Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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Acute Limb Ischemia due to Arterial Thrombosis in a Patient with COVID-19 Pneumonia: A Case Report
Get PDFThe COVID-19 pandemic has caused more than 4 million deaths worldwide to date. During the course of the COVID-19 pandemic, thrombotic complications due to hypercoagulable state have emerged as an important issue. Acute limb ischemia is one of emergency cases in vascular disease caused by a sudden decrease in arterial limbs perfusion. Here, we report a 53-year-old male patient with severe COVID-19 and a history of uncontrolled type 2 diabetes mellitus (T2DM) who developed extensive arterial thrombosis and limb ischemia despite being on therapeutic-dose anticoagulation, requiring surgical intervention. Right and left leg open thrombectomy was performed at day 7 after admission due to the excruciating pain and the worsening of the limb conditions. The patient was transferred to intensive care unit in emergency room because of the unstable hemodynamic and passed away a few hours after the surgery. For critically ill patients with COVID-19, special attention should be paid to abnormal coagulation dysfunction and microcirculatory disorders
Urease, Gastric Bacteria and Gastritis
Get PDFUrease is an enzyme produced by diverse bacterial species including normal flora, non pathogens, and pathogens such as Proteus mirabilis, Staphylococcus saprophyticus, Klebsiella pneumonia, Citrobacter freundii, Enterobacter cloacae Helicobacter spp and Helicobacter pylori. Urease is central in Helicobacter pylori metabolism and virulence, important for colonization in the gastric mucosa. Urease catalyzes the hydrolysis of urea to ammonia and carbamate. This ammonia product can be examined by Urease biopsy test and Urea breath test such as 14C-Urea Breath Test or 13C-Urea Breath Test.Previously, the Urea breath test was intended to detect an increase in ammonia which is a urease product in the gastric mucosa produced by pathogenic gastric bacteria, such as Helicobacter pylori, etc.Acute and chronic gastritis caused by infection with these pathogenic bacteria infection turned out to be positive on Urea breath test. Indirectly, the results of the urea breath test are also related to the presence of inflammation in acute and chronic gastritis, regardless of whether the cause is Helicobacter pylori or other urease-producing pathogenic bacteria.The use of the urea breath test indirectly in diagnosing acute and chronic gastritis should be studied further. The use of the urea breath test is indeed very important to assist health services in countries and regions with limited endoscopic facilities, especially developing countries.We know that the prevalence of Helicobacter pylori infection in causing acute and chronic gastritis by examination of Urea breath test in Indonesia is not too high, ranging from 2-11.2%. So that is why more studies on non-Helicobacter pylori producing urease pathogens are needed, which can appear as a false positive urea breath test
Clinical Application of Stem Cell Therapy for Liver Cirrhosis: Progress, Pitfalls, and Prospects
Get PDFLiver cirrhosis is the advanced stage of liver disease accounting for high morbidity and mortality rates worldwide. Liver transplantation for liver cirrhosis has several limitations, rendering stem cell transplantation as a potential therapy. Clinical trials of stem cell applications for liver cirrhosis are being established using various types of stem cells. This review will provide a current report of the achievements, limitations, and future directions of stem cell transplantation. Current progress of clinical trials is valuable in defining the best type of stem cells, mode of delivery, the number and frequency of cells to be injected, and determining potential candidates for cell therapy. Some of the encountered pitfalls are the limited homing and differentiation potential of stem cells, the use of non-xenofree culture system, and the risk for tumorigenesis in certain types of stem cells. The prospective developments of liver stem cell transplantation are the generation of genetically modified stem cells and the formation of liver organoids for treating liver cirrhosis
The Association Between Uric Acid and Symmetric Dimethylarginine Levels in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis
