to come up with a long list of possible differential diagnoses. Unfortunately, sometimes the daily activity in internal medicine is perceived as lots of thinking and talking but little action. In particular, academic inpatient rounds can perpetuate the stereotype of internal medicine as mental masturbation. This is because internists are thorough individuals who make sure not to leave out any possible diagnoses. Students who love to solve problems and mental puzzles find internal medicine a fascinating specialty. Internists are experts at taking patient histories and performing physical examinations. It is with the information derived from the H&P that they make most diagnoses. After talking to the patient, the internist constructs a list of differential diagnoses for each of the patient’s problems. This process allows them to clearly organize in their minds what is going on with the patient and how to address each issue; many patients have multiple medical problems or complaints. To finalize a diagnosis from a list of many, the internist relies on a great deal of critical thinking and deductive reasoning from the data at hand. They take pieces of evidence from the history, physical, laboratory data, and imaging studies to rule in or rule out various disease states. It is kind of like mental detective work. An internist in academics commented that “figuring out how all the pieces to a patients’ clinical puzzle fit together is extremely rewarding.” With a confident diagnosis in hand, the internist then moves on to treating the patient. Across the subspecialties of internal medicine, therapeutic interventions take the form of either pharmacologic agents or procedures. General internists, for instance, keep up with the advances in treating high blood pressure with the newest medications and are experts at figuring out the proper antibiotic for a patient with bacterial meningitis. Although this specialty requires thorough, organized thought, internists are more than just thinkers; they are also proficient in many technical skills essential for the diagnosis and treatment of illness. These skills include a number of inpatient procedures, such as thoracentesis, paracentesis, lumbar puncture, and central line placement, and outpatient procedures like flexible sigmoidoscopy, endometrial biopsy, and intra-articular injections.

WHAT MAKES A GOOD INTERNIST?

Likes physical diagnosis, pharmacology, and physiology.

Is a thorough, cautious problem- solver.

Can interact well with people and maintain long-term relationships.

Likes working with his or her mind.

Is a good, patient listener.

FELLOWSHIPS AND SUBSPECIALTY TRAINING

Internal medicine is comprised of many subspecialties. In 2000, roughly half of

all graduates from internal medicine residency programs sought fellowship training.

Currently there are 10 possible areas of subspecialization. Before jumping into one of these disciplines, take a moment for some honest self-evaluation. It is essential that you give some thought to

your field of interest and the type of personality most suited to it.

For aspiring physicians who prefer direct primary patient care, general internal

medicine is the place to be. Specialists tend to be much more scientifically oriented

and enjoy more complex and difficult cases. They serve as consultants to the general internist, directing medical care for a specific organ system and often teaching the general internist about the patients’ disease process. For certain specialties, like cardiology, gastroenterology, and critical care, more time is spent caring for patients in the hospital environment than in the office setting. No matter whether you choose cardiology or rheumatology, all subspecialists are, at heart, excellent general internists. You will still be required to have high-quality history and physical examination skills, as well as the ability to interpret laboratory and radiographic findings, to produce a comprehensive differential diagnosis. In every subspecialty, all internists take care of very sick adult patients who have many medical problems.

Infectious Disease

If you love studying bacteria, viruses, parasites, and fungi, then the subspecialty of infectious disease is for you. These physicians take the basic science of microbiology and apply it to clinical situations. In their diagnostic workup, they approach the patient’s disease process by taking into consideration recent travel, geographic region, country of origin, and cultural practice. They are experts in the proper collection and analysis of culture specimens, plus a variety of laboratory tests, such as antibiotic sensitivity tests, CD4 counts, and infectious serologies.

Their treatment regimens are largely pharmacologic and draw on the latest developments in antibiotic therapy. Through the use of vaccines, they practice a great deal of preventive medicine. Most patients who require the expertise of these clinicians have diseases that are short-term in nature. Thus, infectious disease specialists typically serve as consultants for other physicians. In the summer of 2002, they were on the front lines of the West Nile virus outbreak in the United States. They consult on patients in the hospital for diagnostic challenges (e.g., fever of unknown origin) and for treatment regimens of specific infectious diseases (e.g., bacterial endocarditis, meningitis, cellulitis, sepsis). Many infectious disease physicians maintain longer relationships with patients suffering from chronic diseases, such as HIV/AIDS and tuberculosis, who require extensive follow up. Some practice travel medicine, serving as consultants to patients preparing for international travel and to those who acquired illnesses while overseas. Other areas of expertise include infection control within health care settings, international public health, and the prevention of antibiotic resistance through education and research. They also are involved in the tracking and epidemiology of certain communicable diseases. As the threat of biological attack becomes a growing concern, the prevention, recognition, and treatment of bioterrorism are now focal points of infectious disease. Fellowships require 2 years of training after residency.

Semarang, 7-6-2009

*

Reference:

Freeman B. The Ultimate Guide to Choosing Medical Specialty. Lange 2007.

Stratifikasi Risiko, Antibiotika Empirik dan Evaluasi Pasien PPOK Eksaserbasi Akut

Oleh: Dr. Rahajeng

Artikel ini adalah diskusi lanjutan dari Penggunaan Rasional Antibiotik pada PPOK Eksaserbasi Akut di blog ini. Silakan menuju ke artikel tersebut untuk pembahasan awal yang lebih lengkap.

STRATIFIKASI RISIKO, ANTIBIOTIKA EMPIRIK DAN EVALUASI PADA PASIEN PPOK EKSASERBASI AKUT

Salah satu tujuan dari GOLD, Global Initiative for Chronic Obstructive Lung Disease, adalah meningkatkan kesadaran dokter dan masyarakat mengenai gejala penyakit paru obstruktif kronik (PPOK). Klasifikasi derajat PPOK berdasarkan pemeriksaan spirometri dibagi menjadi 4 stage. Pesan kesehatan masyarakat yang penting adalah bahwa batuk dan produksi sputum kronik adalah hal yang tidak normal dan membutuhkan pemeriksaan lebih lanjut mengenai penyebabnya.

Klasifikasi PPOK berdasarkan GOLD adalah (1):

Stage 1: PPOK ringan

Keterbatasan airflow ringan (FEV1/FVC < 70%, FEV1 ≥ 80% predicted), dan kadang, tapi tidak selalu, batuk dan produksi sputum kronik.

Pada tahap ini individu tidak menyadari bahwa fungsi parunya abnormal.

Stage 2: PPOK Sedang

Keterbatasan airflow memburuk (FEV1/FVC < 70%, 50% ≤ FEV1 < 80% predicted), timbul sesak napas setelah aktivitas (exertion)

Pada tahap ini individu biasanya mulai mencari pengobatan karena gejala pernapasan kronik atau eksaserbasi.

Stage 3: PPOK berat

Keterbatasan airflow makin memburuk (FEV1/FVC < 70%, 30% ≤ FEV1 < 50% predicted), sesak napas makin berat, kemampuan latihan menurun, dan eksaserbasi berulang yang berdampak pada kualitas hidup pasien.

Stage 4: PPOK sangat berat

Keterbatasan airflow sangat berat (FEV1/FVC < 70%, FEV1 < 30% predicted) atau FEV1<50% dengan gagal napas kronik.

Pada tahap ini kualitas hidup sangat berkurang dan eksaserbasi dapat menyancam jiwa.

Sebuah studi multicenter menyimpulkan bahwa stratifikasi GOLD dan kebutuhan akan terapi oksigen jangka panjang (Long term oxigen therapy/ LTOT) merupakan prediktor penting untuk perawatan di rumah sakit (2).

Berdasarkan GOLD 2008, indikasi untuk perawatan PPOK eksaserbasi akut di rumah sakit adalah (1):

-          Peningkatan mendadak dari beratnya gejala (misalnya tiba-tiba muncul gejala sesak napas saat istirahat)

-          PPOK berat

-          Timbulnya tanda baru (edema, sianosis)

-          Eksaserbasi yang tidak berespon terhadap penanganan awal

-          Komorbiditas yang signifikan

-          Eksaserbasi yang sering

-          Aritmia

-          Ketidakpastian dalam diagnosis

-          Usia tua

-          Perawatan di rumah yang kurang memadai

GOLD menyarankan pemakaian antibiotik pada kasus-kasus dengan peningkatan volume atau purulensi sputum, peningkatan derajat sesak napas, dan pada kasus yang membutuhkan ventilasi mekanik. Antibiotika diberikan secara empirik dan rasional, dengan memperhatikan stratifikasi faktor risiko yang dimiliki pasien.

Pada eksaserbasi, secara klinis untuk memutuskan antibiotik apa yang digunakan secara empiris dapat digunakan algoritma di atas. Pasien dibedakan menjadi PPOK tanpa komplikasi dan dengan komplikasi (3).

PPOK tanpa komplikasi adalah pasien PPOK dengan usia > 65 tahun, FEV1 > 50% predicted, < 3 eksaserbasi per tahun, tanpa penyakit jantung. Untuk kelompok ini digunakan makrolid advance (azithromycin, clarithromycin), cephalosporin (cefuroxime), Doxycycline, Trimepthoprim-sulfamethoxazole, dan pada paparan antibiotik yang baru terjadi (< 3 bulan) perlu dipilih antibiotik alternatif.

PPOK dengan komplikasi adalah pasien usia ≥ 65 tahun, FEV1 ≤ 50%, ≥ 3 eksaserbasi/tahun, atau adanya penyakit jantung. Digunakan antibiotika: Floroquinolone (levofloxacin, moxifloxacin), amoxicilin-calvulanate, atau pada paparan antibiotik yang baru terjadi dapat dipilih antibiotik alternatif.

Antibiotik yang dipilih berdasarkan berat gejala dan pengelompokan risiko di atas diberikan selama menunggu hasil kultur dan uji sensitivitas atau dilakukan evaluasi dalam 72 jam. Kondisi klinis yang memburuk atau respon yang tidak adekuat dalam 72 jam merupakan indikasi untuk penyelidikan lebih lanjut.

Biasanya pengobatan diberikan selama 7-10 hari. Respon biasanya tampak dalam waktu 3-5 hari dan penggantian antibiotik dapat dipertimbangkan bila respon tidak memuaskan. Jika dilakukan pemberian antibiotik iv, maka penggantian antibiotik oral dilakukan setelah 72 jam (4).

