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"ABSTRAKLatar belakangOsteoarthritis (OA) adalah salah satu penyakit yang paling tua dalam sejarah manusia. Meskipun demikian, persoalan OA sekarang menjadi jauh lebih banyak, Iebih nyata dan lebih bermakna dengan semakin bertambah panjangnya usia.Hasil pengobatan terhadap penyakit ini sampai sekarang masih belum memuaskan oleh karena patogenesisnya belum dapat dipahami dengan baik. Pendekatan epidemiologik yang biasa untuk mengetahui patogenesis OA sebagai suatu keseluruhan dipandang masih belum cukup. Hal itu masih perlu dilengkapi dengan penelitian patogenesis OA pada populasi tertentu, misalnya pada diabetes melitus.Meskipun OA dan diabetes melitus merupakan penyakit yang sering dijumpai, terutama pada orang lanjut usia, kaitan antara kedua keadaan ini belum banyak terungkap. Berbeda dengan komplikasi mikroangiopati, makroangiopati atau neuropati, komplikasi muskuloskeletal diabetes melitus, khususnya OA, kurang dibicarakan. Tak mengherankan kalau dalam konggres International Diabetes Federation yang terakhir (1991), OA telah digolongkan sebagai "overlooked diabetes complications".OA timbul lebih sering, lebih awal dan menimbulkan keluhan yang lebih nyata pada orang-orang dengan diabetes melitus. Prevalensi DISH (Diffuse Idiopathic Skeletal Hyperostosis), salah satu bentuk simpangan OA, pada penderita diabetes melitus adalah 115-13,5%, yang hampir dua kali dari Prevalensi pada non diabetes. Sebaliknya, intoleransi glukosa juga ditemukan jauh lebih banyak (sampai 23%) diantara penderita-penderita DISH. Dua penelitian radiografi menemukan bahwa frekuensi osteofit pada kaki dan tangan dijumpai Iebih sering pada diabetes daripada non diabetes.Penelitian klinik dan radiografik yang dilakukan di RS.Dr. Saiful Anwar Malang juga menemukan kaitan yang serupa. Tanda-tanda radiografik perubahan degeneratif sendi kaki ditemukan pada 15.1% diantara 172 penderita diabetes melitus (usia 32-55 tahun) dibanding pada 8.7% kontrol non diabetes sesuai jenis kelamin dan umumya. Diantara penderita diabetes melitus yang berobat jalan terdapat 50% penderita dengan artrosis (1eher) dibanding 23% pada kontrol.Hasil penelitian-penelitian klinik tersebut disokong oleh hasil penelitianpenelitian pada binatang percobaan. Diskus intervertebra tikus diabetes terbukti mengalami perubahan-perubahan degeneratif yang lebih cepat daripada tikus non diabetes. Disamping itu, spondilosis deforman timbul lebih berat pada tikus diabetes. Pada tulang rawan sendi tikus diabetes timbul perubahan enzim-enzim penghancuran proteoglikan dan kolagen yang dapat dinormalkan kembali dengan tranplantasi pankreas. Pada jaringan tersebut juga terdapat perubahan komposisi kolagen dan proteoglikan matrik.Adanya kaitan antara diabetes dan OA menyokong konsep tentang peranan faktor metabolik dan hormonal pada patogenesis OA. Hormon pertumbuhan (HP), insulin, estradiol dan faktor pertumbuhan seperti insulin-1 (FPI-1) terbukti mempunyai pengaruh nyata pada metabolisme tulang rawan sendi. Adanya perubahan aktivitas hormon tersebut dapat berkaitan dengan patogenesis OA. Meningkatnya HP pada akromegali merangsang pembentukan tulang baru dan hipertropi tulang rawan sendi yang menyerupai gambaran OA.Bagaimana patogenesis OA sebagai salah satu komplikasi menahun diabetes melitus dapat dijelaskan dengan konsep 2 jalur umum patogenesis OA. kerusakan tulang rawan sendi dan reaktivasi pertumbuhan tulang rawan sendi.