Get PDFBackground: Uric acid (UA) levels are associated with increased risk of cardiovascular events and mortality in hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients. In a study with a population of healthy young adults and HD there was a correlation between high blood uric acid levels and blood symmetric dimethylarginine (SDMA) level. However, in CAPD population, there are still conflicting data on the mechanism of increased risks related to uric acid levels. This study aimed to assess the association between uric acid levels and SDMA in the subjects undergoing CAPD. Methods: This was a cross – sectional study conducted in all the adults who underwent CAPD for at least three months in tertiary hospital in Jakarta, Indonesia. Subjects already on uric lowering therapy, pregnant or lactating women, and those with a history of malignancy were excluded. Uric acid and SDMA level were measured at the same time patients controlled to outpatient clinic. Bivariate analysis was performed using the Mann – Whitney test and multivariate analysis performed using logistic regression test. Results: A total of 55 subjects were included. The median level of UA was 7.30 + 1.59 mg/dl and 33 subjects (60%) had UA levels of 7 mg/dl or higher. The median SDMA level was 633.73 + 231.54 ng/mL. Subjects with UA levels > 7 mg/dl had significantly higher SDMA levels compared to subjects with UA levels < 7 mg/dl (721.58 + 220.57 vs 501.95 + 182; P < 0.001). The cut – off value of SDMA 536 ng/mL was obtained from the receiver operating characteristic (ROC) curve with sensitivity 81.8%, specificity 63.6%, PPV 77.78% and NPV 73.68%. After fully adjusted with the confounders, the determinant factors in this study were diabetes mellitus (OR: 7.844; CI95%: 1.899 – 32.395: P value: 0.004) and dyslipidemia (OR: 6.440; CI95%: 1.483 – 27.970; P value: 0.013) as risk factors. Conclusion: In CAPD patients, UA levels above 7 mg/dl were associated with increased SDMA levels. This study demonstrates the determinant factors regarding association between UA level and SDMA in CAPD patients were diabetes mellitus and dyslipidemia. The cut – off value of SDMA above 536 ng/mL were significant to increased risk of cardiovascular events
Hemoperfusion as an Adjuvant Therapy in Maintenance Hemodialysis Patients with Severe COVID-19: A Single Centre Experience
Get PDFMortality rate among maintenance hemodialysis (HD) patients with COVID-19 is alarmingly high. In Fatmawati General Hospital, most of HD patients with COVID-19 presented with acute respiratory distress syndrome (ARDS). Hemoperfusion (HP) is a blood purification therapy used to remove cytokines and inflammatory mediators to prevent ARDS worsening and organ failure. We report 6 cases of COVID-19 in maintenance HD patients. HP and HD were performed in two consecutive days when patient developed early ARDS as indicated by inflammatory markers elevation. HP and HD were conducted by using resin-containing cartridge and high-flux dialyzer, respectively, for 4 hours. Improvements in CRP levels, PaO2/FiO2 ratios, and chest X-rays were observed after 2 sessions of HP in most of our patients. Based on our clinical experience, the timing of HP delivery is critical and should be undertaken in the early phase of ARDS, but larger studies are still needed
Colonoscopy, Biomarkers, and Targeted Therapy in Colorectal Cancer
Get PDFThis review highlights the most versatile diagnostic test of colonoscopy for CRC. It remains the gold standard diagnostic tools for CRC, and to prevent CRC by screening and removing the polyp or premalignant lesions. This work also provides the most promising biomarkers, which highlights the application of the novel biomarkers in conjunction with clinical and pathologic features have allowed for more individualized approaches and targeted therapy to patients with CRC.CRC is the third most common cancer diagnosed, and the second leading cause of cancer-related deaths worldwide. With a population totaling 273,523,621 people, Indonesia has an estimated of 396,914 new cases of all cancers and 234,511 cancer-related deaths. Among those cancer cases, an estimated of 34,189 new CRC cases and 17,786 CRC deaths occurred in 2020. Most of CRC cases were located in the rectum compared to those in the distal colon or proximal colon. Clinical signs, symptoms and therapeutic approaches vary, depending on the stage and the location of CRC. Those cancer locations are different in terms of their associated molecular alterations.Biomarker tests of tumor tissue from colonoscopy biopsy can help doctors to select a specific CRC treatment, and the tests can be used to determine prognostic value, predictive factors and the targeted therapy. Targeted therapies are recommended for advanced or mCRC patients with KRAS/NRAS/BRAF mutated or wild-type tumors, HER2-amplified tumors, and NTRK gene fusion-positive, while immunotherapy is only offered for tumor with MSI-High (dMMR) status. The biomarkers and targeting approaches against colorectal CSCs are being developed and will be quite challenging
How to Diagnose, Treat, and Monitor Treatment Response in Patients with Multiple Myeloma