Berbagai perkumpulan ahli pulmonologi di dunia memiliki panduan yang berbeda mengenai stratifikasi risiko dan pengelompokan pasien serta antibiotik apa yang dapat digunakan (5),(6). Namun pada dasarnya dapat disimpulkan bahwa pemberian antibiotika pada pasien PPOK merupakan keputusan yang didasarkan atas situasi klinis pasien. Kebanyakan antibiotika baru merupakan modifikasi dari struktur yang telah ada, sehingga pemilihan antibiotika secara cermat harus dilakukan untuk mempertahankan sensitivitas antibiotika yang telah ada dan mencegah resistensi.

Referensi

(1). Global Initiative for Chronic Obstructive Lung Disease (GOLD). Pocket Guide to COPD Diagnosis, Treatment and Management 2008.

(2). Lusuardi  M., Lucioni C., De Benedetto F., Mazzi S., Sanguninetti C. M., Donner C. F.GOLD severity stratification and risk of hospitalisation for COPD exacerbations. Monaldi archives for chest disease  2008, vol. 69, no 4, pp. 164-169. http://cat.inist.fr/?aModele=afficheN&cpsidt=21207919

(3). Sethi S. Murphy T. Infection in the Pathogenesis and Course of Chronic Obstructive Pulmonary Disease. N Engl J Med 2008;359:2355-65.

(4). The Australian and New Zealand COPD Reference Site. COPD acute exacerbation plan. http://www.copdx.org.au/guidelines/ex_copd_acute_ex.asp

(5).Wilson R. Bacteria, antibiotics and COPD. Eur Respir J 2001; 17: 995–1007.

(6) Stoller J. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med, Vol. 346, No. 13.

Disclaimer:

Bagan adalah milik New England Journal of Medicine, diunduh dari http://www.nejm.org.

Terima kasih kepada Dr. Nur Farhanah Sp.PD, staf bagian Infeksi Tropik FK Undip atas masukan yang berharga.

Tinjauan Pustaka: Profilaksis Malaria

Tinjauan pustaka oleh: Dr. Rahajeng

Malaria adalah penyakit endemis di lebih dari 100 negara. Tiap tahun pengunjung daerah endemis terjangkit malaria akibat tidak adanya imunitas terhadap malaria. Imigran dari daerah endemis yang pindah untuk tinggal di daerah non-endemis kemudian berkunjung ke area endemis juga dapat tertular malaria akibat berkurang atau tidak adanya imunitas. Demam yang terjadi dalam waktu 3 bulan setelah meninggalkan daerah endemis harus diselidiki untuk kemungkinan malaria. 95% kasus malaria pengunjung daerah endemis terjadi dalam waktu 30 hari setelah kembali dari daerah endemis.

Orang yang kembali dari daerah endemis ke daerah non-endemis dapat mengalami masalah akibat dokter yang tidak familier dengan gejala malaria; diagnosis tertunda, pengobatan tidak tersedia dan menyebabkan tingkat kematian yang tinggi.

Orang yang non-imun di daerah endemis yang terpapar gigitan nyamuk berisiko terkena malaria. Ini termasuk orang semi-imun yang yang kehilangan seluruh atau sebagian imunitasnya akibat tinggal di area non-endemis selama 6 bulan atau lebih.

Malaria dapat timbul dengan gejala influenza-like, termasuk nyeri kepala dan nyeri punggung. Muntah, diare, nyeri perut dan batuk dapat merupakan gejala yang mirip penyakit infeksi lainnya. Buku ajar menggambarkan demam dengan episode antara beberapa jam sampai 2-3 hari, namun pada orang non-imun demam dapat terjadi dengan pola ireguler dalam 1 hari.

Kemoprofilaksis lini pertama didesain untuk mencegah kematian akibat malaria falciparum berat. Obat-obatan ini juga mencegah serangan primer dari spesies non-falciparum. Resistensi P. falciparum terhadap chloroquine hampir universal; chloroquine hanya efektif di Meksiko, area Amerika Tengah di sebelah barat Terusan Panama, Kariba, Asia Timur dan beberapa negara Timur Tengah. Di area endemis lain, WHO dan CDC merekomendasikan atovaquone-proguanil, mefloquine, dan doksisiklin; obat-obatan ini menunjukkan 95% efikasi terhadap P. falciparum.

Resistensi mefloquine terjadi di area rural terbatas di Asia Tenggara. Pilihan obat untuk orang yang bepergian ke area dengan malaria yang resisten chloroquin bergantung pada faktor seperti lama tinggal, usia dan riwayat penyakit, kehamilan dan apakah ada intoleransi obat sebelumnya serta pertimbangan ekonomi. Berikut informasi tentang pilihan obat:

Chloroquine, mefloquine dan doksisiklin tidak mencegah infeksi pertama pada manusia, namun bekerja terhadap parasit yang menginfeksi eritrosit setelahlepas dari fase maturasi awal di hepar. Akibatnya, obat ini harus diteruskan sampai 4 minggu setelah paparan terakhir terhadap nyamuk yang terinfeksi untuk menyingkirkan parasit yang masih mungkin dilepaskan dari hepar pada bulan berikutnya. Namun atovaquone-proguanil tidak hanya bekerja terhadap parasit yang ada di dalam darah namun juga terhadap parasit yang aktif bereplikasi di hepar sehingga dapat dihentikan 1 minggu setelah paparan.

Kemoprofilaksis dengan atovaquone-proguanil dan doksisiklin harus dimulai 1 atau 2 hari sebelum perjalanan ke daerah endemis, sementara chloroquine harus dimulai 1 minggu sebelum perjalanan.

Penggunaan mefloquine harus dimulai 3 minggu sebelum perjalanan, terutama untuk mengamati efek samping yang mungkin menyebabkan penghentian obat dan pemilihan obat lain. Indikasi untuk pemakaian obat jenis lain adalah kecemasan akut, depresi, kelelahan, dan confusio.

Infeksi malaria pada wanita hamil lebih berat dengan risiko untuk ibu dan janin. Tidak ada kemoprofilaksis yang efektif 100%. WHO dan CDC menyarankan wanita hamil tidak bepergian ke daerah endemis malaria. Jika terpaksa menggunakan kemoprofilaksis, mefloquine adalah obat pilihan untuk malaria resisten chloroquine.

Obat pilihan pada anak-anak sama dengan dewasa, namun doksisiklin direkomendasikan untuk tidak digunakan untuk anak kurang dari 8 tahun. Tersedia panduan dosis anak untuk agen antimalaria.

Skizont adalah tahap multinuklear parasit yang mengalami pembelahan mitotik di sel host. Skizontid tahap hepatik seperti atovaquone-proguanil dan primaquine membunuh parasit selama periode perkembangan aktif parasit di hepatosit, obat-obat ini membunuh keempat spesies malaria.

Hanya primaquine yang dapat membunuh hipnozoit sehingga dapat mencegah relaps malaria. Dibandingkan obat lain, atovaquone-proguanil dan primaquine bekerja pada dua titik berbeda dari siklus hidup parasit. Atovaquone-proguanil bekerja terhadap skizont hepar tapi tidak dapat membunuh hipnozoit.

Skizontid tahap darah seperti atovaquone-proguanil, doksisiklin, mefloquine, dan chloroquine menginterupsi perkembangan skizon dalam eritrosit sehingga mencegah manifestasi klinis infeksi malaria.

Referensi:

Freedman, D. Malaria Prevention in Short-Term Travelers. N Engl J Med 359;6. August 7, 2008.

WHO. International Travel and Health. 2009.

*

Disclaimer: Tabel dan gambar adalah milik New England Journal of Medicine, diunduh dari www.nejm.org

REPORT of Health and Disease in The Tropics; Public Health: International Perspective; Infectious Disease Rotation; Honours Programme Lecture @ Radboud University Nijmegen, The Netherlands

By: Dr. Rahajeng Tunjung

This is my report of the course activities I participated in Radboud University Nijmegen as a part of their elective course for the medical undergraduate students.

The following includes report of three separate activities: Health and Diseases in The Tropics, Public Health in an international perspective, and Infectious Disease rotation in Radboud Hospital.

The course took place in early 2007. This report was presented to FK Undip, and I hope the posting of this report will benefit medical students as well as doctors in getting to know the approach in learning these subjects in Radboud University Nijmegen, The Netherlands.

PREFACE

Alhamdu lillahi rabbil ‘aalamiin.

Not just a goal, the 3 months learning programme in UMC Radboud has been more of a starting point for me. Participating in this programme had been my dream since the first time I heard about it in my second day of medical school, almost 5 years ago. It’s been an honour and privilege for me to be given the chance to represent Medical Faculty Diponegoro University  (MFDU) this year and go to UMC Radboud. I’d had the opportunity to learn in the classroom, interact with the Dutch and international students, have stimulating and exciting discussions with the lecturers and attend extra lectures in the evenings. I always looked forward to each and every morning of my stay in Nijmegen.

My interaction with the lecturers, researchers and specialists has inspired me to commit myself to what I truly love. I have understood the importance of preparing good human resource, well prepared with competence and enthusiasm, in the field of infectious disease and medical education.

Personally, this programme has opened so many new doors and possibilities for me, and I am deeply grateful for the guidance, inspiration, encouragement and support I have received from my teachers in MFDU and Radboud.

I thank my family for their love and support, my parents especially for teaching me to think big and giving me the freedom in doing what I am passionate about.

I’d like to express my gratitude to my teachers, Prof. Djoko and Dr. Husein, for giving me the honour to learn from them and undergo this amazing experience and hopefully serving this field of medicine in near future.

Thank you to The Dean of MFDU and faculty members for giving the moral and financial support;

Nijmegen Institute for International Health for providing the fund and making this programme possible for MFDU students; secretaries of NIIH for their assistance before, during and after my stay in Nijmegen;

Dr. Monique Keuter and Dr. Andre van der Ven for their kindness and teaching me what dedication and passion for infectious disease is all about;

Dr. Francoise Barten for mentoring me and giving me the humbling opportunity to write with her;

Dr. Corine Delsing for the friendship and truly inspiring experience: learning from her and having fun working with different specialists and patients for 1 month in UMC Radboud;

Katharina and other Radboud students in the courses for their friendship and allowing me to feel as if Nijmegen had been my home for 3 months;

My colleagues in MFDU who have supported me.

