Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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The Efforts to Implement a Malaria Elimination Strategy in The Highly Endemic Malaria Region of Papua Province, Indonesia
Full text linkIn 2023, Indonesia’s Ministry of Health reported that nearly 75% of districts and cities in the country were free from malaria transmission, meaning 90% of the population lived in malaria-free zones. However, Papua Province, which accounts for only 1.5% of Indonesia’s population, continues to contribute over 90% of the national malaria cases, with more than 16,000 reported cases in 2023.Indonesia has recently completed a malaria vaccine trial, the IDSPZV1, which included the PfSPZ Vaccine and PfSPZ-CVac (CQ), conducted among soldiers deployed to Papua Province, New Guinea, for 10 months. These soldiers were from a battalion located in a malaria-free area in Bangkinang, Riau Province. The results of this clinical trial will be reported separately, but this significant development could offer a potential solution to reduce the risk of malaria infection, particularly among travelers, such as domestic tourists or soldiers visiting Papua.This edition highlights the recent findings from a malaria study conducted in Iwaka District, Mimika, Papua, which revealed that nearly half of the patients presenting with fever at the district hospital were diagnosed with malaria (N=863 patients). The authors explored various factors, including the prevalence of malaria, patient characteristics, history of malaria exposure, housing and environmental conditions, as well as malaria prevention measures among the study participants.In addition to uncomplicated malaria infections, severe malaria cases remain a significant issue, contributing to high mortality rates. Nainggolan et al. investigated the role of host factors, particularly ABO blood groups, in the likelihood of developing severe malaria.Understanding the dynamics of disease prevalence, and risk factors related to both the host and the environment, along with the potential availability of vaccines, chemoprevention, and other preventive measures, are crucial to achieving zero malaria in the island of New Guinea, Papua Province
p.Gly693Arg Homozygote Mutation in Dubin-Johnson Syndrome with Atypical Liver Biopsy due to Reactivation of Hepatitis B Concomitant with Persistent Loss of Kidney Function
Full text linkDubin-Johnson syndrome is a rare genetic disease that causes impaired transport of bilirubin. In most cases, there will be no symptoms. However, some people might develop jaundice due to certain conditions. In this case, we would like to present a 54-year-old male patient with Dubin-Johnson syndrome confirmed through genetic analysis showing homozygote mutation of p.Gly693Arg, with no apparent bile deposition in liver biopsy and reactivation of hepatitis B. The Patient had no symptoms since birth and was recently found to have an increased level of direct bilirubin. Further inspection showed a familial pattern of the disease. This is a unique case of homozygote mutation with p.Gly693Arg with atypical presentation of liver biopsy and reactivation of hepatitis B with no clinical manifestation
Patients with Systemic Lupus Erythematosus with Anxiety or Depression: Clinical Characteristics, Food Intake, and Gut Microbiota Profile
Full text linkBackground: Depression and anxiety are prevalent among patients with systemic lupus erythematosus (SLE), and gut microbiota may be a contributing factor. This study aimed to investigate the clinical characteristics, food intake, and gut microbiota profiles of SLE patients with anxiety or depression. Methods: An analysis of secondary data was conducted. The primary study was conducted at Cipto Mangunkusumo Hospital, Jakarta, Indonesia, in 2017–2018. The inclusion criteria were: a diagnosis of SLE, age 18‒60 years, and gastrointestinal symptoms. The data collected included clinical data, food intake, anxiety and depression scores, SLE disease activity, and stool samples. Sequencing of the 16S rRNA gene was performed to profile the gut microbiota using DNA was extracted from the stool samples. Results: After excluding those with incomplete data, 41 patients were analyzed. Among the subjects, 53.66% and 14.63% had anxiety and depression, respectively. SLE patients with anxiety were significantly more likely to harbor Bacteroides compared to those without anxiety (33.45% vs. 9.78%; p=0.02) and had lower levels of complement C3 (78.72 vs. 100.85 mg/dL; p=0.03). SLE patients with anxiety or depression had significantly lower fat intake compared to those without these conditions (38.78 vs. 48.43 g/day; p=0.04, and 31.48 vs. 45.27 g/day; p=0.04). A significant correlation was observed between the proportion of Bacteroides and SLE disease activity (p=0.02). Conclusion: SLE patients with anxiety showed a significantly higher proportion of Bacteroides and a lower C3 level compared to those without anxiety. Fat intake was significantly lower among SLE patients with anxiety or depression compared to those without either conditio
