Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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The Efficacy and Safety of Monoclonal Antibody Treatments Against COVID-19: A Systematic Review and Meta-analysis of Randomized Clinical Trials
Get PDFBackground: The use of monoclonal antibody as the proposed treatment of COVID-19 showed different results in various prior studies, and Efficacy remains open in literature. This study aimed to comprehensively determine the effect of monoclonal antibodies on clinical, laboratory, and safety outcomes in COVID-19 patients. Methods: Sixteen RCTs were analyzed in this meta-analysis using RevMan 5.4 to measure the pooled estimates of risk ratios (RRs) and standardized mean differences (SMDs) with 95% CIs. Results: The pooled effect of Monoclonal antibodies demonstrated efficacy on mortality risk reduction (RR=0,89 (95%CI 0.82-0.96), I2=13%, fixed-effect), Tocilizumab also show efficacy on mortality risk reduction for severe-critical disease (RR=0.90 (95%CI 0.83-0.97), I2=12%, fixed-effect)), need for mechanical ventilation (RR=0.76 (95%CI 0.62-0.94), I2=42%, random-effects), and hospital discharge (RR=1.07 (95%CI 1.00-1.14), I2=60%, random-effects). Bamlanivimab monotherapy did not reduce viral load (SMD=-0.07 (95%CI -0.21-0.07), I2=44%, fixed-effect). Monoclonal antibodies did not differ from placebo/standard therapy for hospital discharge at day 28-30 (RR=1.05 (95%CI 0.99–1.12), I2=71%, random-effects) and safety (RR=1.04 (95%CI 0.76–1.43), I2=54%, random-effects). Conclusion: Tocilizumab should be used for severe to critical COVID-19 because it is not harmful and can improve mortality risk, mechanical ventilation, and hospital discharge. Bamlanivimab-Etesevimab and REGN-COV2 reduced viral load in mild-moderate outpatients
Diagnosis of Chronic Lymphocytic Leukemia Using iwCLL 2018 Compared with NCI-WG96 Criteria in Cipto Mangunkusumo Hospital: A Practical Consideration in Resource Limited Setting
Get PDFBackground: The diagnosis of chronic lymphocytic leukemia (CLL) is mainly based on blood count, morphology, and immunophenotyping. In Indonesia, the diagnosis is more challenging as the availability of immunophenotyping tests is limited. The European Society of Medical Oncology (ESMO) stated flowcytometry as a prerequisite to establishing diagnosis of CLL, meanwhile in the original International Workshop on Chronic Lymphocytic Leukemia (iwCLL) 2018 criteria, which has been widely accepted by physicians caring for patients with CLL, the diagnosis of CLL can be made in patients with cytopenia using bone marrow biopsy where flowcytometry test is not available. The aim of the study was to compare the utility of International Workshop on Chronic Lymphocytic Leukemia 2018 [iwCLL 2018 (2)] compared with National Cancer Institute Working Group 96 (NCI-WG96) criteria in the diagnosis of CLL in Indonesia, especially in limited resource settings. Methods: The data of newly diagnosed CLL patients, including baseline demographic, clinical, and laboratory characteristics was retrieved retrospectively from medical records in Cipto Mangunkusumo General Hospital from 2015 until 2021. Diagnosis of CLL using iwCLL 2018 diagnostic criteria were then compared with National Cancer Institute Working Group 96 (NCI-WG96) criteria. Results: Thirty-eight patients were enrolled to this study. The median age was 59.5 years and dominated by males. Most of them were classified in the late-stage disease (63.4% in Binet C and about 70% in Rai III-IV). Four cases were CD5-negative CLL. Based on NCI-WG96 guideline, only 24 patients (63.2%) fulfilled all four criteria for CLL. Similarly, using the iwCLL 2018 flowcytometric criteria without biopsy data, 26 patients (68%) were diagnosed as CLL. However, if bone marrow biopsy in patient with cytopenia was taken into account, all patients (100%) can be confirmed as CLL. Conclusion: The iwCLL 2018 criteria which included bone marrow biopsy in the presence of cytopenia was more applicable to establish the diagnosis of CLL in Indonesia where flowcytometry is not available
Antiviral Treatment in COVID-19 Outpatients: A Systematic Review of Randomized Controlled Trials
