Kasus Demam Berdarah meningkat : jumlah trombosit yang rendah saja buka indikasi untuk mendapat transfusi trombosit, By Ari Fahrial Syam

Dalam minggu-minggu terakhir di awal musim hujan ini kita melihat, mendengar dan membaca bahwa kasus demam berdarah dengue (DBD) meningkat dan laporan adanya peningkatan kasus DBD ini hampir terjadi di seluruh kota besar di Indonesia secara khusus di ibukota tercinta Jakarta ini. Peningkatan kasus DBD yang terjadi terutama pada bulan Januari ini, dimana telah terjadi peningkatan kasus demam berdarah dibandingkan beberapa bulan terakhir. Walau sampai saat ini peningkatan kasus DBD yang terjadi belum memenuhi criteria Kejadian Luar Biasa (DBD). Peningkatan kasus DBD inipun diprediksi akan meningkat pada beberapa minggu kedepan.

Satu hal kenapa saya menulis mengenai topic DBD ini karena ada hal yang selalu menggelitik saya dan membuat saya prihatin yaitu bahwa selama terjadinya peningkatan kasus demam berdarah permintaan trombosit di PMI meningkat tajam. Kami dilingkungan Forum Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI) maupun ditingkat Departemen Ilmu Penyakit Dalam FKUI-RSCM, sudah pernah membahas tuntas mengenai hal ini bahwa transfusi trombosit hanya diberikan pada pasien dengan perdarahan yang berat seperti muntah darah, mimisan yang terus menerus atau perdarahan dari saluran cerna bawah berupa BAB berdarah segar. Jumlah trombosit yang rendah bahkan sampai dibawah 20.000 tanpa pendarahan yang signifikan bukan merupakan indikasi untuk diberikan trombosit sehingga kadar trombosit yang rendah saja tidak memerlukan transfusi trombosit.

Sebelum membicarakan lebih lanjut mengenai transfusi trombosit ini saya akan menguraikan sedikit tentang penyakit demam berdarah ini. Menurut WHO secara klinis jika seseorang terinfeksi dengan virus dengue sebagai penyebab penyakit Demam berdarah bisa tanpa gejala maupun dengan gejala. Yang bergejala dibagi 2 lagi yaitu Demam dengue (DD) dan Dengue Haemorhagic fever (DHF). Pasien dengan DHF biasanya dengan gejala yang lebih berat dan gejala perdarahan yang lebih jelas. Saat ini sesuai dengan klasifikasi WHO terakhir yang diterbitkan pada tahun 1997: derajat berat ringannya DHF dibagi menjadi 4. Berat ringannya penyakit ini didasarkan atas perdarahan yang terjadi, serta ada tidaknya gangguan sistim sirkulasi pada saat pasien tersebut masuk rumah sakit. Semakin berat kondisi pada saat masuk semakin tinggi derajat sakitnya dan tentunya hal ini berhubungan dengan terjadinya kematian pada pasien tersebut. Selain demam tinggi yang mendadak pasien kadang kala juga merasakan nyeri di ulu hati, mual bahkan muntah, kepala pusing seperti melayang, pegal dan rasa nyeri di otot. Setelah 2-5 hari bisa terjadi manifestasi perdarahan baik berupa bintik merah pada kulit terutama di tangan, kaki dan dada, mimisan, gusi berdarah bahkan sampai muntah darah.

Sebagai mana diketahui dan umumnya masyarakat juga sudah mengetahui, pasien DHF selalu dihubungkan dengan trombosit yang rendah. Kadar trombosit yang rendah juga menjadi patokan kapan pasien tersebut harus dirawat. Walau sebenarnya selain trombosit yang rendah adanya darah yang semakin pekat (hemokonsentrasi) ditandai oleh hematokrit yang meningkat serta tanda-tanda perdarahan merupakan hal lain yang juga dilihat sebelum memutuskan apakah pasien tersebut perlu dirawat atau tidak.