Effect of Ramadan Fasting on Malondialdehyde, Poly (ADP-Ribose) Polymerase, Sirtuin 1, Nuclear Receptor Subfamily 1 Group D Member 1, and Transforming Growth Factor Beta in Chronic Kidney Disease: A Prospective Cohort Study
Full text linkBackground: Chronic kidney disease (CKD) is a global health problem with increasing prevalence. This study aims to analyze the effect of Ramadan fasting on important biomarkers in CKD patients. Methods: A prospective cohort study was conducted on 30 CKD patients with stages 1, 2, and 3A who underwent Ramadan fasting. Measurements of MDA, PARP, SIRT1, NR1D1, and TGF-β levels were carried out before fasting, 2 weeks during fasting, and after fasting using the Enzyme-linked immunosorbent assay (ELISA) method. Results: There were significant decreases in urea, fasting blood glucose, HbA1C, and uric acid levels (p<0.05). MDA and SIRT1 decreased significantly (p<0.001), while PARP and NR1D1 increased significantly (p<0.001). TGF-β also showed a decrease. There were no significant changes in lipid profiles, creatinine, and albumin. Conclusion: Ramadan fasting has significant effects on several biochemical parameters and biological markers in early-stage CKD patients. These changes indicate potential improvements in oxidative stress, cell autophagy, inflammation regulation, and circadian rhythm. Further studies are needed to evaluate the long-term effects and clinical implications of these findings in CKD management
“Super Responder” of Percutaneous Bicaval Valve Implantation for Severe Tricuspid Regurgitation: A Case Report
Full text linkTricuspid Regurgitation (TR) surgical treatment is associated to high operative mortality, suboptimal long-term survival, and frequent TR recurrence after repair, especially in the elderly. This case report highlights our early experience of TricValve implantation in Indonesia, conducted on a 72-year-old male patient with severe tricuspid regurgitation and advanced right ventricular dysfunction. In this context, the TricValve system offers a promising, less invasive alternative. Despite previous pharmacological management, our patient had been readmitted multiple times due to refractory right heart failure. One month post-TricValve implantation, he showed significant symptomatic relief and stable cardiac function as evidenced by echocardiographic measurements. This case underscores the potential utility of the TricValve system in providing an effective, lower-risk treatment option for patients not suited for traditional surgical intervention
Safety of Six Minute Walking Test in Hospitalized Post-percutaneous Coronary Intervention Patients: Analysis of Vital Signs, Borg Scale, and Angina Scale Responses
Full text linkBackground: Heart disease is one of the non-communicable diseases that cause the highest mortality. Its symptoms affect the patient's functional capacity and activities. The six-minute walking test can be done to assess a person's functional ability, response to therapy, and prognosis of chronic heart-lung conditions. The study aims to determine the safety of the six-minute walking test in inpatients after percutaneous coronary intervention by assessing the response of vital signs, Borg scale, and angina scale. Methods: This study was a one-group pre-and post-test design study with subjects of inpatients after percutaneous coronary intervention at the Integrated Cardiac Service in Cipto Mangunkusumo General Hospital Jakarta. Research subjects conducted a six-minute walking test twice with a five-minute break in between. Examination of vital signs, Borg scale, and angina scale before and after walking test. The number of subjects was 30 (27 male and 3 female) with the majority classified as a low-risk stratification. Results: The six-minute walking test was performed over two days or more in 56.7% of the subjects. The