Get PDFBackground: Most COVID-19 patients have mild or moderate illnesses that can progress to severe illness, leading to hospitalization and/or mortality. The use of antivirals to prevent the progression of COVID-19 in non-hospitalized patients shows conflicting result and efficacy remain unclear. This study evaluates the efficacy and safety of antivirals therapy in COVID-19 outpatients. Methods: Search were conducted in Pubmed, ScienceDirect, Cochrane Library, Springer, medRxiv, Journal Storage [JSTOR], and Directory of Open Access Journals [DOAJ] for articles investigating antivirals in COVID-19 outpatients. In addition, clinical and virological outcomes, COVID-19 hospitalization, all caused mortality, and adverse events were assessed. Results: Thirteen studies were included in this review. The consecutive data from these studies suggested that favipiravir is more optimally used in early disease, but improvement in symptoms shows inconsistent results. Meanwhile, molnupiravir shows consistent results, which can reduce hospitalization and mortality risk. In addition, remdesivir and nirmatrelvir-ritonavir have the potential to prevent the progression of COVID-19 in outpatients, but the data provided in this study are very limited. Finally, there is no significant difference in serious and non-serious adverse events, highlighting that antivirals have a good safety profile. Conclusion: This study provides an overview of the role of various antivirals therapy in COVID-19 outpatients. Molnupiravir, remdesivir, and nirmatrelvir-ritonavir have shown potential to prevent the progression of COVID-19 in early disease. However, this review was based on very limited data. Therefore, further clinical trials are needed to confirm this finding
The Profile of COVID-19 in Patients with Autoimmune Disease: A Case Series
Get PDFAutoimmune diseases are known to be a risk factor for severe COVID-19 infection. This is the first case series of patients with autoimmune disease suffering from COVID-19 infection in Jakarta, Indonesia. There were 12 confirmed cases of COVID-19 infection in autoimmune patients from March 2020 until February 2021. We select 5 patients in this case series. Three of them had systemic lupus erythematous (SLE), one of them had rheumatoid arthritis, and one of them had ankylosing spondylitis. Three of them had high BSR Risk Stratification. Most of them had used daily steroid therapy. Fatigue, abdominal pain, diarrhea, and cough were the common symptoms found. None of the patients were admitted to ICU, used mechanical ventilators, and all of them survived. Most of the patients were prescribed anti-coagulant therapy. This first comprehensive case series can provide valuable information regarding the clinical characteristics of COVID-19 infection in the Indonesian autoimmune disorder patient population
Raising Awareness of Acute Kidney Injury: Unfolding the Truth
Get PDFAKI is rarely being recognized as it may take place without any apparent symptoms. Severe AKI is commonly found in intensive care unit (ICU) patients. AKI in the ICU is an independent risk factor for death, as it may cause systemic effects on other vital organs including the lung, heart, liver, brain and immune system. Some studies have reported that AKI increases susceptibility to infection, doubles the rate of respiratory failure and impairs cardiac function. Considering the substantial impacts of AKI in ICU patients, early implementation of preventive measures should be an essential program which consists of developing AKI risk stratification in the ICU and encouraging the use of novel AKI biomarkers (TIMP-2, IGFBP-7, Cystatin C, IL-18, KIM-1 and NGAL) as well as other risk stratification tools (clinical risk prediction scores, computer algorithms, furosemide stress test). Furthermore, after ICU patients have recovered, AKI survivors are more likely to develop chronic kidney disease (CKD) and end-stage kidney disease (ESKD), imposing significant morbidity in the future. Recent study has shown that nephrologist intervention was associated with lower risk of starting KRT and progression of AKI. The coronavirus disease 2019 (COVID-19) pandemic has caused more than 800,000 deaths worldwide. Kidney involvement in patients with COVID-19 may present as proteinuria or hematuria and may lead to acute kidney injury (AKI). Some initial reports showed that the incidence of AKI in COVID cases was negligible. However, later reports suggested that AKI is actually prevalent in patients with COVID-19, particularly in ICU patients. AKI is now considered as a common complication of COVID-19 and it is also associated with adverse outcomes, including development or worsening of comorbidities, yet little is known about the pathogenesis or optimal management of COVID-19-associated AKI