I hope what has been learned in UMC Radboud won’t just be mine alone, but can also be shared by my colleagues, students of MFDU. This report is a recollection of my study notes from the courses as well as the lectures made available by the teachers.

PERSONAL LEARNING OBJECTIVES

1. Able to live abroad independently for study purpose
2. Able to perform well in the courses and rotation
3. Learn about the teaching and learning method of pre-clinical and clinical medicine in UMC Radboud
4. Learn about tropical medicine from The Netherland’s perspective
5. Learn about public health from the international perspective
6. Make use of the learning opportunities available in Radboud University
7. Sharing experiences with other students about health and disease in the tropics and public health
8. Learn about the Infectious Disease Department in UMC Radboud
9. Learn about the management of infectious disease in UMC Radboud
10. Learn about the infectious disease commonly encountered in The Netherlands
11. Learn if I want to pursue a career in infectious disease

LIST OF ACTIVITIES

1 February 2007: Course of Health and Disease in The Tropics

1 March 2007: Course of Public Health, International Perspective

1 April 2007: Rotation in Infectious Disease Department UMC Radboud

March-April 2007: Evening lectures of Honours Programme, Radboud University

KVZ1: HEALTH AND DISEASE IN THE TROPICS

19 students participated in this course, consisting of 12 dutch students and 7 international students.

Monday, 5/2/07

HEALTH RESOURCE ALLOCATION GAME

The topic for the day is THE DISTRICT: A FRAMEWORK FOR HEALTH.

In the beginning, an introduction of the course and schedule is given by van Asten and Keuter. The international students are encouraged to mix with the Dutch students so that interaction could begin immediately in the classroom. In the practical session, the health resource allocation game is played. The students are given short instructions by the lecturer and must learn further details from the course book.

Health is determined by multiple factors in the environment, as well as the health system used. Components of the primary health care are explored in this game, such as prevention, health promotion, and treatment of common conditions, and supply of drugs. In the end, the cost-effectiveness of health services is determined by the way the health system is managed.

Objectives:

• Insight in design and structure of health system and it’s consequence
• Geographical accessibility of health care

The students must design a health system for a province with a certain budget, and then test the functionality of this system by 200 cards representing 500.000 patients with different conditions and severity.

Two stages of the game:

1. Planning stage : design and describe the health system

1. Operational stage : test the system through patients, then compare results between the different health systems

During the parctical, we realized the limitations of providing extensive medical facilities in a region. The specific province in the game is particularly difficult because of the geographical setting, where villages are scattered sparsely, and there were very few main roads connecting different parts of the province. Most of the areas are not accessible through main roads and people must walk up to 40 km to the nearest main road from their villages. This situation is common in Africa. The limitation also come from the minimum budget allocated to build the necessary health system, which is the situation in many tropical countries.

Discussion:

• It’s cheaper to provide health care in urban settings than rural settings, as the same facility can provide service to more people than is being set up in rural setting, where there were fewer inhabitants within the same reach.
• From the game, we found out that there are many diseases that mostly need primary health care facility, which is the community health worker. The community health workers are the ones who should advise a patient whether he or she need further medical treatments.
• The systems that the students built was “weak on the ground”, meaning there were fewer primary health care than the amount needed. The health care system should be mostly based on primary health care; for referral and supervision purpose then the system built upward.
• The patients need to be treated in different level of health care according to the manifestation and severity of the disease. There were patients who were treated at health care levels that are too high or too low because of those are the only accessible facilities.
• Delay in getting medical help may be caused by:

-          the distance between health care facilities and villages

-          limited transportation

-          people can’t leave their family or their village to seek medical help

Tuesday, 6/2/07

INTRODUCTION OF TROPICAL DISEASE

An overall introduction of tropical diseases was given by dr. Monique Keuter.  The tropical diseases can also be associated with being climate bound, vector bound, or even poverty bound. Poverty plays important role due to the poor living condition such as overcrowded environment, bad sanitation. The lecture also introduced the distribution, causative agent, symptoms and control of schistosomiasis and trypanosomiasis.

The class was then divided into groups of two to look up the internet on the different tropical diseases, the vector, the control and prevention and focus of research. The international students were each paired with Dutch student and asked to study the more prevalent disease in their own country. The diseases selected are the ones listed in Tropical Diseases Research website of WHO. TDR focuses on neglected infectious diseases that disproportionally affect poor and marginalized populations.After the research each team do a short presentation. There were further discussion with dr.van Asten and dr. Keuter.

Wednesday, 7/2/07

TOTAL BURDEN OF DISEASE

The lecture analyze tropical diseases in relation to other diseases. The analysis was based on Disability Adjusted Life Years (DALY). DALY can be used for comparison of diseases.

According to WHO (2002), the biggest health problem based on DALY:

1. Malaria
2. TB
3. Lymphatic

While the order based on total death:

1. TB
2. Malaria
3. Leishmaniasis

Epidemiological trends:

1. Increase in mortality and drug resistance
2. increase in epidemics

Burden of diseases can be calculated from:

1. DALY
2. Death
3. Economic impact

-          Productivity lost

-          Reduction in annual economic growth rate

From the World Health Report 2003:

-          Communicable diseases are starting to decrease while non-communicable diseases are increasing.

-          Tropical diseases in the tropical countries are not the biggest health problem except for malaria in Africa.

WHO 2002:

DALY in developing countries:

1. HIV AIDS
2. Lower respiratory tract infection
3. Diarrhoeal diseases

The highest risk factors for health problems:

1. Underweight
2. Unsafe water, poor hygiene and sanitation
3. Unsafe sex
4. Indoor smoke and fume inhalation
5. Zinc, iron, and Vitamin A deficiency

* These health risks need to be addressed to reduce the burden of disease.

* Resources are lower in the area with the highest burden of diseases

We were then given a chance to look at several different websites about outbreak of diseases. We’re then asked to choose an outbreak disease which interests us the most and create a presentation on it.

Thursday, 8/2/07

HISTORY OF TROPICAL DISEASES

We had a closer look at a figure in a researcher of tropical medicine, Koch. We’re divided into 4 groups, each were given a chapter from his biography that highlight the important parts of his life such as his technical contributions, his research on TB, cholera, and malaria.

Friday, 9/2/07

FORUM PRESENTATION

In this forum presentation, we’re given 30 minutes of presentation and discussion about the outbreak of diseases.  My presentation with Arash Khawaja from Radboud was about avian influenza with a focus on the management by Indonesian government.

Discussion:

-          Poor compliance in cattle vaccination may be caused by disadvantages due to the vaccination such as cattle abortion.

-          Important national and international events may affect the spread of outbreak, such as political unrest and massive imports of cattle and meat due to increasing demand from the hajj.

-          From the chart of outbreak, there was decrease in the case number after a peak. This may be caused by interventional measures. But normally, without any kind of intervention, outbreaks may decrease by itself because of the reduction in the number of people susceptible of the disease. People who recovered from the infection or had sub-clinical infection may gain immunity and not affected by the disease.

Monday, 12/2/07

Self study was instructed to answer cases regarding malaria prophylaxis and travel advice.

MENTAL HEALTH IN DEVELOPING COUNTRY

A lecture is given by Prof. dr. F. Kortmann about establishing mental health service in developing country. We were then asked to do a groupwork and later on a presentation on how to do a mental illness epidemiological study in the population, convince a government to develop mental health care, and design a training program of mental health care for local staff and local community of a developing country.

Investing  in mental health care is necessary as there is high prevalence of mental illness and psychosocial problem in the developing country, the high burden of disease, the mental health care is proportionally cheap, and there will be high cost if mental health is not integrated into the basic health care system.

Tuesday, 13/2/07

• Dr. Keuter gave the class a tutorial on the cases of the self-study assignment.
• Lecture on epidemiological aspect of malaria.

Wednesday, 14/2/07

Presentation:

-          Case management: diagnosis, therapy, intermittent preventive treatment (IPT)

-          Comparison of insecticide treated nets (ITN) and combination of ITN-IPT

-          Malaria and pregnancy

-          Drug resistance

Thursday, 15/2/07

CHILDREN AND HIV INFECTION

Children may get HIV infection from the mother through pregnancy, delivery process and breastfeeding. Risk factors associated with transmission may be

Friday, 16/2/07

Practical is done to observe malaria parasite and the procedure of making thick and thin smear for malaria diagnostic examination.

Wednesday, 21/2/07

• Written test
• Introduction of the research proposal assignment was given. Every student was allowed to choose one of the available topics that interest them the most. I chose to do the research proposal about malaria and iron. A tutor for each topic is available to guide the students through the process of creating the research proposal.

Final version of the research proposal enclosed.

22/2/07-27/2/07

Research proposal preparation

1/3/07-2/3/07

Forum presentation of research proposal

Final version of presentation is enclosed

Feedback session was conducted, and all the students were allowed to give verbal and written feedback on the course.

The strong points of this course the students find positive are:

-          the use of english (especially for the dutch students)

-          the topics of discussions and articles used as references are up to date and recent

-          the group works that allow interaction and exchange between the dutch and the international students

-          the professors were able to give the lectures clearly and with good structure

The weak points of this course are:

-          the dutch students were not well informed before the course started that there would be international students, which might have allowed more dutch students becoming interested in joining this course

-          the international students were not well informed about the content of the course, which would allow better preparation of literature from home countries

-          feedback of the forum presentation was not given, so the students could not improve their performance immediately

KVZ2: PUBLIC HEALTH, INTERNATIONAL PERSPECTIVE

14 people participated in this course, consisting of 7 dutch and 7 international students. The class was divided into 2 working group to allow better dynamic in the discussions. The students must prepare on different health issues in groups, and the class was also divided into 3 groups, each consisting of 4 or 5 students. The topics available for the paper are tuberculosis, HIV/AIDS, and reproductive health. I selected reproductive health as my topic, and worked with 3 other students. A tutor is available for every group.

Monday, 5/3/07

Lecture: Opening and introduction of course

What is public health?

•Public health is the science & art of preventing disease, prolonging life and promoting health and efficiency through organized community efforts

–Policy and planning – of health systems

–Prevention – of diseases

–Promotion – of healthy lifestyles

–Protection – against health hazards

–Partnership – to build coalitions

Aim of the course

•After the course, the student is able to identify..

