MANAGEMENT OF SEVERE COPD REVIEWED

Various strategies and recommendations to treat patients with severe chronic obstructive pulmonary disease (COPD) are provided in a clinical review published in the April 15 issue of the New England Journal of Medicine.

"The sentinel clinical feature of severe ...COPD is dyspnea on exertion," writes Dennis E. Niewoehner, MD, from the Pulmonary Section, Veterans Affairs Medical Center in Minneapolis, Minnesota. "Its onset is usually insidious, and it may progress to severe disability over a period of years or decades. Other common symptoms include cough, sputum production, wheezing, and chest congestion."

The typical clinical manifestations of advanced COPD result from severe airflow obstruction, which can be confirmed by spirometry. Although physical findings may include a barrel-shaped chest, inspiratory retraction of the lower ribs (Hoover's sign), a prolonged expiratory phase, and use of the accessory muscles of respiration, these findings are sometimes absent even in patients with severe COPD.

Failure to confirm COPD with spirometry often leads to misdiagnosis. However, spirometry is a poor guide for decision making regarding treatment continuation or modification in an individual patient. Spirometric evidence of airflow obstruction is defined as a ratio of the postbronchodilator forced expiratory volume in 1 second (FEV₁) to a forced vital capacity of less than 0.70. Overall severity of COPD can be classified based on FEV₁ percentage of the predicted normal value, as well as on clinical criteria, such as the degree of breathlessness caused by specific tasks and the frequency of exacerbations.

Exacerbations often require medical visits and hospitalizations, causing a dramatic increase in healthcare costs. The relative risk for treatment failure (defined as no resolution or clinical deterioration) is lowered by approximately 50% when antibiotics are used for COPD exacerbations. Antibiotics are most effective in patients who have cough productive of purulent sputum.

Complications of severe COPD include pulmonary hypertension and cor pulmonale resulting from chronic hypoxemia and hypercapnia. Severe COPD is also associated with an elevated risk for cardiovascular disease, osteoporosis, lung cancer, depression, and other systemic diseases.

Management Strategies

Management should include patient education during the initial visit, which should focus on the signs and symptoms of a severe exacerbation and the need for prompt recognition and treatment. The most important aspect of management is smoking cessation, which should be addressed at every visit, as long as the patient continues smoking.

Pharmacotherapy may include an inhaled long-acting β2-agonist, an inhaled long-acting anticholinergic agent, and/or an inhaled corticosteroid. The long-acting β2-agonists salmeterol and formoterol offer at least 12 hours of sustained bronchodilation, whereas the inhaled long-acting anticholinergic agent tiotropium is effective for at least 24 hours.

Drugs from 2 of these 3 classes should be combined for patients with severe, exacerbation-prone COPD. Because they lower the relative risk for a severe exacerbation by 15% to 20%, these medications should be continued even if they do not provide symptomatic relief. Adverse events of long-acting bronchodilators are typically mild.

For rescue use, a short-acting bronchodilator should be given. Albuterol or other short-acting β2-adrenergic agonist and ipratropium bromide, a short-acting anticholinergic agent, may be used alone or combined. Patients should be instructed regarding proper inhaler technique. The faster onset of action of albuterol vs ipratropium bromide may give patients more rapid relief.

Long-term oxygen therapy should be prescribed and used for 18 hours or more each day if arterial oxygen saturation is 88% or lower at rest in a stable clinical state.

Patients with COPD should be vaccinated against influenza every autumn, and they should also receive pneumococcal vaccination, with revaccination as needed, unless there is a contraindication.

Patients with access to pulmonary rehabilitation should be offered this therapy, provided there are no medical contraindications.

The recommendations in this review are generally consistent with guidelines on the management of COPD published by the Global Initiative for Chronic Obstructive Lung Disease, the American Thoracic Society-European Respiratory Society, and the American College of Physicians.

Conclusion: Uncertainty Remains

"The role of disease-management programs for patients with COPD remains uncertain," Dr. Niewoehner concludes. "Randomized, controlled trials of case management for COPD have shown promise in reducing hospitalization rates, but the evidence is insufficient to make specific recommendations. Pulmonary rehabilitation improves health status and exercise capability for selected patients, but national surveys indicate that few patients complete such programs, and it is unclear how best to maintain the benefits achieved."

Dr. Niewoehner has received consulting fees from Boehringer Ingelheim, Adams Respiratory Therapeutics, GlaxoSmithKline, AstraZeneca, Nycomed, and Forest Research Institute and speaking fees from Boehringer Ingelheim, Pfizer, Sepracor, and Nycomed.

N Engl J Med. 2010;362:1407-1416.

What Is COPD?

COPD, or chronic obstructive pulmonary (PULL-mun-ary) disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.

Overview

To understand COPD, it helps to understand how the lungs work. The air that you breathe goes down your windpipe into tubes in your lungs called bronchial tubes, or airways.

The airways are shaped like an upside-down tree with many branc

hes. At the end of the branches are tiny air sacs called alveoli (al-VEE-uhl-eye).

The airways and air sacs are elastic. When you breathe in, each air sac fills u

p with air like a small balloon. When you breathe out, the air sac deflates and the air goes out.

In COPD, less air flows in and out of the airways because of one or more of the following:

• The airways and air sacs lose their elastic quality.
• The walls between many of the air sacs are destroyed.
• The walls of the airways become thick and inflamed (swollen).
• The airways make more mucus than usual, which tends to clog the airways.

In the United States, the term "COPD" includes two main conditions—emphysema (em-fi-SE-ma) and chronic obstructive bronchitis (bron-KI-tis).

In emphysema, the walls between many of the air sacs are damaged, causing them to lose their shape and become floppy. This damage also can destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tiny ones.

In chronic obstructive bronchitis, the lining of the airways is constantly irritated and inflamed. This causes the lining to thicken. Lots of thick mucus forms in the airways, making it hard to breathe.

Most people who have COPD have both emphysema and chronic obstructive bronchitis. Thus, the general term "COPD" is more accurate.

Outlook

COPD is a major cause of disability, and it's the fourth leading cause of death in the United States. More than 12 million people are currently diagnosed with COPD. An additional 12 million likely have the disease and don't even know it.

COPD develops slowly. Symptoms often worsen over time and can limit your ability to do routine activities. Severe COPD may prevent you from doing even basic activities like walking, cooking, or taking care of yourself.

Most of the time, COPD is diagnosed in middle-aged or older people. The disease isn't passed from person to person—you can't catch it from someone else.

