Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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The Impact of Frailty on 30-day Post-Elective Surgery Complications in Elderly Patients: a Prospective Cohort Study
Get PDFBackground: late-life surgery poses a greater risk for complications and a higher mortality rate. Frailty has been noted to predict adverse outcomes after surgery in elderly patients. We aimed to investigate the impact of frailty on 30-day post-elective surgery complications in elderly patients. Methods: this prospective cohort study was conducted based on data collected from patients undergoing elective surgery in Cipto Mangunkusumo Hospital, Indonesia. Frailty was assessed using the Frailty Index 40 items, and 30-day post-surgery complications were assessed using Clavien-Dindo classification. Multivariate logistic regression analysis was performed to determined adjusted relative risk (RR) of the development of 30-day post-surgery complications. Results: a total of 180 subjects were enrolled in the study, with average age of 67.1 (SD 6.06) years old. More than half of the subjects fell into pre-frail category (55.6%), followed by frail (26.7%) and fit (17.7%) respectively. About 21.1% experienced complications within 30 days post-surgery. Frail subjects (41.7%) showed higher incidence of complications compared to the pre-frail (15%) and fit (9.4%) group. Multivariate analysis revealed that adjusted RR in the frail group accounted for 4.58 (95% CI 1.8-8.12), considering the surgical severity as a confounding factor. No significant difference in the incidence of complications was observed between the pre-frail and fit groups, despite the pre-frail group having a higher complication rate. Conclusion:being frail increases the risk of 30-day post-elective surgery complications in elderly patients.
Autologous Bone Marrow Transplant in Multiple Myeloma Patient With Bone Marrow Hematopoietic Stem Cell
Get PDFMultiple myeloma (MM) is a malignancy with multiple complications such as recurrent bacterial infections, anemia, osteolytic lesions, bone marrow failure and decreased kidney function. In developed transplant center, the bone marrow transplant procedure is performed by the source of peripheral blood stem cells. Apheresis machine which is not always available in all Haematology and Oncology Centre in Indonesia, is required for harvesting stem cell from PBSC (peripheral blood stem cell). There are only a few reports on marrow-derived stem cells transplant from BM with a 24-hour storage in multiple myeloma cases. We report two cases with non-secretory myeloma stage III and IgG myeloma stage II (International Staging System). Both patients were treated with induction regimens CyBord until a complete remission. Once remission was achieved, an autologous bone marrow transplant procedures were performed. The source of haematopietic stem cells (HSCs) were harvested from bone marrow and stored for 24 hours at a temperature of 4◦ C. The complications were neutropenia, anemia, thrombocytopenia, mucositis, diarrhea, hair loss, and skin darkness. The HSCs grew well on day 12 and 23. After treatment in the isolation room, the patient’s condition improved and the patients were discharged
A Case Report on Cholestatic Jaundice Secondary to Adverse Effect of Phaleria macrocarpa (Mahkota Dewa)
Get PDFDrug induced cholestatic liver injury can posed a great diagnostic difficulty as a result of its long non-exhaustive list of potential offending causes which can be either prescribed or over-the-counter medications, such as medicinal herbs and remedies. Phaleria macrocarpa, or more commonly known as the ‘God’s crown’ by the local people of South East Asia, is not listed as one of the causes. This medicinal plant extract has been increasingly used for traditional treatment for various ailments. Here, we report a case of a young man who has no known medical illness presented with cholestatic pattern of liver injury which caused by chronic ingestion of Phaleria macrocarpa. The objective of this case report is to share the uncommon side effect of taking this traditional product which may have been under-reported due to the unknown effect
Effect of Oral N-Acetylcysteine Supplementation on the Immunity System in Patients with Acute Myocardial Infarction