–the main determinants of major public health problems

–efforts made within health systems to adress these

•for a wide range of situations

–assess the implications for day-to-day practice of medicine

Lecture: Health and its determinants

Measure of disease

nMortality rates

•Historically important

•But do not provide information on morbidty of disease (and this is becoming more and more important)

nMeasure for burden of disease

nDisability-adjusted life years

nLoss of life years, adjusted for quality of these years lived

Disability adjusted life years

nPowerful instrument to compare chronic and fatal diseases

•E.g. depression and HIV/AIDS

nInfluential in policy and planning of health programs in developing countries

Child diseases (0-4 yr)

• Enormous progression since ’70s
• Especially in areas with economic progress
• Progress in Africa offset by HIV/AIDS

Adult diseases

• General mortality decline
• Except in Africa: enormous increase because of HIV/AIDS
• In other areas, non-communicable disease gain importance
• Difference in burden of disease between countries is increasing
• Determinants

The good…

nLife expectancy approaches 80 years in many countries, and is expected to increase to 100 in 2050

nLife expectancy in developing countries has increased from 46 tot 64 since ‘70

nIn all countries of the world, child mortality has decreased between 1960 and 2002.

nPolio is eridicated as epidemic

The bad…

nHIV/AIDS kills 3 million people per year, TB 2 million and malaria 1 million

nTuberculosis and malaria become more and more resistant against medical treatment

nIn 2002 10,5 million children died (< 5 jr)

n6-7 million of these deaths could have been avoided easily through vaccination or treatment

nas caused by malnutrition, pneumonia, disarrhoea, malaria or measles.

The ugly….

nThe difference in life-expectancy between developing and developed countries increases up to 40 years

nThe ratio of child mortality between developing and developed countries was

•5,5 in 1960

•10,3 in 1990

•13,0 in 2002

nAlso major differences between countries – also in eich countries

Tuesday, 6/3/07

Work group: Health and determinants

Wednesday, 7/3/07

Practical: Gapminder: exploring global health

In gapminder, the human develoment index is visualized in graphs, where education and health is put as vertical axis and income (GDP) as horizontal axis.

We analyzed the following graphic series:

1. Human development and income growth 2004
2. Human development trends 2005
3. Milenium Development Goal Achievement Graphs 2003

Conclusions:

-          Countries with the highest HDI and income are the ones in Organization of Economic Cooperation and Development.

-          Region with the lowest is Sub-saharan Africa.

-          Singapore and Hongkong are Asian countries that perform as well as OECD countries.

-          With the same level of income, countries may have different HDI. This may be due to civil wars and other social and political unrest, and the choices of the government on where to invest their money on.

-          Economic growth requires investing in human development first.

-          Indonesia, along with Srilanka and China progress in both income in 1975-2002.

-          Some countries such as Pakistan, Ghana and Nigeria have slow income growth with increase of HDI.

-          Iran, Oman and Algeria improved their HDI but income development was still slow due to their reliance on oil alone for the income.

-          Poverty is currently defined as having less than 1 USD per day. The goal is to reduce the world poverty from 26% in 1990 to 13% (half) by 2015. With the current growth and distribution trend, it is estimated that the goal can be met by 2015.

-          Sub-saharan Africa will have bigger percentage of poor people, and Latin America will experience wider gap between the rich and the poor within the region and countries.

-          Some countries, such as Eritrea, is very efficient in using their income to invest on human development, therefore with relatively low income they manage to achieve high HDI.

-          Big disparities within a country is a big problem in developing countries. Income difference between rich and poor in Namibia is similar to difference between the richest and the poorest countries in the world. Asian countries have lower disparities compared to Africa and Latin America.

Response lecture: Health and determinants

Charts and Graphs from Human Development Reports, UNDP 1997, were discussed.

Lecture: Globalisation

The history and effect of globalisation is explained. In relation to health, globalisation may lead to widening gap in health equality and distribution if the determinants of health are not properly addressed.

Thursday, 8/3/07

Work group: Globalisation

Friday, 9/3/07

Video about the outbreak of cholera in Bangladesh was played. Discussion took place afterwards. The determinants of the disease were poverty (poor sanitation, inadequate waste cycle), inadequate water supply, education (human behaviour regarding hygiene and sanitation, handling of patients in the hospitals, awareness of ORS and sugar-salt solution), political (denial of the problem due to economic consequences), urbanization (transmission of strain and increasing poverty in cities), gender empowerment, and interaction of grass-root movements with the government.

Response lectures: Globalisation

The elements of globalisation include:

1. Economic growth
2. Income distribution
3. Social development

The phases of epidemiological transition:

1. Hunger
2. Pandemics
3. Man made diseases
4. Delayed chronic degenerative diseases
5. Re-emerging infections

Monday, 12/3/07

Lecture: Health systems

-          Government involvement is needed in the health system to ensure equal access for people to health and quality assurance of the health care services. Collective actions are needed in public health efforts, and this is possible only if there is coordination involving the government.

-          Industrial revolution promoted the introduction of health system as healthy workers are needed to maintain the productivity of industries.

-          Technical interventions must work within a good system before becoming effective in solving problems, therefore a good health system is needed. Health system is the link between interventions and outcomes of health; and when the available interventions are not producing proportionally good outcomes, the health system should be assessed.

-          Health system can be broken down into 8 steps for effective implementations of services; and problems in the health system can be traced and possibly solved within these steps.

1. Financial accessibility
2. Physical accessibility
3. Availability of human resources
4. Availability of material resources
5. Organizational quality
6. Relevance of services
7. Technical quality
8. Social accountability

Tuesday, 13/3/07

Discussions: what makes a good health system?

• Health system is defined as all activities whose primary purpose is to promote, restore, or maintain health. While the definition of health care system is provision and investment in health services including preventive, curative, palliative interventions directed individuals or populations.
• Objectives and impacts of the health system was discussed.
• Ensuring health of the population can not simply be done with curative efforts. Once patients are cured, they will return to their environment and community, the places likely contribute to their disease in the first place. For this, public health approach is important.
• Impact of health system to health outcomes is difficult to measure because all the different factors which also play their role.
• Changes in the European health system has happened from national health system, to primary health care, to new universalism. These systems have their own characteristic, advantages and disadvantages. However, the changes of health system had always been a reaction to what happen in the population. Ideally, health system must be able to anticipate problems, not just react to them.

Health systems

Why need a organised health system by government?

–Why not trade health care as e.g. apples on market?

•Need collective action

–for prevention

–to control communicable diseases

•Ensure equal access for rich and poor

–Good health is equally important for rich and poor

Health systems: evolved in past century

–From reliance on traditional remedies to highly complex networks in a century

–Stimulated by industrial revolution

Eight steps to effective implementation of services

1. Financial Accessibility

•Typical problem

–Formal user fees are unaffordable

–Exemptions used for influential individuals

–Insurance serves only urban elite and formal sector workers

•Possible remedies

–Reduce user fees for basic services / strengthen exemption mechanisms

–Develop community financing arrangements   covering informal sector

2. Availability of Human Resources

•Typical problem

–Lack of trained and motivated staff in remote undesirable areas

•Poor deployment policies, wage gap between internal and global market

•Possible remedies

–Improved personnel policies, favoring hard-to-reach areas

•Hardship pay, performance-based payments, improved training and supervision,                          contracting out

3. Availability of Material Resources

•Typical problem

–Shortage of essential drugs, and low quality / fake drugs

•Poor management of drug supply

•Consumers have insuffient knowledge

•Possible remedies

–Improved drug management

•Rigorous forecasting, transparant procurement with reliable providers, contracting out, therapeutic guidelines, equity funds to improve access to drugs for the poor

4. Organizational Quality

•Typical problem

–Long queues / underutilization of facilities, lack of respectful care

•Social distance between provider and community

•Poor service management

•Possible remedies

–Train staff in planning and management

–Introduce community management committees

–Disseminate info about ‘patients rights’

–Include satisfaction measures in evaluation

5. Relevance of Service Mix

•Typical problem

–Ad-hoc, history based priority setting

•Disproportinate supply of curative services,

•Little relation between services ↔ burden of disease

•Public spending favors the least poor

•Possible remedies

–Rational priority setting of services

–Establish core package adressing basic  needs

6. Technical Quality

•Typical problem

–Inefficacious services delivered

•Lack of use of practical guidelines / diagnostic and treatment algorithms

•Poor training / supervision

•Possible remedies

–Improve drug management, with special focus on rational drug use

–Improve training and supervision

–Performance based payments / contracting out

7. Social Accountability

•Typical problem

–Services are unresponsive to needs, characteristics & demand of the poor

•Community is not participating in management

•Possible remedies

–Establish and/or improve formal entities for community participation

•Actively promote participation of vulnrable groups

Wednesday, 14/3/07

Response lecture on “what makes a good health system”

Lecture: Choosing the right interventions

Improvement in health system can be done with two ways: choosing which interventions to be delivered or choosing how interventions should be delivered.

In choosing which interventions to deliver, several things need to be considered: how effective the interventions are, what is the background of the population that will be intervened, and result of cost-effectiveness analysis.

Thursday, 15/3/07

Discussion: Quality of Care

Good quality of care is important because they may encourage people to utilize the health care services and more effective for the health care providers.

Perceived quality of care is how the

Friday, 16/3/07

Response lecture: Choosing the right interventions

Monday, 19/3/07

Lecture: Global Initiatives

The lecture focuses on global initiatives, especially on reproductive health. Most of the problems in reproductive health are related to health system, education, and culture which are the issues in public health.

According to the definition of reproductive health, established in ICPD Cairo, 1994, reproductive health deals with the following issues:

-          sexual health

-          family planning

-          abortion

-          safe motherhood

Tuesday, 20/3/07

Working group: Global Initiatives

Wednesday, 21/3/07

Video: Millenium Development Goals

Thursday, 22/3/07

Working group: Primary Health Care

Friday, 23/3/07

Response lecture: Primary health care

Monday, 26/3/07

Lecture and video: Healthy cities

Tuesday, 27/3/07

Working group and lecture: healthy cities

Thursday, 28/3/07

Examination

Friday, 29/3/07

Presentation of paper

Feedback:

-          The course is confusing in the beginning, however, approaching the final week, the students admitted to having better understanding of the different materials taught in the course and how they are related to one another.