COPD has no cure yet, and doctors don't know how to reverse the damage to the airways and lungs. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.

Other Names for COPD

• Chronic obstructive airway disease
• Chronic obstructive bronchitis
• Chronic obstructive lung disease
• Emphysema

What Causes COPD?

Most cases of COPD develop after long-term exposure to lung irritants that damage the lungs and the airways.

In the United States, the most common irritant that causes COPD is cigarette smoke. Pipe, cigar, and other types of tobacco smoke also can cause COPD, especially if the smoke is inhaled. Secondhand smoke—that is, smoke in the air from other people smoking—also can irritate the lungs and contribute to COPD.

Breathing in air pollution and chemical fumes or dust from the environment or workplace also can contribute to COPD.

In rare cases, a genetic condition called alpha-1 antitrypsin deficiency may play a role in causing COPD. People who have this condition have low levels of alpha-1 antitrypsin (AAT)—a protein made in the liver.

Having a low level of the AAT protein can lead to lung damage and COPD if you're exposed to smoke or other lung irritants. If you have this condition and smoke, COPD can worsen very quickly.

Who Is At Risk for COPD?

The main risk factor for COPD is smoking. Most people who have COPD smoke or used to smoke. People who have a family history of COPD are more likely to get the disease if they smoke.

Long-term exposure to other lung irritants also is a risk factor for COPD. Examples of other lung irritants include air pollution and chemical fumes and dust from the environment or workplace.

Most people who have COPD are at least 40 years old when symptoms begin. Although it isn't common, people younger than 40 can have COPD. For example, this may happen if a person has alpha-1 antitrypsin deficiency, a genetic condition.

What Are the Signs and Symptoms of COPD?

The signs and symptoms of COPD include:

• An ongoing cough or a cough that produces large amounts of mucus (often called "smoker's cough")
• Shortness of breath, especially with physical activity
• Wheezing (a whistling or squeaky sound when you breathe)
• Chest tightness

These symptoms often occur years before the flow of air into and out of the lungs declines. However, not everyone who has these symptoms has COPD. Likewise, not everyone who has COPD has these symptoms.

Some of the symptoms of COPD are similar to the symptoms of other diseases and conditions. Your doctor can determine if you have COPD.

If you have COPD, you may have frequent colds or flu. If your COPD is severe, you may have swelling in your ankles, feet, or legs; a bluish color on your lips due to low levels of oxygen in your blood; and shortness of breath.

COPD symptoms usually slowly worsen over time. At first, if symptoms are mild, you may not notice them, or you may adjust your lifestyle to make breathing easier. For example, you may take the elevator instead of the stairs.

Over time, symptoms may become bad enough to see a doctor. For example, you may get short of breath during physical exertion.

How severe your symptoms are depends on how much lung damage you have. If you keep smoking, the damage will occur faster than if you stop smoking. In severe COPD, you may have other symptoms, such as weight loss and lower muscle endurance.

Some severe symptoms may require treatment in a hospital. You—with the help of family members or friends, if you're unable—should seek emergency care if:

• You're having a hard time catching your breath or talking.
• Your lips or fingernails turn blue or gray. (This is a sign of a low oxygen level in your blood.)
• You're not mentally alert.
• Your heartbeat is very fast.
• The recommended treatment for symptoms that are getting worse isn't working.

How Is COPD Diagnosed?

Your doctor will diagnose COPD based on your signs and symptoms, your medical and family histories, and test results.

He or she may ask whether you smoke or have had contact with lung irritants, such as air pollution, chemical fumes, or dust. If you have an ongoing cough, your doctor may ask how long you've had it, how much you cough, and how much mucus comes up when you cough. He or she also may ask whether you have a family history of COPD.

Your doctor will examine you and use a stethoscope to listen for wheezing or other abnormal chest sounds.

You also may need one or more tests to diagnose COPD.

Lung Function Tests

Lung function tests measure how much air you can breathe in and out, how fast you can breathe air out, and how well your lungs can deliver oxygen to your blood.

The main test for COPD is spirometry (spi-ROM-eh-tre). Other lung function tests, such as a lung diffusing capacity test, also may be used. (For more information, see "Types of Lung Function Tests.")

Spirometry

During this painless test, a technician will ask you to take a deep breath in and then blow as hard as you can into a tube connected to a small machine. The machine is called a spirometer.

The machine measures how much air you breathe out. It also measures how fast you can blow air out.

Your doctor may have you inhale medicine that helps open your airways and then blow into the tube again. He or she can then compare your test results before and after taking the medicine.

Spirometry can detect COPD long before its symptoms appear. Doctors also may use the results from this test to find out how severe your COPD is and to help set your treatment goals.

The test results also may help find out whether another condition, such as asthma or heart failure, is causing your symptoms.

Other Tests

Your doctor may recommend other tests. These tests include:

• A chest x ray or chest computed tomography (CT) scan. These tests create pictures of the structures inside your chest, such as your heart and lungs. The pictures can show signs of COPD. They also may show whether another condition, such as heart failure, is causing your symptoms.
• An arterial blood gas test. This blood test measures the oxygen level in your blood using a sample of blood taken from an artery. The test can help find out how severe your COPD is and whether you may need supplemental oxygen therapy.

How Is COPD Treated?

COPD has no cure yet. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.

Quitting smoking is the most important step you can take to treat COPD. Talk to your doctor about programs and products that can help you quit. Many hospitals have programs that help people quit smoking, or hospital staff can refer you to a program. Ask your family members and friends to support you in your efforts to quit. Also, try to avoid secondhand smoke.

The National Heart, Lung, and Blood Institute's "Your Guide to a Healthy Heart" booklet has more information about how to quit smoking.

Other treatments for COPD may include medicines, vaccines, pulmonary rehabilitation (rehab), oxygen therapy, surgery, and managing complications.

The goals of COPD treatment are to:

• Relieve your symptoms
• Slow the progress of the disease
• Improve your exercise tolerance (your ability to stay active)
• Prevent and treat complications
• Improve your overall health

Specialists Involved

To assist with your treatment, your family doctor may advise you to see a pulmonologist. This is a doctor who specializes in treating people who have lung problems.

Medicines

Bronchodilators

Bronchodilators relax the muscles around your airways. This helps open your airways and makes breathing easier.

Depending on how severe your disease is, your doctor may prescribe short-acting or long-acting bronchodilators. Short-acting bronchodilators last about 4 to 6 hours and should be used only when needed. Long-acting bronchodilators last about 12 hours or more and are used every day.