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ABSTRACT

Introduction

It is known that diabetes mellitus (DM) increases the risk of osteoarthritis, however the factors play important role in its pathogenesis has not established yet. Osteoarthritis is characterized by joint cartilage degradation and bone formation.

Many studies reported that the duration of DM and the metabolic control in DM become important factors in the development of chronic diabetic complications. It is suggested that some hormones are increased in diabetics, such as insulin, growth hormone (OH), insulin like growth factor-1 (IGF-1) and estradiol. Those hormones are known to promote metabolic action in bone and cartilage joints.

Therefore, some factors that influence the pathogenesis mechanism in DM increased the risk of OA, of which are the level of insulin, GH, 1GF-1 and estradiol serum concentrations, the duration of diabetes and the severity of hyperglycemia.

It is hypothized that the duration of DM and good metabolic control could increase the risk of QA in diabetics. There is a basic concept that the level of insulin, HP1 FPI-1 and estradiol could be risk factors for OA among the diabetics.

The aim of this research is to determine the role of the duration of suffering DM, metabolic control, concentration of insulin, GH, IGF-1 and estradiol in the occurrence of OA among the diabetics.

Material and methods

This study was conducted in the Metabolic and Endocrine clinic of the Dr. Saiful Anwar Hospital in Malang during 1988 up to 1991. Sampling was "purposive" collected among the diabetics (n= 372) who has non obese non insulin dependent diabetes, average body mass index (BMI) = 22.56 + 4.11, ages more than 44 years old, average age= 59.13 + 7.96 years, and onset of DM is older than 30 years.

A case control study to the duration of DM (more or less than 8 years) and the metabolic control was used on this study. Good metabolic control was determined by the average of fasting blood glucose < 120 mg/dl, the compliance of patients and the blood level of fructosamine (< 3 mmol/l). The role of each risk factor was shown by odds ratio (OR).

Radiography of the knee was taken in all samples, to find out knee osteoarthritis (KOA), using diagnostic criteria and gradation of Kellgreen and Lawrence , besides getting the clinical symptoms among the diabetics based on the ARA criteria.

To evaluate the risk of OA in diabetics, the similar study was conducted among the 172 samples non obese (ages and BMI matched). The exclusion criteria are other joint diseases than KOA, obesity, history joint injury and lower extremities paralyses.

Radio immuno assays was measured among the 30 cases of KOA, 30 cases without KOA, for good and poor metabolic control. The assays included the concentration of blood insulin, GH, IGF-1 and estradiol. The results of concentration of serum hormones are statistically analyzed by ANOVA.

In this study was also observed the possible correlation between KOA and high level of insulin related to the complication of diabetes, such as hypertension, Coronary Heart Disease and lipid disturbance. The clinical finding was determined to see the possible correlation KOA in diabetics and the peripheral neuropathy and also diabetes retinopathy."

"Depresi merupakan penyakit yang terbanyak didapati baik pada praktik spesialis maupun umum. Gangguan psikiatrik ini dapat bersifat ringan atau penyakit yang berat. Gangguan penyakit yang berat dapat fatal, karena biasanya penderita mencoba untuk bunuh diri (suicidium). Diagnosis penyakit tidak mudah. Gangguan yang ringan, sering bermanifestasi sebagai penyakit fisik, dan gangguan emosional tersamar oleh keluhan somatiknya. Pada masa akut sering gangguan yang berat menyerupai gangguan lain seperti skizofrenia. Banyak sarjana di bidang psikiatri mencari markah biologik sebagai alat untuk membantu diagnosis depresi. Salah satu markah biologik adalah gambaran poligrafik tidur. Hasil yang positif dari laboratorium tidur sulit dipakai di klinik, karena mahal dan sangat memakan waktu, baik penilaian maupun interpretasi. Kelompok Studi Psikiatri Biologik Jakarta (KSPBJ) telah melakukan modifikasi dari teknik standar dengan teknik yang dinamakan Teknik KSPBJ. Pada teknik ini hanya merekam satu menit dari lima menit selama perekaman yang berlangsung tujuh jam. Dari penelitian kami dengan sukarelawan normal dan pasien depresi didapatkan bahwa Teknik KSPBJ mempunyai agreement yang tinggi dengan teknik standar. Lebih lanjut didapatkan bahwa dengan teknik itu, seperti juga pada teknik standar didapatkan markah biologik untuk depresi. Penderita depresi mempunyai latensi REM yang rendah, yang berbeda dengan normal (P<0,001). Selaln itu ternyata pula pada penderita depresi terjadi shifting p-REM ke 1/3 awal malam dan pada perbaikan depresi terjadi shifting ke 1/3 akhir malam. Penelltian ini konsisten dengan hipotesis adanya ketidak-seimbangan sistem kolinergik - noradrenergik pada mekanisme latency REM, dan ketidak-seimbangan noradrenergik-serotonergik pada phasic REM.