-          The class was divided into two discussion groups. The students felt that this group is too small to allow interesting discussion to take place. In the last week of the course the students chose to have the discussion in one big group instead, resulting in a more lively discussion and broader views on the problems.

-          The subjects were always repeated, by having the same problems for self-study assignment, group discussions, and response lectures.

INFECTIOUS DISEASE ROTATION

Entering the third month, my programme was to have an infectious disease rotation in UMC Radboud. Dr. Monique Keuter assigned Dr. Corine Delsing to tutor and supervise me. Dr. Delsing is a fellow resident who were at the time giving consultation on infectious disease patients in UMC Radboud. The departments asking for consultations usually were the orthopaedics, cardiology, neurology and ICU.

My main activity with Dr. Delsing started before 09.00 and finished around 18.00. We usually started the day by checking the latest laboratory or imaging reports of the patients. Everyday we have a printout with the list of patients and their conditions. This list is also available for the supervising infectiologists, and they usually keep track of the patients everyday. Then we started the consultation, visiting the different departments and patients in the hospital.

The infectious disease department is usually asked for consultation when patients from other departments develop a fever with a suspicion of infection. The history, physical examination, laboratory and imaging investigation are conducted to diagnose the cause of fever. The infectiologists are giving diagnostic and therapeutic plans to be done in the wards. Materials obtained for culture or other diagnostic tests are sent to the microbiology department. Infectiologists must also make sure that the suggestions are being carried out by the doctors or nurses in the wards.  This may be difficult as there are often many different specialists involved in the patient care who do not always immediately agree on the plans for patients.

The common cause of fever in UMC Radboud is infection of prostheses, respiratory tract, urinary tract, and the heart. Culture of material from patients is important in isolating the causing organism of infection, and only after the organism and the antibiotics susceptibility is known then the antibiotics will be started. Sometimes, the presumptive therapy is given but only under protocols and guidelines used in the hospital.

Every afternoon the microbiology meetings are held. This daily meetings are attended by the infectiologists and microbiologist. There is always discussion about the clinical condition of patients, materials for culture and antibiotics susceptibility test, and the response to treatment. Discussions take place regarding the sensitivity and specifity of diagnostic examinations, and whether these results are enough to start treatment or further examinations are needed.

Starting treatment usually requires discussions with the microbiologist and the infectiologists, especially in choosing the antibiotics, the length of treatment and route of administration.

I also had the chance to join Dr. Brouwer and Dr. Delsing in the out-patient department, meeting boreliosis and HIV patients.

1. A consultation meeting is held weekly with all the infectious disease supervisors and residents mostly for educational purpose, as different opinions on the patients are discussed.  An HIV/AIDS meeting is held weekly for discussing the latest treatment of the patients. The weekly orthopaedics meeting allow the surgeons to have a discussion with the infectious disease specialists and microbiologists regarding the orthopaedic patients.

During my rotation, I had the chance to work with several different patients.

• Mr. R, born 11-07-1930. Consulted with fever after placement of aortic prostheses.
• Mr. H, born 02-01-1933. Consulted with fever and necrotic ulcer of the foot.
• Mrs. L, born 11-05-1944. Fever for 3 weeks after CABG.
• Mrs. KH, born 07-04-1952. Staphilococcus aureus endocarditis, Marfan syndrome.
• Mr. M, born 15-8-1939. S. aureus spondylodiscitis, fever.
• Mr. J, born 23-11-27. Mediastinitis with CABG and CNS infection.
• Mr. J, born 21-02-30. Fracture of the hip and humerus with fever.
• Mrs. L, born 27-12-58. Aneurysmatic bone cyst with positive culture for bacillus.
• Mrs.G, born 21-12-52. Fever, fracture of the hip, chronic progressive ophthalmoplegi.
• Mr. H, born 15-03-43. Infection of the knee prosthesis.
• Mr. G, born 22-11-66. Cavernous lung: aspergilloma.
• Mr. C, born 01-01-77. Brain abscess, Down syndrome.

UMC Radboud has a computer system for the medical records, with all laboratory and imaging results. The records can be accessed from all computers in the hospital and even from the doctors’ home, making it easier to access up to date information on patients and make a decision.

HONOURS PROGRAMME

I had the opportunity to participate in the lectures of the Honours Programme. Honours Programme is a 2 year inter-disciplinary programme with several different courses during the period. This programme is for motivated students from different faculties, and there were about 20 students in the course that I participated in. The lecturers come from different disciplines and institution. Initially, on 21 April 2007 all the international students from KVZ2 were invited to come to the course, which was about Health Determinants, Health System, and Primary Health Care. However, Dr. Francoise Barten, who is coordinating the Honours Course, offered us to come again to the next lectures, which is about ‘Right to Health’ and ‘Health Care for Immigrants’ in the Netherlands at 28 March 2007. From then on I always attended the weekly lectures, and thus the lectures were always delivered in English.

Undocumented Immigrants Health and Health Care (28 April 2007, 18.00-21.00 Aula Radboud University)

Review of lecture:

The lecture highlights the undocumented immigrants in The Netherlands, which consist of:

-          75% of which are male and work mostly in farming, food, or sex industries

-           Rejected asylum seekers

-          Ex-partners or family of legal immigrants

The effects of their undocumented status in The Netherlands are:

-          poor working and living conditions

-          little amount of money, and therefore stuck to stay in The Netherlands

-          in fear and uncertainty about their condition

-          vulnerability to violence, especially the women

-          no social network

-          pre-existing illness

The health problems in undocumented immigrants are:

-          anxiety

-          sleeping problems

-          contraception problems

-          abortion for economic reasons

-          more serious illness (delay in seeking treatment)

-          higher perinatal death

-          more problems in pregnancy

-          depression

-          HIV/AIDS

-          TB

Problems encountered causing limited access to care by undocumented immigrants are:

-          no health insurance

-          no money for paying treatment cost

-          barriers of doctors and hospital (refuse to give treatment, hesitancy due to patients’ undocumented status and cultural differences)

-          barriers of patients (patients don’t know their right for health care and how to reach the health care services)

Barriers from the doctors are:

-          financial reason (patients unable to pay)

-          knowledge/ psychological barrier: status of patients are illegal/undocumented, doctors must comply to hospital policy

-          practical difficulties (language, time, lack of knowledge due to different diseases

-          lack in the continuity of care (patient is homeless and live in poor condition)

Public health implications if undocumented immigrants with health problems are not treated:

-          spread of communicable disease (TB, STI)

-          self treatment by using underground doctors (without quality control, promoting spread of drug-resistant microorganisms)

-          inequity and inequality

Integrated approach for the health of undocumented migrants:

-          improvement not just in fulfilling legal rights but also social rights (housing, working condition)

-          providing stability in supportive network

-          education for doctors (about the obligation to treat everyone)

-          education for migrants (about how to seek health care)

Why Poor People Stay Ill: Chronic Poverty and Shock (4 April 2007, 18.00-21.00 Aula Radboud University)

Review of lecture:

- Chronic poverty causes vulnerability to illness.

- Out of poverty in the world, 30-40% is chronic poverty, meaning that they stay below the poverty line for more than 5 years.

- People at risk for chronic poverty are:

- Those with low level of education

- land degradation

- large families with high dependency

- women and children

- widows, caste, ethnicities (related to ownership esp. in Africa)

- Type of poverty:

1. Income poverty

2. Asset poverty:

- absence of critical assets required for survival

- asset loss after occurrence of shocks (illness, death, natural disaster, marriage)

- There is need to search for risk-coping and insurance mechanism

1. Before events happen

2. After events happen

- The shocks, or critical life events, can be categorized as follows:

1. Stochastic: affecting all households (eg. Natural disasters, wars)

2. Idiosyncratic: affecting individuals (eg. Fire hazard, thief)

- Critical life events are events that have such impact that can put people in poverty after they happen. For example: flood, crop loss, illness, death, marriage, theft, fire hazards.

- Level of intervention:

1. Macro: economic growth of the country

2. Meso: development of insurance network

3. Micro: asset creation (land, schooling, etc)

- Conclusion: there is the need to provide mechanism that can protect people from poverty in case critical life events happen.

Health and the WTO by Albert de Vaal (11 April 2007, 18.00-21.00 Aula Radboud University)

The relation of WTO and health can either be direct or indirect. In direct relation, the health issues are comprised in treaties of WTO; in indirect relation, WTO contributes to factors that determine health.

Free trade, according to the WTO will be mutually beneficial if both countries involved open up their borders for trade. Free trade also allows smaller countries to specialize in products and services most beneficial for them and gain is potentially higher for smaller countries. Gain will be highest also if the trade is between countries that are most different. Generally, trade improve growth, but this is empirically hard to prove. Countries involved in free trade economically grow, however, the growth may not always be equal for all countries involved where some have higher growth than others.

The developing countries need better terms of agreement for free trade. Implementation is somewhat more difficult for developing countries due to the slower and costly process, thus assistance is needed. However, as international agreements are made in WTO headquarter, the countries without resource can’t be involved in the decision making.

To ensure fair trade is actually fair for the developing countries, the political commitment of governments is needed. Often, the governments are not making decisions on the best interest of the people. The governments should ensure that the trade agreement is a give and take process, or else no trade will be done. Capacity building is essential for global commerce, especially for taking part in the decision making.

Conclusion: reciprocity is vital in ensuring that fair trade will be beneficial for socio-economic development of people in developing countries.

Food,  Health, and The Role of International Community

Many countries still give ‘tied aid’, meaning that the aid is tied to sets of agreements between the donor and recipient countries, such as that the money is spent on goods from the donor countries. This can lead to competition between different donors.  For example, The Netherlands built a hospital in Java and equipped it, with the intention of providing health services to people. The project was however was criticized of having low contribution to health effects because of limited coverage of the hospital. The hospital also relied heavily on equipments, causing rise in the cost of service and eventually, prices of service.

The water and sanitation programmes of the donor countries in the 60’s and 80’s had emphasized on engineering, and criticized because the project had low maintenance and therefore, low sustainability. From the 80’s on, programmes have paid more attention on the importance of the position of women and people participation in policy making.

Critiques were delivered by Oxfam in the 90’s about the gap between the principles and practices of World Bank:

1. Limited expenditures
2. Introduction of user fees of public services
3. Rejection of taxation as financing means
4. Increasing inequities

Social Capital and Health (18 April 2007, 18.00-21.00 Aula Radboud University)

Social capital consists of these elements:

-          Material resources

-          Immaterial resources

-          In network of social relations

-          Mobilized by individual or collective actors

The concept of social capital is depoliticized and considered as ‘neutral’. Social capital also includes financial, physical, human and cultural capital.