Get PDFBackground: inflammation, oxidative stress, and fibrosis play important roles after an acute myocardial infarction (AMI) event. The most studied inflammatory biomarker in cardiovascular disease is C-reactive protein (CRP). It has been demonstrated that myeloperoxidase (MPO) and Galectin-3 (Gal-3) have some essential roles on immune system when an AMI event occurs. We aimed to determine the effect of oral N-acetylcysteine (NAC) supplementation at the dose of 600 mg 3 times daily for 3 consecutive days on the immune system of AMI patients. Methods: our randomized single-blinded experimental study using pre- and post-treatment evaluations was performed at Dr. Moewardi Hospital, Indonesia, from May to August 2018. Thirty-two patients with AMI and ST segment elevation (STEMI) who received fibrinolytic therapy were included. There were 17 patients received standard therapy plus 600 mg oral NAC supplementation every 8 h for 3 days and 15 patients received standard therapy, which served as the control group. High-sensitivity C-reactive protein (HsCRP), MPO, and Gal-3 levels of both groups were evaluated at admission and after 72 h receiving treatment. Results: HsCRP, MPO, and Gal-3 levels between NAC and control groups at admission were not significantly different; while intergroup differences after 72 h of NAC supplementation were significant (p values of HsCRP, MPO, and Gal-3 levels were 0.0001, 0.001, and 0.017, respectively). Furthermore, in the NAC group, HsCRP, MPO, and Gal-3 levels at 72 h after treatment were significantly different from the corresponding levels at admission (p values: 0.0001, 0.0001, and 0.0001, respectively); the control group did not show these differences. There were also significant intergroup differences between the NAC and control groups regarding HsCRP, MPO, and Gal-3 levels (p values: 0.011, 0.022, and 0.014, respectively). Conclusion: oral supplementation of 600 mg NAC every 8 h for 72 h can reduce HsCRP, MPO, and Gal-3 levels in AMI patients receiving fibrinolytic therapy. Results of our study will provide more options for supplementation therapy to improve management of IMA patients
Validity and Reliability of the Indonesian Version of Kidney Disease Quality of Life (KDQOL-36) Questionnaire in Hemodialysis Patients at Hasan Sadikin Hospital, Bandung, Indonesia
Get PDFBackground: the prevalence of chronic kidney disease (CKD) and dialysis patients is increasing every year in Indonesia. The impact of CKD and dialysis on patient quality of life (QOL) has been recognized as an important outcome measure in the management of CKD. The Kidney Disease Quality of Life (KDQOL-36) has been validated and is widely used as a measure of QOL for CKD and dialysis patients in many countries, but not in Indonesia. The aim of this study is to determine the reliabity and validity of the Indonesian version of KDQOL-36 on hemodialysis patients in Indonesia. Methods: the KDQOL-36 was translated into Indonesian language by a certified translator and then it was back-translated into English. The translated questionnaire was further reviewed by an expert panel. The final questionnaire was administered to hemodialysis patients in Hemodialysis Unit at Hasan Sadikin General Hospital. Validity was measured using Pearson’s correlation between the kidney disease-targeted scores, generic dimensions (SF-12) scores and each scale score in KDQOL-36. The internal consistensy was assessed using Cronbach’s Alpha and reliability was examined using test-retest. Results: out of 103 patients, we found that most subjects were male (52.4%) with median age of 51 (22-75) years. The duration of hemodialysis was 3.4 (SD 2.1) years. The validity test showed a significant correlation (p<0.001) on kidney disease-targeted total score, SF-12 and each score of the scale within it. All of the KDQOL-36 scales showed good test-retest reliability. Internal consistency reliability values were acceptable, with Cronbach’s Alpha >0,7 for all scales. Conclusion: the Indonesian version of the KDQOL-36 questionnaire is valid and reliable for evaluating QOL in reguler hemodialysis patients
Renal Tuberculosis: The Masquerader
Get PDFTuberculosis (TB) remains a worldwide scourge and the most common cause of mortality from infectious disease. Around 95% of cases occur in developing country. Renal TB is a rare cases that complicates 3-4% of pulmonary TB patients and commonly overlooked in clinical practice due to its symptoms may mimic other diseases.A-39-year-old man was admitted to our institution due to flank pain. He had history of low grade fever and oligouria since 5 months prior. He had no complaint of cough, dyspnea, or night sweat. He was a non smoker and had no past medical history of tuberculosis. Previous 4 months abdominal ultrasound showed left pelvocaliectasis and ureteral dilatation with suspicion of left ureteral stenosis. Ureterolithiasis could not be excluded. No prostate enlargement or vesicolithiasis was seen. Intravenous pyelography (IVP) examination demonstrated similar finding. Initial laboratory blood examination showed anemia (10.7 g/dl), leukocytosis (14,080/ul), increased in serum creatinin (4.2 mg/dl), ureum (227 mg/dl), and calcium (6.78 mg/dl). Serology examinations were negative for HIV, HBsAg, anti HCV and blood culture had no growth. Urinary examination revealed severe leucocyturia, hematuria, and negative for bacteria, nitrite and cast. Urine culture was positive for Candida glabrata. Pulmonary X-ray suggested right pleural fibrotic. He was initially diagnosed as multiple myeloma with fungal infection. Nevertheless, additional peripheral blood smear showed neither rouleaux formation nor blast. He underwent percutaneous nephrostomy and got micafungin intravenously. Instead of improving, the patient deteriorated and transferred to intensive room. We then explored the possibility of TB infection. Further examination revealed positive for Mycobacterium tuberculosis in urinary polymerase chain reaction (PCR) test. Tracheal sputum examination was positive for acid fast bacilli staining. There was low level of serum vitamin D2 (5.8 ng/ml). He got TB treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol. Unfortunately, the patient eventually succumbed