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Sleep In Depressed Patient (A Study On Sleep, REM, and Phasic REM In Depressed Patients)Up to 10 % of all patients seeing a doctor are depressed. This conclusion emerged from an enquiry conducted in 1973 by over 10.000 physicians practicing in Austria, Federal Republic of Germany, France, Italy and Switzerland. Approximately 15% of the severely depressed commit suicide, whereas the moderate and mild forms usually cause reduction in the quality of life of these patients. The diagnosis of depression is not easy. Depressive states often escape diagnosis because these patients are so overwhelmed by the impact of their physical symptoms, particularly since they can more easily accept the idea that their illness is of physical, as opposed to mental origin. By referring only to their physical complaints, and deliberately failing to disclose their slate of mind, they lead the unwary physician up the wrong diagnostic path. In most mental hospitals, or departments of psychiatry, the diagnosis of depression is also not easily made. In the acute and severe forms these condition sometimes are wrongly diagnosed as schizophrenia. Numerous scientists are presently searching for a biological marker of depression. The Ideal biological marker must be sensitive, specific, easy to identify and relatively Inexpensive In its operation. Research over the past two decades has led to the development of a standardized sleep EEG methodology, which has been proven useful for the identification of characteristic sleep abnormalities of depressed patients. Application of REM abnormalities as a biological marker has produced an accurate, reliable and objective laboratory method for a diagnostic aid in the identification of depression. Even though this is proven to be a useful tool, in clinical practice it is not presently practical as a routine screening test in depressed patients. One of the drawbacks of these methods is the limited number of and the access to standard sleep laboratories. Expenses of EEG sleep studies run high, approximately US$ 500.00 per night. The other factor is that it is time consuming to evaluate 1200 pages of EEG sleep records. In 1980 KSPBJ (Study Group for Biological Psychiatry) developed a modification of the Rechtschaffen and Dales method. The KSPBJ technique records only one minute in every five minutes. That is one minute on and four minutes off for a period of seven hours. In this dissertation a comparison was made between the KSPRJ technique and the standard technique. With 18 normal volunteers, 14 new cases of depression, and 13 medicated depressed patients, the conclusion can be made that the KSPBJ technique has a statistically high agreement with the standard technique. (Po m 0.78 - 0.82, Kappa - 0.71 - 0.75). Another result of these studies with 91 depressed patients and 50 normal volunteers is finding that depressed patients have shortened REM Latency (<60 minutes). This shortened REM Latency could be used in predicting the diagnosis of depression with a quite high level of sensitivity (73-76%), and specificity (over 90%). Yet another conclusion with this KSPBJ technique is that in depressed patients, there seem to be a shifting to the left of phasic REM (to one third of initial night), and on recovery a shifting to the right (to one third of terminal night). These findings are consistent with the hypothesis, of choilnergic - noradrenergic balance mechanism in the forming of latency REM, and the balance of noradrenergic - serotonergic mechanism in the forming of phasic REM. When comparing this technique with the standard technique, there is an 80% reduction of the cost of sleep EEG recording, and an 80% saving in time for evaluation. In conclusion, the KSPBJ technique can be considered as a biological marker for depression which is reasonably sensitive and specific, easy to identify, and in addition relatively inexpensive."