Most bronchodilators are taken using a device called an inhaler. This device allows the medicine to go right to your lungs. Not all inhalers are used the same way. Ask your health care team to show you the right way to use your inhaler.

If your COPD is mild, your doctor may only prescribe a short-acting inhaled bronchodilator. In this case, you may only use the medicine when symptoms occur.

If your COPD is moderate or severe, your doctor may prescribe regular treatment with short- and long-acting bronchodilators.

Inhaled Glucocorticosteroids (Steroids)

Inhaled steroids are used for some people who have moderate or severe COPD. These medicines may reduce airway inflammation (swelling).

Your doctor may ask you to try inhaled steroids for a trial period of 6 weeks to 3 months to see whether the medicine is helping with your breathing problems.

Vaccines

Flu Shots

The flu (influenza) can cause serious problems for people who have COPD. Flu shots can reduce your risk for the flu. Talk with your doctor about getting a yearly flu shot.

Pneumococcal Vaccine

This vaccine lowers your risk for pneumococcal pneumonia (nu-MO-ne-ah) and its complications. People who have COPD are at higher risk for pneumonia than people who don't have COPD. Talk with your doctor about whether you should get this vaccine.

Pulmonary Rehabilitation

Pulmonary rehab is a medically supervised program that helps improve the health and well-being of people who have lung problems. Rehab may include an exercise program, disease management training, and nutritional and psychological counseling. The program aims to help you stay more active and carry out your day-to-day activities.

Your rehab team may include doctors, nurses, physical therapists, respiratory therapists, exercise specialists, and dietitians. These health professionals work together and with you to create a program that meets your needs.

Oxygen Therapy

If you have severe COPD and low levels of oxygen in your blood, oxygen therapy can help you breathe better. For this treatment, you're given oxygen through nasal prongs or a mask.

You may need extra oxygen all the time or just sometimes. For some people who have severe COPD, using extra oxygen for most of the day can help them:

• Do tasks or activities, while having fewer symptoms
• Protect their hearts and other organs from damage
• Sleep more during the night and improve alertness during the day
• Live longer

Surgery

In rare cases, surgery may benefit some people who have COPD. Surgery usually is a last resort for people who have severe symptoms that have not improved from taking medicines.

Surgeries for people who have COPD that's mainly related to emphysema include bullectomy (bul-EK-to-me) and lung volume reduction surgery (LVRS). A lung transplant may be done for people who have very severe COPD.

Bullectomy

When the walls of the air sacs are destroyed, larger air spaces called bullae form. These air spaces can become so large that they interfere with breathing. In a bullectomy, doctors remove one or more very large bullae from the lungs.

Lung Volume Reduction Surgery

In LVRS, surgeons remove damaged tissues from the lungs. This helps the lungs work better. In carefully selected patients, LVRS can improve breathing and quality of life.

Lung Transplant

A lung transplant may benefit some people who have very severe COPD. During a lung transplant, your damaged lung is removed and replaced with a healthy lung from a deceased donor.

A lung transplant can improve your lung function and quality of life. However, lung transplants have a high risk of complications. These include infections and death due to the body rejecting the transplanted lung.

If you have very severe COPD, talk to your doctor about whether a lung transplant is an option. Discuss with your doctor the benefits and risks of this type of surgery.

Managing Complications

COPD symptoms usually slowly worsen over time. However, they can become more severe suddenly. For instance, a cold, the flu, or a lung infection may cause your symptoms to quickly worsen. You may have a much harder time catching your breath. You also may have chest tightness, more coughing, changes in the color or amount of your sputum (spit), and a fever.

Call your doctor right away if this happens. He or she may prescribe antibiotics to treat the infection and other medicines, such as bronchodilators and glucocorticosteroids, to help with your breathing.

Some severe symptoms may require treatment in a hospital.

How Can COPD Be Prevented?

You can take steps to prevent COPD before it starts. If you already have COPD, you can take steps to prevent complications and slow the progress of the disease.

Prevent COPD Before It Starts

The best way to prevent COPD is to not start smoking or to quit smoking before you develop the disease. Smoking is the leading cause of COPD.

If you smoke, talk to your doctor about programs and products that can help you quit. Many hospitals have programs that help people quit smoking, or hospital staff can refer you to a program. The National Heart, Lung, and Blood Institute's "Your Guide to a Healthy Heart" booklet has more information about how to quit smoking.

Also, try to avoid secondhand smoke and other lung irritants that can contribute to COPD, such as air pollution, chemical fumes, and dust.

Prevent Complications and Slow the Progress of COPD

If you have COPD, the most important step you can take is to quit smoking. This can help prevent complications and slow the progress of the disease. You also should avoid exposure to the lung irritants mentioned above.

Follow your treatments for COPD exactly as your doctor prescribes. They can help you breathe easier, stay more active, and avoid or manage severe symptoms.

Talk with your doctor about whether and when you should get flu and pneumonia vaccines. These vaccines can lower your chances of getting these illnesses, which are major health risks for people who have COPD.

Living With COPD

COPD has no cure yet. However, you can take steps to manage your symptoms and slow the progress of the disease. You can:

• Avoid lung irritants
• Get ongoing care
• Manage the disease and its symptoms
• Prepare for emergencies

Avoid Lung Irritants

If you smoke, quit. Smoking is the leading cause of COPD. Talk to your doctor about programs and products that can help you quit. Many hospitals have programs that help people quit smoking, or hospital staff can refer you to a program. The National Heart, Lung, and Blood Institute's "Your Guide to a Healthy Heart" booklet has more information about how to quit smoking.

Try to avoid secondhand smoke and other lung irritants that can contribute to COPD, such as air pollution, chemical fumes, and dust. Keep these irritants out of your home. If your home is painted or sprayed for insects, have it done when you can stay away for awhile.

Keep your windows closed and stay at home (if possible) when there's a lot of air pollution or dust outside.

Get Ongoing Care

If you have COPD, it's important to get ongoing medical care. Take all of your medicines as your doctor prescribes. Make sure to refill your prescriptions before they run out. Bring all of the medicines you're taking when you have medical checkups.

Talk with your doctor about whether and when you should get flu and pneumonia vaccines. Also, ask him or her about other diseases for which COPD may increase your risk, such as heart disease, lung cancer, and pneumonia.