mean covered distance was 294.68 ± 57.02 meters. Vital signs of systolic and diastolic blood pressure, pulse rate, respiratory rate, and Borg rating of perceived exertion (RPE) scale increased during the test. They decreased to baseline after resting for five minutes with p-value <0.05 in the Wilcoxon Signed Rank test. Changes in saturation, dyspnea, and leg fatigue of the Borg scale, and angina scale were not statistically significant. All study subjects did not have major adverse events. Conclusion: The six-minute walking test is safe to do in inpatients after percutaneous coronary intervention with vital signs, Borg scale, and angina scale change accordingly to physiological response
The Role of Inflammatory Parameters and Antibody Seroconversion on COVID-19 Outcomes in Patients with Central Obesity
Full text linkBackground: Central obesity increases the risk of developing poor outcomes of COVID-19. The pro-inflammatory state and antibody dysfunction are thought to contribute to poor outcomes; however, the evidence is unclear. Methods: This is a cohort study among COVID-19 patients with central obesity in Dr. Cipto Mangunkusumo National General Hospital Jakarta, Indonesia, during the early phase of the COVID-19 pandemic. Our study is a part of the COVID-19, Aging, and Cardiometabolic Risk Factors (CARAMEL) study. From the CARAMEL study, we selected adult non-ICU/HCU inpatient subjects with central obesity that met inclusion/exclusion criteria, collected clinical and anthropometric data, and measured inflammatory cytokines and IgG S-RBD SARS-CoV-2 antibody titers from a stored sample taken at day 2 of hospitalization. The poor clinical outcome of hospitalization was observed. We used the Mann-Whitney test to analyse non-normally distributed data, and T-test for normally-distributed data. The adjusted-relative risk of negative seroconversion antibody for poor outcomes was analysed using logistic regression. Results: 23 of 178 (12.9%) subjects developed poor clinical outcomes during hospitalization. Subjects with poor outcomes had a higher visceral fat area (14.5 vs. 11, p < 0.05), waist circumference and BMI. The level of CRP, pro-inflammatory cytokines (IL-6 and MCP-1) and anti-inflammatory cytokines (IL-1Ra, IL-4, and IL-10) were significantly higher in subjects with poor outcomes, alongside with the lower antibody titer in subjects with poor outcomes. Antibody seroconversion failure increased the risk of developing poor outcomes (aRR 2.696, 95% CI 1.024-7.101), after adjusting for age and sex. Conclusion: In COVID-19 patients with central obesity, we confirmed the association between higher pro- and anti-inflammatory parameters, and lower SARS-CoV-2 antibody with poor outcomes of COVID-19
Performance of Tokyo Guidelines 2018 and Predictors of Mortality in Acute Cholangitis Patients in Indonesia
Full text linkBackground: Acute cholangitis is associated with high mortality, necessitating prompt diagnosis and intervention. The Tokyo Guidelines 2018 (TG18) are a crucial diagnostic tool, but their sensitivity and specificity require evaluation. Moreover, factors influencing acute cholangitis mortality in Indonesia remain unidentified. This study evaluates the diagnostic accuracy of TG18 and identifies mortality predictors in adult patients with acute cholangitis in Indonesia. Methods: A retrospective cohort study was conducted using the medical records of acute cholangitis patients at Cipto Mangunkusumo Hospital from 2019 to 2022. TG18 was compared with endoscopic retrograde cholangiopancreatography (ERCP). Bivariate and multivariate analyses were employed to identify mortality predictors. Results: The study involved 163 individuals (male: 51.5%; mean age: 51.0 ± 12.81 years). The in-hospital mortality rate was 11.6%. TG18 demonstrated a sensitivity and specificity of 84.05% (95% confidence interval (CI):77.51%–89.31%) and 95.65% (95%CI: 78.05%–99.89%), respectively, compared with ERCP. Significant mortality predictors in univariate analysis included TG18 grade III (risk ratio (RR): 13.85; 95%CI: 3.31–57.89; p<0.001), history of malignancy (RR: 4.40; 95%CI: 1.52–12.68; p=0.006), noncompliance with antibiotic guidelines (RR: 3.27; 95%CI: 1.36–7.85; p=0.008), and procalcitonin levels ≥ 2.0 ng/dL (RR: 2.44; 95%CI: 1.056–5.63; p=0.037). Multivariate analysis revealed that significant predictors included TG18 grade III (RR: 10.67; 95%CI: 2.50–45.56; p<0.001), non-compliance with antibiotic guidelines (RR: 2.92; 95%CI: 1.34–6.36; p=0.007), and procalcitonin levels ≥ 2.0 ng/dL (RR: 2.37; 95%CI: 1.18–4.75; p=0.015). Conclusion: TG18 demonstrates favorable sensitivity for diagnosing acute cholangitis. Independent predictors of acute cholangitis mortality include TG18 grade III, noncompliance with antibiotic guidelines, and procalcitonin levels ≥ 2.0 ng/dL