With globalization, the state retreats with the increasing role of the market; there is a need for the increase of the role of civil society. This rise of civil society requires social capital to act.

When discussing about social capital, it is important to understand which types of social capital is being talked about:

1. Bonding: not good for larger societal development, as capital is available only for people within a group, which may lead to inequities between different groups.
2. Bridging: interaction is based on trust and may lead to joint action. Groups of the same level may join forces to change policy.
3. Linking: from lower to higher level for increasing the resource, for example from local organizations to government.

Social capital is important in health for socialization, protection during crisis, improving access to services and psychosocial process.

With the alternative model, social capital are joined together in pressure groups to force policy change. In synergy model, the social capital is in collaboration with the government to ensure better health for the people.

Health in Urban Settings by Dr. Francoise Barten

Interventions are often focused on prevention of exposure to health risks, however, the underlying social and economic policy of the country should also be influenced. Governments are often only interested in short term plans with immediate results, when long term and sustainable plans are needed. There is a need of empowerment, the deepening in the participation of people in determining their living and working condition. There’s also a need for social contract between people and the government.

Diseases are interrelated, but interventions are being singled out. Integrated approach is needed but donors pick out specific issues to deal with separately and decisions are made not according to the local context. This integrated approach involves multiple actors and multiple activities in confronting the crisis.  Health and its determinants are included in the policy making process.

SUMMARY

The first course is KVZ 1, Health and Disease in the Tropics. The course was coordinated by Dr. Monique Keuter. The second course, KVZ2, is Public Health: International Perspective. Both of the courses are elective courses for the fourth year medical students in UMC Radboud.

In KVZ1, the programme was designed to allow intensive interaction between the Dutch and international students. After lectures, the students had to immediately work in groups, usually preparing a presentation to be presented again in the class the same day. We spent the whole day almost every day in the faculty, whether in the classrooms or the library.

We were getting used to reading a lot of articles in short time, make a summary and present them. The discussions are always interesting as most of the students were actively participating, giving questions or comments about the presentations. Everyone felt comfortable asking or answering questions without being afraid.

The teachers also participated in the discussion but always encourage the students to contribute more and explore different possibilities. The teachers always managed to stimulate interesting and lively discussion. When answer to a question was not known, we’re used to look up the answers together in a book or journals. Learning with the teacher was pleasant and we felt like we were learning together instead of just being lectured all the time.

The discussions with other students were not just about the course, but also practical experiences in dealing with the diseases in our own countries. The discussion goes beyond the classroom, as we also spent a lot of our free time outside the class together.

The materials used for our presentation assignments are always up to date, based on recently published articles. This is something new for me, as I’ve never had this structure of learning in Indonesia where students are given articles to summarize, answer questions and present. This had been a fun learning experience for me.

The proposal writing was an important part of the course. We formed a group of 4 or 5 students and given a tutor with extensive research experience to supervise in writing the proposals. I found this very helpful, as being in a small group with a tutor allows us to have a better understanding of the materials being discussed, compared to just reading articles with other students. I was especially impressed that the tutors were all very attentive and had the time to coach us in writing a research proposal. They helped to explain concepts, structure of proposals and edit them. It was easy to communicate with the tutors. The editing could even be done by exchanging emails.

I was impressed with the course also because I had experienced a different teaching and learning structure.

KVZ2 was different in the structure, as we were given lectures on a subject, followed by self-study assignments of reading articles and answering problems, then meet with our group and a tutor to discuss the answers. The next day we would have a response lecture with the whole class about the problems. This resulted in us always repeating the same problems and discussions. Although we gained a deeper understanding, the repetition was found to be rather boring.

There was an assignment of writing a paper throughout the duration of the course and presenting it after the written exam. However, with we could only have a satisfying view on the health problems only after the last week of the course where we could integrate and understand all the different aspects of public health as being taught by the teachers. The result is that we ended up re-writing some part of the paper just days before the deadline with this new and comprehensive understanding of the problem.

I had suggested that my group focus on maternal mortality in Indonesia. We all agreed, and had a challenging experience in trying to gather data regarding maternal mortality and efforts to reduce it in Indonesia. Finding accurate and current information is difficult, as there were only few articles found in international journals regarding maternal mortality in Indonesia. This made me realized that research and publication is still lacking in Indonesia. And although national journals exist, they are not readily available online, limiting the use of information.

This course deals more with health economics and the social and political aspects of health, which turned out to be a very important knowledge for health professionals. I have never been introduced to these topics before, as public health in Indonesia deals mainly with community medicine, strictly discussing only diseases, interventions and community education. I learned about the functioning of the health system, the cost-effective analyses of interventions and the international initiatives to improve health.

Health is beyond the walls of the hospitals, and that influencing health of a population requires us to step into national and international policies. Understanding these wider aspects of health is important for clinicians, as those who want to make a difference have to take into account the different determinants of health. I am personally interested in these issues and enjoyed the vast new knowledge I got from the course.

Dr. Francoise Barten from KVZ2 offered me to join the Honours Programme lectures on Wednesday evenings during the second and third month. The Honours Programme is an integrated course for students from different faculties. The lecturers come from different backgrounds (university, NGO, professionals) and disciplines, enriching the course with different perspectives on problems.

I also had the opportunity to give a presentation to Dutch students who considered doing their 3 months of rotation or research in developing countries. These groups of students are called Tropico. At first I was asked by Dr. Keuter to introduce rotation in Semarang and Jepara because she couldn’t be in the meeting. But after seeing a report on my work with UNESCO in Paris and Italy in 2005 about intercultural learning, she suggested that I also introduce the importance of intercultural learning. I eventually gave a presentation about intercultural learning and afterwards have a discussion about living in Java.

I am impressed by the experiences of the teachers and residents in the field of research. The supervisors, most of the residents in infectious disease and many of the medical students I met have had experiences in doing research, working or volunteering abroad in tropical countries. This brings the advantage of having a more realistic view about medicine and health care, rather than just rely on the fully facilitated hospitals of the Netherlands. Students were encouraged to join in other activities than studying medicine such as working or volunteering in nursing homes or retirement houses.

I immediately started my rotation in the hospital on the beginning of April, and assigned to a fellow resident of infectious disease, Dr. Delsing. I joined her everyday from 9 am to 6 pm, visiting patients, discussing cases with other specialists and attending meetings.

Joining the rotation has provided me with some insight of the infectious disease department. I learned more about how important it is to work closely with different specialists in patient care. The cooperation and discussion between the infectiologists and microbiologists is crucial in ensuring the best diagnostics and treatment for patients.

Following a resident full time allowed me to learn a lot about the patients and their conditions, as well as how to communicate with patients. I have learned a great deal about how to approach a patient with fever and suspicion of infection, how important it is to ensure a diagnosis before starting therapy and how to carefully choose the best antibiotics. It’s especially interesting to see how old patients in the wards are, compared to ones in Indonesian wards, showing higher life expectancy.

During a consultation meeting, the supervisors often asked the residents to find information regarding comparison of antibiotics efficacy, certain diseases or syndromes and treatment options based on the patients conditions. The residents then would look up in journals and present the answer on the next meeting with the supervisors, allowing continuous learning relevant to the clinical cases in the hospital.

Meeting the patients in the out-patient clinic had also gave me example on how things are done differently in the Netherlands. Almost all examination rooms have their own computers. The doctors can access patient information and connect to the internet for quick research about a certain disease or even look up information regarding drugs dosage and side effects. Several times, after a patient presented a complaint, the physician looked up the hospital website to check whether the complaint was a side effect of the antibiotics. The patient seemed glad that the doctor had consulted a reference website, ensuring that she would get correct information. In Indonesia, when doctors look up to check on information, patients perhaps are more likely to doubt their competence.

The cosschap in The Netherlands are similar to the programme in Indonesia. However, the senior coass can choose where they want to do the final 3 month, whether in Internal Medicine, Paediatrics, Surgery, Obstetrics or development internship in tropical countries. These senior coass doing the last 3 months in the Netherlands are assigned their own patients, with all the responsibilities of a physician. In the ward, they have the same authority and responsibilities of the residents, but with fewer patients.

The whole programme has allowed me have a better understanding of tropical medicine, international perspective of public health and infectious disease. There were of course advantages of studying in a richer university, with easy and free access to the library, internet and online journals. However, learning is also about the attitude and the will to go forward despite the limitations. I believe that the experience didn’t only teach me medicine, but also about lifelong learning and serving people with our knowledge.

Malnutrisi

TINJAUAN PUSTAKA

oleh: Dr. Rahajeng

Malnutrisi adalah suatu keadaan di mana tubuh mengalami gangguan dalam penggunaan zat gizi untuk pertumbuhan, perkembangan dan aktivitas. Malnutrisi dapat disebabkan oleh kurangnya asupan makanan maupun adanya gangguan terhadap absorbsi, pencernaan dan penggunaan zat gizi dalam tubuh.[1]

Malnutrisi merupakan masalah yang menjadi perhatian internasional serta memiliki berbagai sebab yang saling berkaitan. Penyebab malnutrisi menurut kerangka konseptual UNICEF dapat dibedakan menjadi penyebab langsung (immediate cause), penyebab tidak langsung (underlying cause) dan penyebab dasar (basic cause).[2]

Gambar 1.

Kurangnya asupan makanan dan adanya penyakit merupakan penyebab langsung malnutrisi yang paling penting. Penyakit, terutama penyakit infeksi, mempengaruhi jumlah asupan makanan dan penggunaan nutrien oleh tubuh. Kurangnya asupan makanan sendiri dapat disebabkan oleh kurangnya jumlah makanan yang diberikan, kurangnya kualitas makanan yang diberikan dan cara pemberian makanan yang salah.