Manage COPD and Its Symptoms

You can do things to help manage your disease and its symptoms. Depending on how severe your disease is, you may ask your family and friends for help with daily tasks. Do activities slowly. Put items that you need often in one place that's easy to reach.

Find very simple ways to cook, clean, and do other chores. Some people find it helpful to use a small table or cart with wheels to move things around and a pole or tongs with long handles to reach things. Ask for help moving things around in your house so that you will not need to climb stairs as often.

Keep your clothes loose, and wear clothes and shoes that are easy to put on and take off.

Prepare for Emergencies

If you have COPD, knowing when and where to seek help for your symptoms is important. You should seek emergency care if you have severe symptoms, such as trouble catching your breath or talking. (For more information on severe symptoms, see "What Are the Signs and Symptoms of COPD?")

Call your doctor if you notice that your symptoms are worsening or if you have signs of an infection, such as a fever. Your doctor may change or adjust your treatments to relieve and treat symptoms.

Keep phone numbers handy for your doctor, hospital, and someone who can take you for medical care. You also should have on hand directions to the doctor's office and hospital and a list of all the medicines you're taking.

Key Points

• COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.
• COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.
• Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.
• In the United States, the term "COPD" includes two main conditions—emphysema and chronic obstructive bronchitis. Most people who have COPD have both conditions. Thus, the general term "COPD " is more accurate.
• COPD is a major cause of disability, and it's the fourth leading cause of death in the United States.
• COPD develops slowly. Symptoms often worsen over time and can limit your ability to do routine activities. Severe COPD may prevent you from doing even basic activities like walking, cooking, or taking care of yourself.
• Your doctor will diagnose COPD based on your signs and symptoms, your medical and family histories, and test results.
• COPD has no cure yet. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.
• Quitting smoking is the most important step you can take to treat COPD. Other treatments include medicines, vaccines, pulmonary rehabilitation, oxygen therapy, surgery, and managing complications.
• You can take steps to prevent COPD before it starts. The best way to prevent COPD is to not start smoking or to quit smoking before you develop the disease. Also, try to avoid other lung irritants that can contribute to COPD.
• If you have COPD, you can take steps to manage your symptoms and slow the progress of the disease. Quit smoking and try to avoid other lung irritants. Also, get ongoing care, manage the disease and its symptoms, and prepare for emergencies.

HEALTH TIPS FOR MUSICIAN

HEALTH TIPS FOR THE MUSICIAN

Being healthy means you don't miss gigs, and don't have to spend money you would rather spend on studio time or instruments on a doctor's visit. Here are a few ways you can keep a little more of that money in your pockets, and where it can do more for your career.

WATER IS YOUR FRIEND

Sometimes the simplest things are the hardest to do. There is a lot to be said for drinking more water and less other things. Water has no calories, costs very little to nothing, and is great for keeping vital things like vocal cords and skin healthy. There are few things more irritating than a scratchy throat or split fingers if you are trying to play your instrument, and drinking plenty of water can help prevent both of these. This can also help you keep your skin less wrinkled and your weight down, allowing you to need less money in the long run trying to fix appearance problems as you age, and, in this sadly Hollywood-image field we are in, can probably up your chances of getting contracts simply because you are more youthful and healthy looking than your competition. If you happen to play in a very air-conditioned or heated area, keeping the place humidified can also keep your instruments in better shape and prevent a lot of cracking problems in things like wooden parts and skins, saving you money in repairs and replacement costs. To help keep humidity in the place if you can't afford a humidifier, try keeping a few potted plants around-keeping them moist enough to be healthy seems to keep the air around them the right moisture level as well. Keeping some lotion around that you find works helps a lot, too-seal in all that good moisture to your hands and face.

LEARN TO RELAX

This is another simple thing that is really hard to do. Many musicians have a really hard time "coming down" from a stage show, big meeting with industry bigwigs, or a really good writing session. Many methods exist to allow one to sit still and force oneself to unwind without the need for chemicals so you can get a decent night's sleep. Consider taking a class in Yoga or meditation; find something that really helps you wind down like a warm bubble bath, reading or some other pursuit. Things that work for me, strangely enough, are working on my taxes (so boring it numbs my brain out), curling up in front of the television watching cartoons, a long, slow workout followed by a hot shower or reading a book-especially if the book has a lot of imagery or highly technical data to absorb. I've also found that doing the meditation trick of thinking about sitting and relaxing doing something that soothes you is very helpful-many classes do the scene about sitting on a beach and thinking about being there, while I find thinking about doing yard work or building very relaxing. The important thing is to bore yourself with something that is fun for you, or lets you feel you are accomplishing something beneficial to you. Avoiding chemicals also prevents you from becoming habituated to them-something that can hurt you in the long run. Longer and longer runs or reading can only do you good, while costly chemical solutions often end careers in one way or another. Try to find fun, healthy, low-cost rituals instead.

CREATIVE FIDGETING

You can never really get enough practice, so try to find ways to practice even if you don't have your instrument around. Flexing your fingers backwards like your hands are eagle claws about to strike is great for many instrumentalists, as is doing this then drawing your fingers towards your palms after doing the claw stretch, as if you were about to make a fist, but then allowing the finger to come back to the initial position. I find this is a great way to work kinks out if I have been doing too much work with a pencil, too, at times when I have been frantically writing lyric ideas down. Pretending you are doing scales with both fingers or trying to make your fingers hold a certain chord position helps, too. Drawing your knees up as high as you can one at a time while sitting watching television or doing desk duty at work can help keep your legs and waistline in shape, too, and this can not only help your appearance but help things like your singing or ability to stand holding your instrument for longer periods of time, too. Try surfing the web for other fun exercises you can do while seated-there are lots of fun ones, and any exercise helps keep your weight down and helps you avoid all the health problems associated with that.

So try these simple suggestions and see how it helps your writing. It is amazing how much more endurance you may find you'll have just by drinking more water, learning to relax, and getting a little more exercise.

WHAT MAKES MUSICIANS PRONE TO REPETITIVE STRAIN INJURIES (RSI) ?

What makes musicians prone to Repetitive Strain Injuries (RSI)?

Many musicians have heard horror-stories about comrades who were excellent performing artists until they developed a repetitive strain injury to the arm or hand. Then their career either temporarily stopped or was finished due to this debilitating injury. Why are musicians prone to these injuries? What can be done about them? In this article you will learn why your hands and arms are at risk for injury, and what you can do to help prevent problems from developing in the first place.