Predictors of Technical and Clinical Success of ERCP in Patients with Biliary Obstruction: A Study from a Tertiary Referral Center in Indonesia
Full text linkBackground: Endoscopic retrograde cholangiopancreatography (ERCP) is a primary therapeutic modality for managing malignant and benign biliary obstruction. Technical success (TS) and clinical success (CS) of modality are essential indicators of procedural efficacy, which is influenced by various patient- and procedure-related factors. Therefore, this study aims to evaluate the TS and CS rates of ERCP and identify their predictors in patients with biliary obstruction at a tertiary referral center in Indonesia. Methods: A retrospective analysis was conducted on patients with biliary obstruction who underwent therapeutic ERCP at Cipto Mangunkusumo Hospital between January 2022 and December 2024. Patients with diagnostic ERCP or prehepatic/parenchymal jaundice were excluded. Results: A total of 259 patients were included (49.4% female, mean age 50.6 years) in this study. The results show that the TS rate is 96.5%, with multivariate analysis identifying ulcerative fragile papillary mass (AOR 0.075; P=0.001) as an independent negative predictor. Meanwhile, the CS rate is 88%, with pre-ERCP bilirubin >3 mg/dL (AOR 8.545; P<0.001) and previous ERCP stenting/pre-cutting (AOR 0.330; P=0.037) being independent predictors. Distal malignant obstruction causes a higher pre-ERCP bilirubin level (P=0.025) of >3 mg/dL (OR 6.116; P=0.011). Conclusion: ERCP showed high technical and clinical success rates in managing biliary obstructions. TS was negatively predicted by ulcerative fragile papillary mass. CS was positively predicted by pre-ERCP bilirubin >3 mg/dL and negatively by prior stenting or pre-cutting. These findings should be taken into consideration when planning and delivering ERCP to achieve better outcomes
A Rare Case of Late Onset Familial Long QT Syndrome Presented with Recurrent Cardiac Arrest, Complete Heart Block, and NSTEMI
Full text linkLong QT Syndrome (LQTS) is a rare cardiac condition whose etiology is acquired or congenital. It has a wide range of clinical manifestations ranging from asymptomatic to sudden cardiac death due to malignant arrhythmia such as ventricular tachycardia. Congenital LQTS usually occurs at an early age in the form of prolonged QT interval in ECG examination, but such a condition may occur in later life. Therefore, QT interval should be assessed thoroughly to minimize the risk of iatrogenic ventricular tachycardia. A 72-year-old Javanese female with recurrent syncope episodes for 8 months was referred to the emergency department for temporary pacemaker implantation due to a complete heart block and NSTEMI. Family history revealed a first-degree family history of sudden cardiac death. She had a history of recurrent cardiac arrest due to ventricular arrhythmia and was treated with amiodarone continuous intravenous infusion in the previous hospital. During examination in the emergency department, she experienced another episode of cardiac arrest due to ventricular arrhythmia. Electrocardiogram examination pre-cardiac arrest revealed a complete heart block, atrial rate 60 bpm, ventricle rate 60 bpm, T Inversion in I, aVL, V2-V6, with prolonged QT interval (QT 616 ms, QTc 578 ms). Thus, amiodarone was subsequently stopped, and defibrillation was administered under ACLS guidelines. After the return of spontaneous circulation, revascularization was conducted due to ongoing typical chest pain and increased troponin level (117 ng/mL) to the LAD. Despite optimal revascularization and normal electrolyte level (Sodium 137 mEq/L, Potassium 3.8 mEq/L, Chloride 104.5 mEq/L), prolonged QT interval was observed in the patient until the 9th day post-revascularization and the double-chamber pacemaker implantation was conducted on patient. Thus, the prolonged QT interval subsided after double-chamber pacemaker implantation. Long QT Syndrome may occur at any period of life and may be asymptomatic. A thorough ECG examination before commencing treatment on a patient was pivotal to preventing malignant arrhythmia