Pontine Infarct as Initial Presentation of Catastrophic Antiphospholipid Syndrome in Systemic Lupus Erythematous
Get PDFAntiphospholipid syndrome (APLS) is an autoimmune condition which commonly manifests as an arterial or venous thrombosis affecting medium to large vessels, with the presence of antiphospholipid antibodies. APLS can be a primary disease by itself, or secondary to other autoimmune diseases, such as Systemic Lupus Erythematosus (SLE). Catastrophic APLS is a rare but a fatal sequelae of APLS, affecting up to three or more organs, and progresses rapidly with a high mortality rate. We report a case of catastrophic APLS in a young woman with underlying SLE who presented to us with multiple cranial nerve palsies due to bilateral pontine infarct, and eventually developed deep vein thrombosis and pulmonary embolism during the course of the illness. She was treated with high dose corticosteroids and intravenous cyclophosphamide with biochemical improvement. In this case report, we would like to highlight the fact that our patient had bilateral pontine infarcts as the initial presentation, with no inciting events and antiphospholipid antibodies were negative during the acute illness
Palliative Prognostic Index Validation in Hospitalized Advanced Cancer Patients in Indonesia Tertiary Hospitals
Get PDFBackground: Accurate prediction of survival is important for advanced cancer patients to determine medical interventions plan the patient’s lives and prepare for their death. The palliative prognostic index (PPI) is most popular scores used worldwide to predict life expectancy in advanced cancer palliative patients. The purpose of this study was to test validity and the performance of PPI in Cipto Mangunkusumo Hospital as a Tertiary Referral Nasional Hospital. Methods: This retrospective cohort study, uses total subject during study with consecutive sampling. Palliative prognostic index was assessed by a palliative care team (PCT). Demographic data were summarized as n (%) and Chi square for categorical variables and median or mean for continuous variables. Overall survival was calculated using the Kaplan-Meier method with hazard ratios. The performance of PPI analyzed using SPSS version 20.0, includes for Receiving Operator Characteristics (ROC) and Hosmer-Lemeshow calibration test. Results: 160 patients were included in the PPI study. The subjects have an average age of 50.08 years and are mostly women 68.10%. 28 (17.50%) had symptoms of dyspnoea, 22 (14.60%) pneumonia, and 19 (11.90%) had pain. The number of patients who died during hospitalisation was 83 (51.90%). PPI sum score >6 109 (68,10%). Calibration performance PPI score reached x2 = 8.915 (p = 0.259), and showed correlation r 0.799 (p 0.000). The accuracy of PPI scores in predicting survival in advanced cancer patients in studies for survival <3 weeks 81%, with a sensitivity of 85%, specificity 70%, PPV 86%, and NPV 67%. Predictive accuracy of survival within 3-6 weeks had 76%, sensitivity 66%, specificity 88%, PPV 85% and NPV 70%. PPI score discrimination performance is had a AUC value of 0.822 (95% CI 0.749-0.895). Conclusion: Palliative Prognostic Index (PPI ) is valid and has good performance in predicting the survival of advanced cancer patients and may be used to help clinicians in palliative care consultation
Extrapulmonary Manifestations COVID-19
Get PDFAfter being declared as a pandemic on March 11, 2020 by the World Health Organization, COVID-19 has affected 497 million people worldwide as of 9 April 2022. COVID-19 is a disease with a plethora of clinical manifestations, which extends to those beyond pulmonary signs and symptoms. Studies that report on the clinical presentation of COVID-19 rarely report specifically on cases with only extrapulmonary manifestations of COVID-19. Extrapulmonary clinical presentations of COVID-19 without pulmonary signs and symptoms is rare, and in such cases, COVID-19 is rarely suspected.We herewith describe four patients with extrapulmonary manifestations of COVID-19, with positive SARS-COV-2 PCR when the test was performed for initial patient screening. The first patient is a 44-year-old female who developed painful ulcer with burning sensation at the lateral side of the tongue along with low grade fever. This symptom appeared after the initial complaints of coughing and nasal congestion subsided. The second patient is a 37-year-old male, who complained of red eyes with itchiness and increased tear production for 3 days before seeing an