Pada pasien demam berdarah selain jumlah trombosit yang menurun fungsi trombosit juga menurun. Oleh karena itu biasanya disebutkan bahwa pada pasien DHF trombosit terganggu baik secara jumlah maupun secara kualitas. Sebagai mana kita ketahui bahwa trombosit merupakan salah satu sel darah yang berperan pada sistim keseimbangan proses pembekuan dan perdarahan (hemostasis) di dalam tubuh kita. Oleh karena adanya gangguan pada trombosit ini juga akan meningkatkan terjadinya proses pendarahan.

Adanya trombosit yang rendah bukan berarti kita harus meningkatkan trombosit sesegara mungkin. Ada 3 hal yang diduga sebagai penyebab penurunan kadar trombosit didalam darah yaitu penurunan produksi trombosit karena penekanan produksi di sumsum tulang, penggunaan trombosit yang berlebihan dan adanya antibodi anti trombosit dalam darah. Jika melihat hal-hal yang menjadi penyebab kenapa trombosit turun ini, maka transfusi trombosit yang tidak pada tempatnya justru akan memperburuk keadaan karena akan merangsang proses inflamasi lebih lanjut sehingga penghancuran trombosit akan lebih meningkat.

Seperti telah saya sebutkan tadi, indikasi pemberian trombosit telah dibicarakan beberapa kali di Forum Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI) dan di tingkat Departemen Ilmu Penyakit Dalam FKUI/RSCM. Protokol mengenai tatalaksana pasien dengan DHF khususnya mengenai kapan transfusi trombosit ini diberikan, juga pernah disampaikan oleh pakar dari Divisi Penyakit Trofis dan Infeksi Departemen Ilmu penyakit Dalam serta pakar dari Divisi Hematologi dan Onkologi Medis Departemen Ilmu Penyakit FKUI-RSCM. Pada protokol tersebut disampaikan bahwa transfusi trombosit diberikan pada pasien dengan perdarahan spontan dan massif (banyak). Pemberian transfusi trombosit juga harus dilakukan dengan hati-hati dengan melihat komponen sistim pembekuan darah yang lain. Oleh karena itu jumlah trombosit yang rendah bahkan lebih rendah dari 20.000 tanpa perdarahan yang signifikan bukan merupakan indikasi dilakukan transfusi trombosit. Pada pengalaman dilapangan karena ketidak tahuan kadang kala keluarga pasien meminta kepada dokter agar keluarganya yang sedang dirawat untuk segera ditransfusi trombosit padahal tidak ada indikasi untuk pemberian transfusi trombosit.

Pengalaman penulis dalam merawat pasien dengan DBD biasanya trombosit akan naik dengan sendirinya setelah hari ke-7 sejak mulai terjadinya demam. Selama perawatan jika tidak terjadi syok atau perdarahan massif, cairan infus yang diberikan yaitu cairan kristaloid seperti cairan ringer laktat atau asering yang diberikan untuk menjaga agar volume cairan didalam pembuluh darah tetap baik.

Pada akhinya jika penanganan pasien DBD sesuai protocol yang telah ditetapkan, pemberian komponen darah trombosit dapat diberikan secara selektif. Sehingga pada saat dibutuhkan oleh pasien sesuai indikasi tentunya komponen trombosit tetap tersedia. Karena selain pada kasus DBD dengan perdarahan yang massif, transfusi trombosit dibutuhkan juga untuk pasien-pasien dengan kelainan darah yang lain dan juga pasien dengan gangguan liver yang berat yang akan dilakukan tindakan.

Mudah-mudahan informasi ini dapat menekan permintaan komponen darah trombosit yang tidak sesuai dengan indikasi.

Well-Rounded Docs: That's the goal as medical schools seek out and admit

One week into his premed classes at Washington University in St. Louis, Ryan Jacobson was rethinking his plan to become a doctor. His biology and chemistry classes were large, competitive and impersonal-not how he wanted to spend the next four years. "Sitting in a chemistry class, I knew it wasn't the right place for me," he says.

Jacobson found the history department, with its focus on faculty interaction and discussion, a better fit. But he had no intention of leaving his medical aspirations behind. So Jacobson majored in history while also taking the science and math courses required for medical school. When he graduated last spring, he won the departmental prize for undergraduate thesis for his work on the history of
race relations in Tulsa, Okla. He started medical school at the University of Illinois last month. "Historians are supposed to integrate information with the big picture," he says, "which will hopefully be useful as a physician."