In my experience working with hundreds of people who have suffered RSIs, there's a common trait among them. It is the "I thought the pain would go away" concept. Many musicians are out their (maybe yourself) who are currently attempting to play their instrument, even though their arms, elbows, shoulders, or neck are killing them. You have to realize that pain is your body's warning signal. It is like the oil light in your car. If the oil light goes on, do you simply say "let's see if that will turn off by itself. It can't be that important." That would be ludicrous, wouldn't it? Eventually, the engine would dry out, heat up, and for all intensive purposes seize up and be destroyed.

Are you letting this happen to your body? Are you letting the signs and symptoms of a major malfunction in your body, escalate to the point of total
destruction? I'm sorry to say, but I usually see musicians who've reached this point. They come in my office in desperation, stating they can't play anymore because of the pain, and their career is ruined. Don't let this happen to you!

Let's first begin to understand why the body malfunctions. There's some basic information you need to know about the body. I'll keep it simple and
as short as possible.

1. Your nervous system (the brain, spinal cord, and all the nerves that branch off the spinal cord) controls EVERYTHING in your body. This includes muscles, organs, glands, tissues, cells, immunity, hormones, etc. Let's put it another way - there's nothing that occurs in your body without the brain
   controlling it.
2. The nerve system is the "life force" of the body. It literally supplies life to the muscles, tissues, glands, and organs. Without this life-supplying nerve input, your tissues disease and eventually die. Ever see what a spinal cord injury does to a person? That's a pure example of a deadened nerve system.
3. Insults to your body, in the form of physical stresses, chemical stresses, or emotional stresses can "blow fuses" and irritate the nervous system. This causes abnormal signals to reach the tissues, organs, and glands. Let's break down these types of stresses and how they relate to musicians:
   • Physical stresses: (things that physically stress your body) Bad posture while playing your instrument, prolonged playing times without breaks,
     playing in one position (sitting for example) for a long time, previous car or motorcycle accidents, birth injuries (as a baby), quickly ramping up practicing times due to an upcoming gig or recital, being out of shape & overweight, sitting at computers for a long time, playing computer games hour after hour.
   • Chemical Stressors: (things to knowingly, or unknowlingly put into your body), drugs and alcohol, prescription drugs, fast food, vaccines, toxic
     chemicals in your environment (like chemicals you're exposed to by work or at home), a bad water supply.
   • Emotional stressors: (stuff you're thinking about) getting that recording contract, composing and finishing songs by a deadline, record company execs being a pain is the most, family stresses, relationship stressors, job stresses other than your music career, death of loved ones, relocating, being on tour without family or loved ones nearby, and finally your negative thinking AKA "stinkin' thinkin'" I bet you never thought that all these things mentioned have a direct impact on your body!
4. Continued physical, chemical, and emotional stressors will short-circuit your nervous system and lead to things called "spinal subluxations". "A spinal what?" you ask? A subluxation is a misalignment of a spinal bone(s) that exerts stress on your nerve system. This leads to malfunction of the
   tissues that affected nerves supply, in some cases muscles, in some cases organs, and in some cases, both!
5. These continued stressors will eventually lead to symptoms due to repeated stress on the nerve system. Prolonged, uncared for stresses will lead to disease, disability, and eventually a shortened life-span.

So let's summarize in a real, practical situation that every musician can understand. You feel that you're in pretty good health, except for the fast food (chemical stress) that seems to be part of your lifestyle lately. You know that you're not eating right, but hey, there's this recording deal that you have to provide music for. You're spending 8 to 10 hours a day composing music, (physical stress) sitting at your guitar and piano. That certainly doesn't give you time to fix good meals. What's worse is that your girlfriend (or boyfriend) is hounding you because you don't spend enough time with them. (Emotional stress) Your dad recently had a heart attack, and your torn because you can't spend enough time with him right now. (emotional stress) You're finding that one or two beers isn't sufficing anymore. Drinking a six-pack is becoming part of your practice sessions. (chemical stress) To top things off, your back is beginning to hurt after playing guitar for more than a few hours, so you begin taking some ibuprofen every day to make it through the sessions. (chemical stress)

Now do you see what I'm getting at? Your health is a conglomerate of YOU. What you're eating, taking, saying, doing, and hearing. YOU ONLY DEVELOP AN INJURY WHEN THESE CONTINUED STRESS FACTORS BEGIN TO BREAK DOWN YOUR NERVOUS SYSTEM AND CAUSE YOUR MUSCLES, ORGANS, AND GLANDS TO DISEASE.

So, let's consider your injury, if you have one, at this point in time. Look back at this list of stressors and see which ones you've experienced lately.
And it doesn't have to be within the past month or two. This list can go back to birth! Complicated you say? You're right. When a person walks in my office with an RSI, we have to investigate that entire person's life to find out what stressors led him/her to this current symptom. In many cases, even though the pain is in the arm, the actual nerve stress that is leading to the symptom can stem from the brain stem, neck, upper back, and lower
back. You have to investigate the whole body.

So what can you do now that you understand this better? First, work at relieving stressors in your life. (That's not easy) Second, if you think your life stressors have taken their toll on your body, then visit a chiropractor to determine if your nervous system is shutting down, or is working at half-mast. Third, if you are having active RSI-type symptoms, don't wait - run, to a chiropractic office for a complete eval and treatment. And the last, feel free to asking me some advice if you meet some problems likes above...

LONG LASTING VALUES

I'm a medical doctor,
I'm a hardcore kids and musician as well,
well in the mean time,
one of my biggest endeavour is to make how my music (HxC / Hard Core) become
more healthy, more safe, avoid whole injuries in gigs, and more productive...
I brought whole knowledge that I had,
and contribute for ourselves with my own capabilities
in the scene itself,
I hope you all guys in the same line with me...

(Iman Firmansyah, B.Sc., M.D.)

CARCINOGENS FROM PARENT'S " TOBACCO SMOKE FOUND IN THEIR BABIES"

Carcinogens From Parents 'Tobacco Smoke Found In Their Babies'

PHILADELPHIA - When mom or dad puffs on a cigarette, their infants may inhale the resulting second-hand smoke. Now, scientists have detected cancer-causing chemicals associated with tobacco smoke in the urine of nearly half the babies of smoking parents.

"The take home message is, 'Don't smoke around your kids,'" said Stephen S. Hecht, Ph.D., professor and Wallin Chair of Cancer Prevention at The Cancer Center at the University of Minnesota.