Di Indonesia, angka kebutuhan energi untuk kelompok umur 0-6 bulan adalah 550 kkal/hari, kelompok umur 7-12 bulan 650 kkal/hari,  kelompok umur 1-3 tahun 1000 kkal/hari, dan  kelompok umur 4-6 tahun 1550 kkal/hari.[3]

Pemberian makanan tambahan sebagai pendamping ASI dimulai saat anak berusia 6 bulan dengan tetap memberikan ASI. Pemberian makanan tambahan ASI dinaikkan bertahap dari segi jumlah, frekuensi pemberian, dan jenis dan konsistensi makanan yang diberikan. Untuk anak yang mendapatkan ASI, rata-rata makanan tambahan yang harus diberikan 2-3 kali/hari untuk usia 6-8 bulan, 3-4 kali/hari untuk usia 9-11 bulan dan 4-5 kali/hari usia 12-24 bulan.[4] Jika densitas dalam makanan rendah atau anak tidak lagi mendapatkan ASI mungkin diperlukan frekuensi makan yang lebih sering. Variasi makanan diberikan untuk memenuhi kebutuhan nutrien. Daging, ayam, ikan atau telur harus diberikan setiap hari atau sesering mungkin. Demikian pula buah dan sayuran, sebaiknya diberikan setiap hari. Kegagalan untuk menyediakan asupan makanan sesuai angka kebutuhan ini secara terus-menerus akan menyebabkan gangguan pertumbuhan dan perkembangan.[5]

Cara pemberian makanan yang salah dapat dapat disebabkan karena ibu tidak memiliki pengetahuan yang cukup, misalnya mengenai pemberian ASI eksklusif maupun cara pemberian makanan pendamping ASI. Ibu seharusnya mendapatkan informasi yang lengkap dan obyektif mengenai cara pemberian makanan yang bebas dari pengaruh komersial. Mereka perlu mengetahui masa pemberian ASI yang dianjurkan; waktu dimulainya pemberian makanan tambahan; jenis makanan apa yang harus diberikan, berapa banyak dan berapa sering makanan diberikan, dan bagaimana cara memberikan makanan dengan aman.[6]

Kematian akibat penyakit dapat disebabkan salah satu atau kombinasi dari berbagai penyebab lain seperti rendahnya pemanfaatan pelayanan kesehatan, kurangnya suplai air bersih dan fasilitas sanitasi, kurangnya kebersihan makanan serta pengasuhan anak yang tidak memadai. Pengasuhan anak yang tidak memadai sendiri dapat dikarenakan ibu bekerja sehingga ibu juga memiliki lebih sedikit waktu untuk memberi makan anaknya.

Penyebab tidak langsung yang dapat menyebabkan malnutrisi adalah kurangnya ketahanan pangan keluarga, kualitas perawatan ibu dan anak, pelayanan kesehatan serta sanitasi lingkungan. Ketahanan pangan dapat dijabarkan sebagai kemampuan keluarga untuk menghasilkan atau mendapatkan makanan. Sebagai tambahan, perlu diperhatikan pengaruh produksi bahan makanan keluarga terhadap beban kerja ibu dan distribusi makanan untuk anggota keluarga. Sanitasi lingkungan berpengaruh terhadap kesehatan, produksi serta persiapan makanan untuk dikonsumsi serta kebersihan. Pelayanan kesehatan bukan hanya harus tersedia, namun juga harus dapat diakses dengan mudah oleh ibu dan anak. Status pendidikan dan ekonomi perempuan yang rendah menyebabkan kurangnya kemampuan untuk memperbaiki status gizi keluarga. Adapun penyebab dasar berupa kondisi sosial, politik dan ekonomi negara.

Malnutrisi, yang dapat berupa gizi kurang atau gizi buruk, dapat bermanifestasi bukan hanya di tingkat individual namun juga di tingkat rumah tangga, masyarakat, nasional dan internasional sehingga upaya untuk mengatasinya perlu dilaksanakan secara berkesinambungan di berbagai tingkatan dengan melibatkan berbagai sektor.[7] Dengan demikian, penting untuk mengenali penyebab gizi kurang dan gizi buruk di tingkat individu, masyarakat, maupun negara agar selanjutnya dapat dilakukan tindakan yang sesuai untuk mengatasinya.

UNICEF memperkenalkan pendekatan “Assessment, Analysis and Action” dalam penanganan malnutrisi. Setelah adanya penilaian (assessment) mengenai adanya malnutrisi, selanjutnya perlu dilakukan analisis mengenai penyebabnya. Berdasarkan analisis penyebab dan penilaian sumber daya yang tersedia, tindakan (action) dirancang dan dilaksanakan untuk mengatasi masalah. Malnutrisi merupakan manifestasi dari serangkaian penyebab yang saling berkaitan. Namun demikian, identifikasi penyebab langsung malnutrisi pada kasus-kasus individual ataupun pada masyarakat dengan prevalensi malnutrisi yang tinggi tetap relevan untuk dilakukan agar dapat dilakukan penanganan yang sesuai konteks kasus maupun masyarakat.[8]

Secara klinis, malnutrisi dinyatakan sebagai gizi kurang dan gizi buruk. Gizi kurang belum menunjukkan gejala khas, belum ada kelainan biokimia, hanya dijumpai gangguan pertumbuhan. Gangguan pertumbuhan dapat terjadi dalam waktu singkat dan dapat terjadi dalam waktu yang cukup lama. Gangguan pertumbuhan dalam waktu yang singkat sering terjadi pada perubahan berat badan sebagai akibat menurunnya nafsu makan, sakit seperti diare dan ISPA, atau karena kurang cukupnya makanan yang dikonsumsi. Sedangkan gangguan pertumbuhan yang berlangsung lama dapat terlihat pada hambatan pertambahan panjang badan.

Pada gizi buruk disamping gejala klinis didapatkan pula kelainan biokimia yang khas sesuai bentuk klinis. Pada gizi buruk didapatkan 3 bentuk klinis yaitu kwashiorkor, marasmus,dan marasmus kwashiorkor. Kwashiorkor adalah gangguan gizi karena kekurangan protein biasa sering disebut busung lapar. Gejala yang timbul diantaranya adalah edema di seluruh tubuh terutama punggung kaki, wajah membulat dan sembab, perubahan status mental: rewel kadang apatis, menolak segala jenis makanan (anoreksia), pembesaran jaringan hati, rambut kusam dan mudah dicabut, gangguan kulit yang disebut crazy pavement,pandangan mata tampak sayu. Pada umumnya penderita sering rewel dan banyak menangis. Pada stadium lanjut anak tampak apatis atau kesadaran yang menurun.[9]^,[10]

Marasmus adalah gangguan gizi karena kekurangan karbohidrat. Gejala yang timbul diantaranya tampak sangat kurus (tinggal tulang terbungkus kulit), muka seperti orangtua (berkerut), tidak terlihat lemak dan otot di bawah kulit, perut cekung, kulit keriput, rambut mudah patah dan kemerahan, gangguan pencernaan (sering diare), pembesaran hati dan sebagainya. Anak tampak sering rewel dan banyak menangis meskipun setelah makan, karena masih merasa lapar. Pada stadium lanjut yang lebih berat anak tampak apatis atau kesadaran yang menurun.[11]

Untuk menentukan status gizi menggunakan beberapa langkah. Langkah pertama adalah dengan melihat berat badan dan umur anak disesuaikan dengan grafik KMS (Kartu Menuju Sehat). Bila dijumpai berat badan di bawah garis merah (BGM) maka dilanjutkan dengan langkah menentukan status gizi balita dengan menghitung berat badan terhadap tinggi badan (BB/TB) berdasarkan standar WHO-NCHS. Dinyatakan gizi buruk bila BB/TB <-3 SD standar WHO-NCHS.[12]

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[1] UNICEF. A UNICEF Policy Review: Strategy for Improved Nutrition of Children and Women in Developing Countries. New York: 1990. Hal: 8.

[2] UNICEF. A UNICEF Policy Review: Strategy for Improved Nutrition of Children and Women in Developing Countries. New York: 1990. Hal: 20-22.

[3] Hardinsyah, Tambunan V. Angka kecukupan energi, protein, lemak dan serat makanan. Dalam: Widyakarya Nasional Pangan dan Gizi VIII. Jakarta; 2004.

[4] Michaelsen KF. What is known? Short term and long term effects of complementary feeding. Nestle Nutr Workshop Ser Pediatr Program. 2005; (56):h.185.

[5] LINKAGES. Guidelines for appropriate complementary feeding of breastfed children 6-24 months of age. USAID. Academy for Educational Development. 2001.

[6] WHO. Global Strategy for Infant and Young Child Feeding. Geneva: 2003. Hal: 12.

[7] UNICEF, Nutrition Section Programme Division. Toward a Common Understanding of Malnutrition: Assessing the Contributions of the UNICEF Framework. New York: 2002. Hal: 2-15.

[8] UNICEF. A UNICEF Policy Review: Strategy for Improved Nutrition of Children and Women in Developing Countries. New York: 1990. Hal: 16-18.

[9] Depkes RI. Pemantauan Pertumbuhan Balita. Jakarta: Depkes RI. 2002.

[10] Pusponegoro DP, Hadinegoro SRS, Firmanda D, et al. Standar Pelayanan Medis Kesehatan Anak. Edisi 1. Jakarta: Badan Penerbit IDAI. 2005.

[11] Pusponegoro DP, Hadinegoro SRS, Firmanda D, et al. Standar Pelayanan Medis Kesehatan Anak. Edisi 1. Jakarta: Badan Penerbit IDAI. 2005

[12] Depkes RI. Buku Bagan Tatalaksana Anak Gizi Buruk. Jakarta: Depkes RI. 2003. Hal: 2.

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Reaksi Transfusi

Risiko transfusi darah ini dapat dibedakan atas reaksi cepat dan lambat.

Reaksi Akut

Reaksi akut adalah reaksi yang terjadi selama transfusi atau dalam 24 jam setelah transfusi. Reaksi akut dapat dibagi menjadi tiga kategori yaitu ringan, sedang-berat dan reaksi yang membahayakan nyawa. Reaksi ringan ditandai dengan timbulnya pruritus, urtikaria dan rash. Reaksi ringan ini disebabkan oleh hipersensitivitas ringan. Reaksi sedang-berat ditandai dengan adanya gejala gelisah, lemah, pruritus, palpitasi, dispnea ringan dan nyeri kepala. Pada pemeriksaan fisis dapat ditemukan adanya warna kemerahan di kulit,  urtikaria,  demam,  takikardia,  kaku otot. Reaksi ringan diatasi dengan pemberian antipiretik, antihistamin atau kortikosteroid, dan pemberian transfusi dengan tetesan diperlambat.