Even as breakthroughs in science and advances in technology make the practice of medicine increasingly complex, medical educators are looking beyond biology and chemistry majors in the search for more well-rounded students who can be molded into caring and analytic doctors. "More humanities students have been applying in recent years, and medical schools like them," says Gwen Garrison, assistant vice president for medical-school services and studies at the Association of American Medical Colleges. "The schools are looking for a kind of compassion and potential doctoring
ability. This makes many social-science and humanities students particularly
well qualified."

The number of science majors applying to medical school has been steady for the past decade-about 65 percent of applicants major in biology or another physical science. What's changing is who gets in. When Gail Morrison, who runs admissions at the University of Pennsylvania School of Medicine, sorts through the school's 6,500 yearly applicants, she is not looking for students who spent their undergrad years hunched over biology and physics textbooks. "It doesn't make you a better doctor to know how fast a mass falls from a tree," she says. Approximately 40 percent of the students that Penn accepts to its medical school now come from nonscience backgrounds.

That number has been rising steadily over the past 20 years. "They've got to be happy and have a life outside of medicine," says Morrison, "otherwise they'll get overwhelmed. We need whole people." In 1999, a national survey of first-year medical students found that 58 percent took a social-science class for personal interest. In last year's entering class, the number was more than 70 percent. Humanities students
also fare better on the MCAT, the standardized test for medical-school admissions. Among the 2006 applicants to medical school, humanities majors outscored biology majors in all categories.

Michael Sciola, who's been advising premed students at Wesleyan University for the past 13 years, has seen liberal-arts majors become more attractive to medical schools. And he's not surprised that those who stray from science are finding success. "Medical schools have really been looking for that scholar-physician in the past few years," he says. "We're living in an increasingly complex world, and the liberal arts give you the skills to understand that better."

The Mount Sinai School of Medicine in New York has a program designed to attract nonscience majors. Each year, Mount Sinai accepts about 30 college sophomores from around the country through its humanities and medicine program. The students do not have to take the MCAT, but they are required to pursue a humanities major as undergrads before starting at Mount Sinai. "The students who come in with a humanities background see patients more as a whole patient," says Miki Rifkin, the program's director. She says that these students often outperform their peers, with higher rates of competitive residency placements.

Andrea Schwartz, a third-year medical student in the Mount Sinai program, attended Columbia University and the Jewish Theological Seminary and has a dual degree in history and Bible studies. "Having such a varied experience has given me the opportunity to appreciate different angles," says Schwartz, who is interested in geriatrics. "The intense text study I did as an undergrad helps me when I'm taking patients' histories. It taught me to be a better listener." That sort of training may be just what the doctor ordered.
[NW]

New drug combo could speed TB treatment

Adding a new antibiotic to the standard mix of drugs used to treat tuberculosis could shave at least two months off the current grueling six-month regimen, U.S. researchers said on Tuesday.

By substituting the Bayer antibiotic moxifloxacin for an older drug, researchers said they saw a 17 percent increase in effectiveness.

"Our finding shows that moxifloxacin is potent against tuberculosis, " Dr. Richard Chaisson of Johns Hopkins University in Baltimore, said in an interview. "It shows very dramatically that people get better faster."

Chaisson, who presented his findings at the Interscience Conference on Antimicrobial Agents and Chemotherapy meeting in Chicago, said adding this antibiotic could cut treatment time by about two months.

"If we simplify treatment, it will be easier for people to take the drugs," he said.
People often do not take their full regimen of TB drugs, which has in turn spawned drug resistance, making TB more dangerous and more difficult to treat.

Shortening treatment time could help people stick to the prescribed therapy better and reduce the development of resistant strains, Chaisson said. About 1.6 million people died from TB in 2005, according to the World Health
Organization.

Chaisson's eight-week study, which was funded by the U.S. Food and Drug Administration, tested 170 men and women with TB in Brazil. They took the traditional mixture of drugs, which includes the antibiotic ethambutol, or a mix replacing ethambutol with moxifloxacin.

After two months, cultured sputum samples from moxifloxacin patients were far less likely to grow TB bacteria. Sold under the brand name Avelox, moxifloxacin is approved for respiratory infections including pneumonia. It is marketed in the United States by Schering-Plough.