ophthalmologist. The third patient is a 44-year-old female who developed burning sensation and soreness on her throat upon swallowing with fever and chills. These symptoms appear consecutively without any respiratory complaint. The fourth patient is a previously healthy, 30-year-old female, with a normal weight and BMI, and without any comorbidity, cardiovascular risk and neither personal nor family history of cardiovascular disease. In these 4 patients, COVID-19 stomatitis, conjunctivitis, pharyngitis and COVID-19-associated atrial fibrillation was subsequently diagnosed, respectively.In the pandemic stage of COVID-19, COVID-19 screening has often been routinely performed due to the high risk of transmission. However, the decrease in the number of COVID-19 cases may prompt physicians to perform SARS-COV-2 testing based on clinical suspicion. It is imperative to consider the likelihood of COVID-19 and perform SARS-COV-2 PCR in patients with extrapulmonary complaints that have persisting complaints despite treatment
Risk Factors for Temporary Vascular Access Infection in Patients with End-Stage Renal Disease Undergoing Hemodialysis in Cipto Mangunkusumo Hospital
Get PDFBackground: Temporary vascular access is used to provide adequate hemodialysis for patients who are initiating dialysis or are awaiting maturation of a more permanent vascular access. However, infection is one of the most frequent complications of using temporary vascular access and is the second leading cause of death in patients undergoing hemodialysis after cardiovascular events. There has been no research on the risk factors for the incidence of infection in patients using temporary vascular access in Indonesia. Methods: This is a retrospective cohort study utilizing secondary data from medical records of 318 subjects aged 18 years and older with end-stage renal disease and undergoing hemodialysis using temporary vascular access at Cipto Mangunkusumo Hospital. Results: Temporary vascular access infection was found in 125 of 318 subjects (39.3%). The risk factors of temporary vascular catheter infection in the multivariate analysis were females (OR 1.731; 95% CI 1.050-2.854; p=0.032), low hemoglobin levels (OR 2.293; 95% CI 1.353-3.885; p=0.002), presence of diabetes mellitus (OR 2.962; 95% CI 1.704-5.149; p<0.001) and duration of catheter insertion (OR 5.322; 95% CI 1.871-15-135; p=0.002). The association between ferritin and catheter insertion site was not analyzed as a risk factor because it was not performed in all subjects. Conclusion: The incidence of infection in patients with end -stage renal disease undergoing hemodialysis using temporary vascular access at Cipto Mangunkusumo Hospital was 39.3%. Female gender, low hemoglobin level, diabetes mellitus, and duration of catheter insertion were risk factors for temporary vascular access infection
Growth Differentiation Factor-15 (GDF-15) as a Predictor of Major Adverse Cardiac Event in Acute Myocardial Infarction Patients
Get PDFBackground: Growth Differentiation Factor-15 (GDF-15) has emerged as a biomarker that capable to predicting cardiovascular events. Recent studies suggest that GDF-15 is elevated in patients with acute myocardial infarction (AMI), but the prognostic remains incompletely defined. This study aimed to investigate the role of GDF-15 levels with major cardiac adverse events (MACE) on three months follow up in patients with AMI. Methods: This cohort study was conducted from November 2020 until May 2021 at Dr. Moewardi Hospital. GDF-15 was measured at admission, clinical data was collected and 3 months follow up events was registered. Prognostic value of GDF-15 and hazard ratio between high and low GDF-15 level were analyzed. Results: A total of 64 AMI patients were included in this study. MACE at three months follow-up occurred in 26.5% of patients. In multivariate analysis, GDF-15 was independently associated with risk of MACE at 3 months follow up (OR 1.501; p = 0.003). The cut-off point value of GDF-15 was analyzed with the ROC curve, obtained 2256 pg/mL which has a sensitivity of 94.1% and a specificity of 73.8% (area under the curve (AUC) 86.2%; 95% CI 0.768-0.956). Risk model with Kapplan Meier showed significant association between high GDF-15 levels (≥ 2256 pg/mL) and the incidence of MACE at 3 months follow up (HR 12.029; 95% CI 3.429- 42.197; p <0.001) Conclusion: In patients with AMI, high level of GDF-15 was significantly associated with the risk of MACE at 3 months of observation