Get PDFMultiple myeloma (MM) is a B-cell malignancy characterized by clonal proliferation of malignant plasma cells in the bone marrow, monoclonal protein production in the serum, and organ dysfunction. It is part of a disease spectrum called plasma cell disorders, and to establish the diagnosis, a bone marrow biopsy should be conducted with clinical signs of end-organ damage and/or significantly elevated monoclonal protein (M-protein). MM can also be diagnosed without end-organ damage when certain conditions are met since the International Myeloma Working Group (IMWG) has come up with new diagnostic criteria for multiple myeloma.Treatment for all patients with MM aims to enhance the depth and duration of response while limiting drug toxicity to lengthen survival, improve quality of life, alleviate symptoms and prevent further organ damage. Development of new drugs has improved the survival of patients4 Available tests for monitoring of patients with MM most often include assessments of monoclonal paraprotein and serum-free light chain levels with bone marrow examination, which directly identifies the level of malignant plasma cells
Aquaretics Use in Acute Decompensated Heart Failure (ADHF) Patients: A Literature Review
Get PDFThis is a literature review of the use of aquaretic in patients with acute decompensated heart failure (ADHF), including the physiologic function of vasopressin and its mechanism of action in heart failure patients, and aquaretic drugs with their respective risks and benefits.Vasopressin is one of several hormones that can cause hyponatremia and worsen congestion in ADHF patients. Aquaretics are a class of drugs that have an antagonistic effect on vasopressin receptors, especially V2R. Aquaretics use in ADHF patients can provide relief for congestive symptoms with no serious adverse effects. In-depth additional understanding regarding aquaretics may be useful for clinical judgments in treating ADHF patients
Similar Blood Glucose Pattern with Highest Peak at Minute 45 on Oral Glucose Tolerance Test Despite Higher Fasting Insulin and Insulin Resistance in Healthy Obese than Non-Obese Subject
Get PDFBackground: Obesity increase the risk for type 2 diabetes through induction of insulin resistance. Diagnosis of diabetes were based on blood glucose level. However, insulin resistance may had happened far before diagnosis itself. This study aimed to compare fasting insulin level, insulin resistance, and blood glucose pattern during oral glucose load in healthy obese and non-obese subject. Methods: This semi-experimental study was conducted at Department of Internal Medicine, Sanglah Hospital, Denpasar. Sixteen subjects in each obese and non-obese group were matched by age and sex. Obesity was defined based on body mass index (BMI) of ≥25kg/m2 and waist circumference (WC) ≥80cm (female) or ≥90cm (male). The non-obese group was defined by BMI of 18-25kg/m2 and WC <80cm (female) or <90cm (male). Fasting insulin level and blood glucose was measured at minute 0, 15, 30, 45, 60, 75, 90, 120 after glucose load of 75 grams. Insulin resistance was calculated based on homeostasis model assessment of insulin resistance (HOMA-IR) with the following formula: HOMA-IR = (FPI×FPG)/22.5. Normal glucose tolerance (NGT) and impaired glucose tolerance (IGT) subject was defined by American Diabetes Association (ADA) criteria. Results: Fasting insulin level in obese subjects was higher than non-obese subjects with median 12.75 (range 3.70 – 41.30) vs 3.80 (1.80 – 36.80) µU/mL, p=0.041. HOMA IR was also higher in obese subjects compared to non-obese subjects: 2.45 (0.70 – 8.00) vs 0.80 (0.40 – 8.50), p=0.001. Fasting insulin level was correlated with BMI (r=0.559, p=0.001) and WC (r=0.633, p<0.001). A significant correlation was also detected between HOMA IR with BMI (r=0.528, p=0.002) and WC (r=0.600, p<0.001). Blood glucose pattern in four groups: obese IGT, obese NGT, non-obese IGT, and non-obese NGT, were typically similar, in particular two peaks of blood glucose. The first peak was the highest blood glucose, shown in minute 45 in both obese and non-obese subjects. The second peak was lower than the first peak, found in minute 75 among NGT and minute 90 among IGT subject. Blood glucose level for each measurement point was consistently higher in obese than non-obese subjects. Conclusion: Fasting insulin level and HOMA-IR were higher in obese than in non-obese subjects. BMI and WC were significantly correlated with fasting insulin level and HOMA IR, so that high BMI and WC can be an earlier clinical sign of insulin resistance and prediabetes. Pattern of blood glucose level after oral glucose load were similar with two peaks, and blood glucose consistently higher in obese compared to non-obese subjects. The highest peak of blood glucose, shown in minute 45 in both obese and non-obese subjects
Atrial Failure: What Do We Know About It?
Get PDFHeart failure is the end of all pathological conditions in the heart. Most accepted paradigms in heart failure are always preceded by left ventricle disfunction. Currently, there are several clinical studies that show that heart failure may occur without prior left ventricular dysfunction. Left atrial dysfunction may play a more important role in heart failure than previously expected. Failure of the left atrium can exist independently of left ventricle dysfunction and mitral valve abnormalities. Atrial failure, just like left ventricular failure, can lead to global heart failure. Etiology, pathomechanism and clinical symptoms of atrial failure are complex and not well understood. This review will explain atrial failure