According to a study of 144 infants, published in the May issue of Cancer Epidemiology, Biomarkers & Prevention, Hecht and his colleagues found detectable levels of NNAL* in urine from 47 percent of babies exposed to environmental tobacco carcinogens from cigarette smoking family members.

NNAL is a cancer-causing chemical produced in the human body as it processes NNK**, a carcinogenic chemical specific to tobacco. "The level of NNAL detected in the urine of these infants was higher than in most other field studies of environmental tobacco smoke in children and adults," Hecht said. "NNAL is an accepted biomarker for uptake of the tobacco-specific carcinogen NNK. You don't find NNAL in urine except in people who are exposed to tobacco smoke, whether they are adults, children, or infants."

A previous study by Hecht and his colleagues indicated that the first urine from newborns whose mothers smoked during pregnancy contained as much as one-third more NNAL compared to the babies in the current study. The newborn infants, however, took in the carcinogen directly from their mothers through their placentas rather than by breathing second-hand smoke in the air in their family homes and cars. In the current study, when babies had detectable levels of NNAL, Hecht said that family members smoked an average of 76 cigarettes per week, in their home or car while the babies were present. In children of smokers whose babies had undetectable levels of NNAL in their urine, the average number of cigarettes smoked by family members was reported at 27 per week. "With more sensitive analytical equipment, the NNAL from urine of babies in lower frequency cigarette smoking households would most likely be detectable " Hecht said.

While studies have not determined how the long term risk of exposure to cancer-causing tobacco smoke affects the genetics of babies during their early years when they are growing rapidly, Hecht said that this study demonstrated substantial uptake of NNK and its metabolite NNAL in infants exposed to environmental tobacco smoke. "These findings support the concept that persistent exposure to environmental tobacco smoke in childhood could be related to cancer later in life," he said. Hecht conducted his study in collaboration with Steven G. Carmella, Ky-Ahn Le, Sharon E. Murphy, Angela J. Boettcher, Chap Le, Joseph Koopmeiners, Larry An, and Deborah J. Hennrikus from the Transdisciplinary Tobacco Use Research Center and The Cancer Center, University of Minnesota.

* 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol
** 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone

SINUSITIS, BAGAIMANA MENGHADAPINYA ?

Sinusitis, bagaimana menghadapinya?

(Bahasa Indonesia Version)

Selesma yang umumnya dianggap penyakit rutin setiap pergantian musim, tetapi bagi penderita sinusitis lebih dari derita yang tiada berakhir, kepala terasa nyeri untuk nenunduk, hidung tersumbat, ingus kuning kehijauan tak henti mengalir, hidung berbau tak sedap. Apa yang harus dilakukan untuk meredakan infeksi dan radang sinus itu ? Pada tahap pertama, sinusitis dapat diobati dengan obat-obatan tradisional dan antibiotik yang membunuh bakteri penyebab infeksi. Andai kata Anda penderita sinusitis kronis atau musiman, jangan sepelekan penyakit itu, sebab, salah diagnosa dan terapi, penyakit pun akan tetap saja membandel. Rongga hidung terdiri dari empat set rongga cekung, lapisan dengan selaput tipis terletak di atas, belakang dan samping hidung. Fungsi utamanya menghasilkan lendir, normalnya sampai dua liter perhari untuk membersihkan bakteri, debu, dan polutan lain yang ikut terhirup waktu bernafas. Lapisan cilia ( bulu getar ) yang mirip dengan rambut di rongga hidung berguna untuk menyapu lendir sampai ke hidung, kemudian ke bagian belakang kerongkongan yang ditelan dan dilarutkan oleh asam pencernaan. Lapisan cilia tidak akan berfungsi sebagaimana mestinya bila rongga hidung meradang. Akibatnya, lendir terjebak di dalam rongga dan menjadi tempat pembiakan bakteri.

Sebenarnya ada dua macam sinusitis yang masing-masing membutuhkan terapi tersendiri. Sinusitis akut lebih umum terjadi dan di sertai selesma, penderitaan ini biasanya dapat disembuhkan dalam waktu kurang dari tiga minggu, bila dideteksi lebih dini biasanya memberi hasil yang cepat dan optimal, cukup dengan meminum obat-obatan di rumah. Beberapa langkah terapi berikut :

• Manfaatkan dengan air panas. Saat mandi, gunakan shower air hangat, usap dahi, hidung dan dagu dengan waslap yang dibasahi air panas, agar lubang hidung terbuka lebar. Rongga hidung yang kering lebih mudah terinfeksi daripada yang basah.

• Gunakan obat semprot bergaram. Caranya sangat mudah, hanya di semprot atau di teteskan kedalam hidung, selaput akan lembab, bakteri dan debu pun terbuang, cuma jangan di gunakan lebih dari 4-6 hari, efeknya akan memburuk dan justru bisa menyebabkan peradangan. Akibatnya hidung menjadi tambah tersumbat dan Anda pun membutuhkan dosis obat ini yang lebih banyak lagi, ketahuilah, semakin sering obat semprot digunakan, kian buruk kondisi hidung. Perbanyak memakan makanan yang pedas, umumnya makanan berbumbu pedas dapat memperlebar lubang hidung.

• Usahakan hidung selalu dalam kondisi lembab, terutama tatkala cuaca di luar panas terik.

• Perbaiki daya tahan tubuh. Caranya, istirahat yang cukup dan makan panganan yang penuh gizi. kurangi merokok atau kalau bisa berhenti merokok.

Sinusitis yang kronis, dengan infeksi terus-menerus, kebanyakan yang terjadi akibat infeksi berulang-ulang atau sebelumnya tidak tuntas di tangani. Gejalanya berupa batuk, hidung tersumbat, berbau tidak sedap, pilek, rongga hidung memerah, kemampuan mencium berkurang dan lendir dari hidung berwarna kuning kehijauan, keluhan ini mungkin bisa hilang dalam waktu lebih dari enam minggu. Akibatnya akan terluka oleh infeksi sebelumnya, rongga hidung menyempit atau tertutup dan tidak dapat mengeluarkan ingus. Sinusitis yang kronis sulit diobati, kondisinya akan makin parah jika tidak cepat-cepat diobati ketika kambuh. Bisa-bisa terbangun pada pagi hari, kelopak mata menonjol, rasa sakit menusuk dari dahi sampai ke bagian atas gigi dan demam, tidak hanya itu, daya menciumnya juga hilang, seperti kebal. Salah satu jalan yang terbaik bagi penderita sinusitis yang kronis adalah operasi, operasi sinus adalah alternatif pengobatan yang terakhir. Itu juga merupakan indikasi sinusitis yang berat dan gagal diterapi.