TB researchers are already preparing to study this finding in larger clinical trials, with support from the Global Alliance for TB Drug Development.
"We really do hope to shorten therapy to four months," Melvin Spigelman of the alliance told reporters, adding that it will take a number of large trials to get there. Meanwhile researchers at Johns Hopkins are working on even shorter treatment
regimens.

A study led by Dr. Jacques Grosset showed the antibiotic rifapentine achieved cures in eight weeks or less in TB infected mice. Chaisson said he plans to study that combination in humans and he thinks it could yield even better results. [Reuters]

Better Bedside Manners

Every patient wants to find a doctor who listens. But wouldn't it be easier if all doctors were just better listeners?
A new paper in the Sept. 5 issue of the Journal of the American Medical Association suggests that it might not be so hard to make it happen: in the first comprehensive study of clinical-skills exams given to doctors, researchers from McGill University in Montreal show that poor scores in the communication portion of the test are highly predictive of which new doctors are likely to clash with patients in the future. By evaluating communication skills early on, say the study's authors, physicians and academics can better train and select the next generation of medical professionals.

For their study, the McGill researchers tracked all 3,424 physicians who took the Medical Council of Canada clinical-skills examination between 1993 and 1996, and who were then licensed to practice in Ontario or Quebec. The exam, which was rolled out between 1992 and 1993, requires doctors to interact with actors posing as patients in a series of standardized scenarios; trained physician evaluators then judge how well the doctor takes patient histories, makes diagnoses, manages treatment and communicates with
the patients.

When researchers followed up with the doctors in 2005, they found that the docs' scores in communication were strongly correlated to the number of patient complaints they had racked up in their first years of practice.

Overall, the 3,424, physicians had 1,116 complaints among them, of which 696 were deemed valid after medical-authority investigation. The physicians who scored low on the test - the poor communicators, who were, say, condescending, judgmental or flippant in their behavior - had generated a disproportionate number of those complaints. Doctors with scores in the bottom quartile on the test's communication- related portion had 70% more legitimate complaints per year of practice than the top-quartile performers; the poor communicators had 4.3 complaints per 100 doctors per year while their higher-scoring peers had 2.5 complaints per 100 doctors per year. No surprise: the link between poor test scores and patient complaints was strongest when it came to doctors' style of communication and attitude - the way a doctor tells a patient he has cancer, for example, or whether a doctor ignores a mother's description of what ails her child.

The current JAMA paper is the first to measure how accurately a standardized test can evaluate doctors' skills and how effectively those grades can predict future patient-complaint rates. According to the study's authors, when patients complain in the U.S. and Canada, it's most often about doctors? communication or attitude problems, rather than, say, quality-of-care issues or office screw-ups. And plenty of past studies have shown a link between lousy doctor communication and poor medical outcomes, such as inadequate care and malpractice suits.

Now that doctors know the exam works pretty well, maybe more countries will put it to use. When Canada first mandated that doctors pass the communication test for licensure, it was the only country in the world to do so - and the move was seen as controversial. Since then, the U.S. licensing system has also introduced a clinical skills exam, which every domestic and foreign medical school graduate must pass. Robyn Tamblyn, the lead author of the JAMA paper and a professor of medicine at McGill, thinks the test ought to be given even earlier than that. Why have doctors slog through med school only to be pushed out of the profession afterward because their bad bedside manner? Tamblyn recommends testing students' aptitude for communication as part of the med-school admissions process, or at least testing students early enough in medical school that they can get remedial help if they need
it."I think that's the most efficient thing to do. I think that way, essentially, you raise the bar," says Tamblyn.

While few physicians or educators doubt that communication matters, many people question how well you can test something as subjective as communication - especially when every new doctor must complete the exam on a single given day, no matter how grouchy he or she feels. But both the Canadians and the Americans have gone to great lengths to ensure their tests are fair, says Tamblyn. Her study shows that the predictive power of such exams holds irrespective of the doctors' gender or whether they went to med school in another country. "It's a good-news story," says Tamblyn of her study. If we know how to evaluate what makes a good doctor, after all, maybe
we can produce better ones. "This could diminish quite substantially the number of complaints," says Tamblyn. [TM]