Reaksi sedang-berat biasanya disebabkan oleh hipersensitivitas sedang-berat, demam akibat reaksi transfusi non-hemolitik (antibodi terhadap leukosit, protein, trombosit), kontaminasi pirogen dan/atau bakteri.

Pada reaksi yang membahayakan nyawa ditemukan gejala gelisah, nyeri dada, nyeri di  sekitar tempat masuknya  infus, napas pendek, nyeri punggung, nyeri kepala, dan dispnea. Terdapat pula tanda-tanda kaku otot, demam, lemah, hipotensi (turun ≥20% tekanan darah sistolik), takikardia (naik ≥20%), hemoglobinuria dan perdarahan yang tidak jelas. Reaksi ini disebabkan oleh hemolisis intravaskular akut, kontaminasi bakteri, syok septik, kelebihan cairan, anafilaksis dan gagal paru akut akibat transfusi.

Hemolisis intravaskular akut

Reaksi hemolisis intravaskular akut adalah reaksi yang disebabkan inkompatibilitas sel darah merah. Antibodi dalam plasma pasien akan melisiskan sel darah merah yang inkompatibel. Meskipun volume darah inkompatibel hanya sedikit (10-50 ml) namun sudah dapat menyebabkan reaksi berat. Semakin banyak volume darah yang inkompatibel maka akan semakin meningkatkan risiko.

Penyebab terbanyak adalah inkompatibilitas ABO. Hal ini biasanya terjadi akibat kesalahan dalam permintaan darah, pengambilan contoh darah dari pasien ke tabung yang belum diberikan label, kesalahan pemberian label pada tabung dan ketidaktelitian memeriksa identitas pasien sebelum transfusi. Selain itu penyebab lainnya adalah adanya antibodi dalam plasma pasien melawan antigen golongan darah lain (selain golongan darah ABO) dari darah yang ditransfusikan, seperti sistem Idd, Kell atau Duffy.

Jika pasien sadar, gejala dan tanda biasanya timbul dalam beberapa menit awal transfusi, kadang-kadang timbul jika telah diberikan kurang dari 10 ml. Jika pasien tidak sadar atau dalam anestesia, hipotensi atau perdarahan yang tidak terkontrol mungkin merupakan satu-satunya tanda inkompatibilitas transfusi. Pengawasan pasien dilakukan sejak awal transfusi dari setiap unit darah.

Kelebihan cairan

Kelebihan cairan menyebabkan gagal jantung dan edema paru. Hal ini dapat terjadi bila terlalu banyak cairan yang ditransfusikan, transfusi terlalu cepat, atau penurunan fungsi ginjal. Kelebihan cairan terutama terjadi pada pasien dengan anemia kronik dan memiliki penyakit dasar kardiovaskular.

Reaksi anafilaksis

Risiko meningkat sesuai dengan kecepatan transfusi. Sitokin dalam plasma merupakan salah satu penyebab bronkokonstriksi dan vasokonstriksi pada resipien tertentu. Selain itu, defisiensi IgA dapat menyebabkan reaksi anafilaksis sangat berat. Hal itu dapat disebabkan produk darah yang banyak mengandung IgA. Reaksi ini terjadi dalam beberapa menit awal transfusi dan ditandai dengan syok (kolaps kardiovaskular), distress pernapasan dan tanpa demam. Anafilaksis dapat berakibat fatal bila tidak ditangani dengan cepat dan agresif dengan antihistamin dan adrenalin.

Cedera paru akut akibat transfusi (Transfusion-associated acute lung injury = TRALI)

Cedera paru akut disebabkan oleh plasma donor yang mengandung antibodi yang melawan leukosit pasien. Kegagalan fungsi paru biasanya timbul dalam 1-4 jam sejak awal transfusi, dengan gambaran foto toraks kesuraman yang difus. Tidak ada terapi spesifik, namun diperlukan bantuan pernapasan di ruang rawat intensif.

2. Reaksi Lambat

Reaksi hemolitik lambat

Reaksi hemolitik lambat timbul 5-10 hari setelah transfusi dengan gejala dan tanda demam, anemia, ikterik dan hemoglobinuria. Reaksi hemolitik lambat yang berat dan mengancam nyawa disertai syok, gagal ginjal dan DIC jarang terjadi. Pencegahan dilakukan dengan pemeriksaan laboratorium antibodi sel darah merah dalam plasma pasien dan pemilihan sel darah kompatibel dengan antibodi tersebut.

Purpura pasca transfusi

Purpura pasca transfusi merupakan komplikasi yang jarang tetapi potensial membahayakan pada transfusi sel darah merah atau trombosit. Hal ini disebabkan adanya antibodi langsung yang melawan antigen spesifik trombosit pada resipien. Lebih banyak terjadi pada wanita. Gejala dan tanda yang timbul adalah perdarahan dan adanya trombositopenia berat akut 5-10 hari setelah transfusi yang biasanya terjadi bila hitung trombosit <100.000/uL. Penatalaksanaan penting terutama bila hitung trombosit ≤50.000/uL dan perdarahan yang tidak terlihat dengan hitung trombosit 20.000/uL. Pencegahan dilakukan dengan memberikan trombosit yang kompatibel dengan antibodi pasien.

Penyakit graft-versus-host

Komplikasi ini jarang terjadi namun potensial membahayakan. Biasanya terjadi pada pasien imunodefisiensi, terutama pasien dengan transplantasi sumsum tulang; dan pasien imunokompeten yang diberi transfusi dari individu yang memiliki tipe jaringan kompatibel (HLA: human leucocyte antigen), biasanya yang memiliki hubungan darah. Gejala dan tanda, seperti demam, rash kulit dan deskuamasi, diare, hepatitis, pansitopenia, biasanya timbul 10-12 hari setelah transfusi. Tidak ada terapi spesifik, terapi hanya bersifat suportif.

Kelebihan besi

Pasien yang bergantung pada transfusi berulang dalam jangka waktu panjang akan  mengalami akumulasi besi dalam tubuhnya (hemosiderosis). Biasanya ditandai dengan gagal organ (jantung dan hati). Tidak ada mekanisme fisiologis untuk menghilangkan kelebihan besi. Obat pengikat besi seperti desferioksamin, diberikan untuk meminimalkan akumulasi besi dan mempertahankan kadar serum feritin <2.000 mg/l.

Infeksi

Infeksi yang berisiko terjadi akibat transfusi adalah Hepatitis B dan C, HIV, CMV, malaria, sifilis, bruselosis, tripanosomiasis)

Referensi

WHO. The clinical use of blood: handbook. Geneva, 2002. Didapat dari URL: http://www.who.int/bct/Main_areas_of_work/Resource_Centre/CUB/English/Handbook.pdf

HTA. Transfusi Komponen Darah: Indikasi dan Skrining. Jakarta, 2003.

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Dr. Rahajeng

Sindroma Pierre Robin

Dalam sebuah ujian dengan konsulen muncul pertanyaan, “Apa itu sindroma Pierre Robin?”

Setelah mencari referensi, ternyata…

Sindroma pierre robin adalah sekelompok kelainan yang terutama ditandai dengan adanya rahang bawah yang sangat kecil dengan lidah yang jatuh ke belakang dan mengarah ke bawah. bisa juga disertai dengan tingginya lengkung langit-langit mulut atau celah langit-langit.

Penyebab yang pasti tidak diketahui, bisa merupakan bagian dari sindroma genetik.

Gejalanya berupa:

-          rahang yang sangat kecil dengan dagu yang tertarik ke belakang

-          lidah tampak besar (sebenarnya ukurannya normal tetapi relatif besar jika dibandingkan dengan rahang yang kecil) dan terletak jauh di belakang orofaring

-          lengkung langit-langit yang tinggi

-          celah langit-langit lunak

-          tercekik/tersedak oleh lidah.

Bayi harus ditempatkan pada posisi membungkuk sehingga gaya tarik bumi akan menarik lidah ke depan dan saluran udara tetap terbuka.

Pada kasus yang agak berat perlu dipasang selang melalui hidung ke saluran udara untuk menghindari penyumbatan saluran udara.

Pada kasus yang berat, jika terjadi penyumbatan saluran udara berulang, perlu dilakukan pembedahan. kadang perlu dilakukan trakeostomi.

Menyusui atau memberi makan harus dilakukan secara sangat hati-hati untuk menghindari tersedak dan terhirupnya cairan/makanan ke saluran udara,

Tersedak dan gangguan pemberian makan/susu akan berkurang secara spontan, sejalan dengan pertumbuhan rahang.

Dr. Rahajeng

Abses perimandibular, submandibular dan pterygomandibular

Abses perimandibular adalah abses yang berlokasi pada margo mandibula sampai “submandibular space”, merupakan kelanjutan serous periostitis.

Patofisiologi : Proses supurasi yang mencari jalan keluar ekstraoral dan terlokalisir di  antara margo inferior mandibula sampai submandibular space.

Pada pemeriksaan didapatkan:

Keadaan umum:

-          Lemah, lesu, malaise

-          Demam

Pemeriksaan Ekstra oral :

-          Asimetri wajah

-          Tanda radang jelas

-          Trismus

-          Fluktuasi +/-

-          Tepi rahang tidak teraba

Pemeriksaan intra oral:

-          Periodontitis akut

-          Muccobuccal fold normal

-          Fluktuasi (-)

Abses submandibular adalah abses yang berlokasi pada submandibular space.

Submandibular space memiliki batas inferior fascia profunda dari hyoid sampai mandibula, batas lateral corpus mandibula, dan batas superior mukosa dasar mulut.

Keadaan umum:

-          Lemah, lesu, malaise

-          Demam

Pemeriksaan Ekstra oral :

-          Asimetri wajah

-          Tanda radang jelas

-          Fluktuasi +

-          Tepi rahang teraba

Pemeriksaan intra oral:

-          Periodontitis akut

-          Muccobuccal fold

-          Fluktuasi (-)

Abses pterygomandibular adalah abses yang terjadi pada “petrygomandibular space”. Abses dibatasi di bagian medial oleh M. pterygoideus dan lateral oleh ramus mandibula.

Klinis: nyeri telan, trismus +/-, bengkak EO tidak nyata

Intraoral: Fluktuasi (+)

Dr. Rahajeng