Operasi dengan endoskopik secara dramatis dapat mengurangi derita pasien, dan pada umumnya lebih cepat memulihkan fungsi drainase. Ada prosedur pengobatan baru dengan memakai teknologi tinggi, suatu tabung semacam pipa kecil, yang dilengkapi kamera fiberopik dan instrumen lainnya dimasukkan melalui hidung. Kemudian diberi antibiotika selama sepuluh hari dan nasal steroid untuk mengurangi peradangan yang lebih jauh dan wajib istirahat antara tiga hingga lima hari. Kasus sinusitis terburuk terjadi empat tahun terakhir, mengapa ? Karena dunia telah banyak terkontaminasi. polusi di mana-mana, Akibatnya banyak organisme yang lebih kebal di lingkungan sekitar kita saat ini. Harapan satu-satunya adalah agar segera di kembangkan antibiotika baru. Kalau tidak, sinusitis tetap mewabah, tetapi sejauh ini, sinusitis masih dapat dikontrol, asal gejalanya dapat di ketahui dan ditangani secara dini.

Trichomoniasis: Sexually Transmitted Disease Without Symptoms

Trichomoniasis: Penyakit Menular Seksual Tanpa Gejala (Bahasa Indonesia Vesion)


Sebagai pria yang menyenangi kesehatan, tentunya Anda perlu mengetahui berbagai penyakit yang berada di sekitar kita. Apalagi jika berkaitan dengan penyakit yang bersamaan dengan seks. Mengerikan sekali jika kita tidak mengetahuinya sejak awal. salah satunya adalah Trichomoniasis.

Trichomoniasis alias "trich", merupakan infeksi parasit yang bisa terjadi pada laki-laki dan perempuan. Pada laki-laki, tanda-tandanya muncul pada uretra (saluran yang mengalirkan urin ke luar tubuh). Pada perempuan, yang terkena adalah vagina dan serviks (leher rahim).

Pada laki-laki yang terinfeksi parasit ini tidak merasakan gejala apapun namun dapat menularkan ke pasangannya. Demikian juga sebaliknya, saat perempuan terinfeksi parasit ini, dia bisa juga tidak merasakan gejalanya. Trichomoniasis kerap terjadi bersama dengan penyakit menular seksual lainnya, seperti gonorrhea dan nongonococcal urethritis (chlamydia), khususnya pada perempuan.

Trichomoniasis di negara AS lebih tinggi terjadi pada perempuan dibanding laki-laki. Diperkirakan 5 juta kasus baru terjadi setiap tahunnya dan infeksi ini terjadi pada 10% perempuan yang datang untuk mengobati penyakit menular seksual yang dideritanya. Pada 2000, the Centers for Disease Control and Prevention (CDC) melaporkan bahwa trichomoniasis biasanya dapat diobati pada perempuan muda dengan kehidupan seksual aktif.

Untuk lebih mengetahui penyebabnya, Anda perlu tahu adalah Trichomoniasis disebabkan oleh parasit yang disebut Trichomonas vaginalis, yang ditularkan khususnya melalui kontak seksual secara langsung. Penyakit ini juga dapat ditularkan melalui mutual masturbation dan berbagai sex toys (alat bantuk seks)

Gejala umumnya muncul dalam 4-20 hari setelah infeksi. Perempuan yang terinfeksi parasit Trichomonas akan mengeluarkan cairan dari vagina berwarna kuning kehijauan atau abu-abu serta berbusa dalam jumlah banyak, kadangkala disertai pendarahan dan bau tidak sedap, gatal pada vulva sehingga menimbulkan rasa tidak nyaman.

Sering buang air kecil dan terasa sakit, pembengkakan vulva, rasa tidak nyaman selama berhubungan seksual dan sakit di wilayah perut. pendarahan di serviks mungkin terjadi, namun ini bukan gejala umum.

Sementara gejala pada laki-laki jarang terjadi. Namun jika pasangan mengeluhkan keluarnya cairan dari fanis berwarna putih pucat dan merasa sakit atau sulit saat buang air kecil, besar kemungkinan dia terkena trichomoniasis. Namun sekali lagi hal ini harus dipastikan dengan pemeriksaan klinis.

Trichomoniasis yang tidak ditangani tuntas dihubungkan dengan meningkatnya risiko terinfeksi HIV (virus yang menyerang sistem kekebalan tubuh yang akan berkembang menjadi AIDS). Perempuan hamil yang terinfeksi Trichomonas berisiko melahirkan bayi prematur, berat badan lahir rendah dan infeksi hingga pelepasan plasenta. Sedangkan peradangan pada prostat (prostatitis) dan saluran kencing (cystitis) kerap dikaitkan dengan trichomoniasis pada laki-laki.

Diagnosis

Membiakkan sampel cairan vagina/penis merupakan metode yang dapat diandalkan untuk menegakkan diagnosis trichomoniasis. Diperkirakan butuh waktu 10 hari untuk mendapat hasilnya. Pada perempuan untuk menegakkan diagnosis juga perlu dilakukan pemeriksaan mikroskopis cairan vagina, pap smear dan urinalysis. Leher rahim juga diperiksa jika terjadi pendarahan. Karena trichomoniasis sering terjadi bersama penyakit menular seksual lainnya, pasien perlu diperiksa untuk menentukan jenis infeksinya, apakah chlamydia, gonorrhea, syphilis, atau HIV.

Pengobatan

Sejauh ini metronidazole dikenal sebagai obat yang dapat mengobati trichomoniasis, yang diminum dalam dosis tunggal. Orang yang mengonsumsi metronidazole harus menghindari alkohol selama pengobatan, sebab reaksi kimia yang ditimbulkan dapat menyebabkan mual dan muntah. Efek samping yang timbul antara lain mual, sakit kepala dan kram bagian perut. Perempuan hamil yang hendak mengonsumsi obat ini harus konsultasi dulu ke dokter.

Meski gejala trichomoniasis pada laki-laki dapat sembuh dengan sendirinya dalam beberapa minggu, namun karena laki-laki yang terinfeksi parasit Trichomonas bisa saja tak menunjukkan gejala sehingga dia dapat menularkannya ke orang lain, untuk itu sebaiknya rajin memeriksakan diri ke dokter dan meminum obatnya secara teratur untuk mematikan parasit ini.



Trichomoniasis: Sexually Transmitted Disease Without the Symptoms (English Version)


As a man who enjoys the health, of course you need to know the various diseases that are all around us. Especially when it comes to the same disease with sex. How awful if we did not know it from the beginning. one of them is Trichomoniasis.

Trichomoniasis or "trich", is a parasitic infection that can occur in men and women. In men, the signs appear in the urethra (the channel that drains urine out of the body). In women, the affected are vagina and cervix (neck of the uterus).

In men infected with this parasite does not feel any symptoms but can pass on to their partner. And vice versa, while women are infected with this parasite, she may not feel the symptoms. Trichomoniasis often occurs along with other sexually transmitted diseases, such as gonorrhea and nongonococcal urethritis (chlamydia), especially in women.

Trichomoniasis in the U.S. state higher occur in women than men. An estimated 5 million new cases occur each year and this infection occurs in 10% of women who came to treat sexually transmitted diseases suffered. In 2000, the Centers for Disease Control and Prevention (CDC) reported that Trichomoniasis can usually be treated at a young woman with an active sexual life.

To know better about the cause, you need to know is Trichomoniasis is caused by a parasite called Trichomonas vaginalis, which is transmitted mainly through sexual contact directly. This disease can also be transmitted through mutual masturbation and other sex toys (sex bantuk tool)

Symptoms generally appear within 4-20 days after infection. Women who are infected with the parasite Trichomonas will remove fluid from the vagina yellow-green or gray and foaming in large quantities, sometimes accompanied by bleeding and odor, itching at the vulva, leading to discomfort.

Frequent urination and pain, swelling of the vulva, discomfort during intercourse and pain in the stomach area. bleeding in the cervix may occur, but this is not a general phenomenon.

While the symptoms in men are rare. But if the couple complained fanis discharge from pale white and feel sick or difficult urination, chances are he hit Trichomoniasis. But again this must be confirmed by clinical examination.

Trichomoniasis is not handled thoroughly associated with an increased risk of HIV infection (the virus that attacks the immune system will develop into AIDS). Pregnant women infected with Trichomonas risk of premature babies, low birth weight and placental infection until the release. While inflammation of the prostate (prostatitis) and urinary tract (cystitis) often associated with Trichomoniasis in men.

Diagnosis

Vaginal fluid samples breed / penis is a reliable method for diagnosis Trichomoniasis. Estimated to take 10 days to get results. In the women to make the diagnosis also needs to be done vaginal fluid microscopic examination, pap smear and Urinalysis. The cervix is also checked if there is bleeding. Because Trichomoniasis often occurs with other sexually transmitted diseases, patients need to be examined to determine the type of infection, whether chlamydia, gonorrhea, syphilis, or HIV.

Theraphy

So far, metronidazole is known as a drug that can treat Trichomoniasis, which is taken in a single dose. People who take metronidazole must avoid alcohol during treatment, because the resulting chemical reaction may cause nausea and vomiting. Side effects that arise include nausea, headache and abdominal cramps. Pregnant women who want to take this medication should consult a doctor first.

Although symptoms of Trichomoniasis in men can be healed by itself within a few weeks, but because men are infected with the parasite Trichomonas may not show symptoms so he can spread it to someone else, for that should be diligently went to the doctor and take his medicine regularly to kill these parasites.

PO CHAI PILLS WILL CAUSE A CANCER (in Bahasa Indonesia)

Obat Sakit Perut Po Chai yang Sebabkan Kanker

Departemen Kesehatan Hong Kong melarang dan menarik kembali peredaran dua jenis obat sakit perut tradisional China Po Chai. Akankah obat yang telah dikonsumsi anak-anak hingga manula sejak berusia ratusan tahun itu berakhir?

Pil Po Chai telah menjadi akrab di kalangan masyarakat Asia termasuk di Indonesia. Jika anak-anak sakit perut, ibu-ibu zaman dulu hingga saat ini masih menggunakan Po Chai untuk penyembuhannya.

Pil Po Chai digunakan untuk meredakan gangguan pencernaan, mulas, muntah, diare dan kembung. Obat ini juga digunakan untuk mencegah mabuk.

Seperti dilansir dari data perusahaan pochaipills.com, pil Po Chai pertama kali dibuat oleh Li Shiu Kei di Foshan, Guangdong pada tahun 1896. Li kemudian mengembangkan usahanya ke Hong Kong setelah perang saudara di China yang berakhir pada 1936.
Di Hong Kong, Li kemudian mengibarkan bendera Li Chung Shing Tong (Holdings) Limited yang menjual pil Po Chai ke seluruh dunia. Sedangkan perusahaan di Guangzhou, China di bawah bendera Wanglaoji Guangzhou Pharmaceutical Company Limited hanya menjual obat untuk
daratan China saja.

Po Chai adalah ramuan herbal yang mengandung Halloysitum, akar Rhizoma, Oryzae Satiae, daun Herba Menthae, Selerotrum Porifungal, Radix Puepariae, daun Herba Agastaches, Excarpium Citri, Cortex magnoliae dan daun Masse Fermentata Neaven. Namun kini Po Chai bakal susah dicari.

Departemen Kesehatan Hong Kong melarang dan menarik obat-obat Po Chai dari pasaran sejak 24 Maret 2010.

Selain Hong Kong, Singapura sudah terlebih dahulu melarang penjualan obat ini sejak 8 Maret 2010.

Dalam keterangannya seperti dilansir dari news.gov.hk, Selasa (30/3/2010), Departemen Kesehatan Hong Kong memerintahkan semua pil Po Chai baik dalam bentuk kapsul maupun botol ditarik dari gerai ritel lokal.

Penarikan tersebut dilakukan setelah mempelajari hasil temuan otoritas Singapura yang melarang obat yang mengandung phenolphthalein dan sibutramine karena menyebabkan kanker dan obesitas. Po Chai ternyata mengandung dua bahan tersebut.
Hasil temuan Departemen Kesehatan Hong Kong, obat yang tercemar ini adalah bahan bubuk dalam kapsul. Dua kapsul yang dicurigai berbahaya yang telah diekspor ke Singapura itu adalah kapsul nomor 21217 dan 21133.

Dan juga berdasarkan pengalaman saya dalam praktek sehari-hari, dalam 3 tahun belakangan ini, saya menemukan reaksi alergi (Drug Eruption) pada pasien saya yang mengkonsumsi pochai pills ini. Semoga bermanfaat.