Six-month Survival of Patients with Malignant Distal Biliary Stricture Following Endoscopic Biliary Stent Procedure and Its Associated Factors
Get PDFBackground: unresectable malignant distal biliary stricture patients require endoscopic biliary stent placement procedure. The survival rate and its associated factors in Indonesia are unknown. Objectives. To identify 6-month survival of patients with malignant distal biliary stricture following endoscopic biliary stent procedure and its associated factors. Methods: a retrospective cohort study was conducted using medical records of patients with unresectable malignant distal biliary stricture, which involved caput of pancreas, ampulla of Vater or distal cholangiocarcinoma following endoscopic biliary stent procedure between June 2015 and August 2017 at Cipto Mangunkusumo National Central General Hospital. The cumulative survival was defined by using the Kaplan-Meier curve. Bivariate and multivariate analyses were performed using Cox regression of some factors including failure of biliary stent insertion, bleeding, sepsis, comorbidities, malnutrition, and serum albumin levels. Results: out of total 120 subjects, 85 subjects died within 6 months following the stent procedure with a proportion of 180-day survival of 24% and a median survival of 81 days (CI 95%: 56–106 days). In bivariate analysis, factors of comorbidities, sepsis, malnutrition and albumin levels ≤ 3.0 g/dL had p values of < 0.25; while the subsequent multivariate analysis showed that albumin level of ≤ 3.0 g/dL had HR of 2.73 (CI 95%: 1.48 – 5.05; p = 0.001). Conclusion: the 6-month survival following endoscopic biliary stent procedure is 24% with a median survival of 81 days. Albumin level of ≤ 3.0 g/dL has a 2.73 times greater risk for 6-month mortality rate
Hyperkalemia Associated with Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor Blockers in Chronic Kidney Disease
Get PDFInhibition of the renin-angiotensin-aldosterone system (RAAS) is a key strategy in treating hypertension in cardiovascular and renal diseases. However, RAAS inhibitors (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists, and direct renin inhibitors) increase the risk of hyperkalemia (serum potassium >5.5 mmol/L). This poses a therapeutic challenge because these patient groups comprise in whom the drugs are therapeutically indicated. Important considerations when initiating ACEI or ARB therapy include obtaining an estimate of glomerular filtration rate and a baseline serum potassium concentration, as well as assessing whether the patient has excessive potassium intake from diet, supplements, or drugs that can also increase serum potassium. Serum potassium monitoring shortly after initiation of therapy can assist in preventing hyperkalemia. If hyperkalemia does develop, prompt recognition of cardiac dysrhythmias and effective treatment to antagonize the cardiac effects of potassium, redistribute potassium into cells, and remove excess potassium from the body is important. Understanding the mechanism of action and monitoring of ACEI and ARB coupled with judicious drug use and clinical vigilance can minimize the risk to the patient of developing hyperkalemia
Palliative Management of Advanced Pancreatic Cancer: The Role of Gastroentero-hepatologist
Get PDFPancreatic cancer commonly diagnosed at late stage due to subtle clinical manifestation and associated with low 5-year survival rate. Only 10-20% of patients were found in resectable or localized stage. Several complications may arise due to advanced pancreatic cancer such as obstructive jaundice, gastric outlet obstruction, pancreatic cancer cachexia, pruritus of cholestasis, and cancer pain. Palliative management should be optimized in order to improve patient’s quality of life. A gastroentero-hepatologist should collaborate with other specialties to give comprehensive palliative care for advanced pancreatic cancer patients
Clinical Profile of Elderly Patients with COVID-19 hospitalised in Indonesia’s National General Hospital
Get PDFLatar BelakangSebanyak 38.6% kasus kematian pasien COVID-19 di Indonesia terjadi di populasi lansia. Data mengenai profil klinis pasien rawat inap lansia dengan COVID-19 masih tidak ada. Padahal kelompok pasien ini adalah pasien risiko tinggi selama pandemi ini yang memerlukan perhatian lebih.MetodeStudi deskriptif ini menggunakan data lengkap pasien lansia dengan COVID-19 yang dirawat inap di Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo (RSUPN Cipto Mangunkusumo) dari April hingga akhir Agustus 2020. Data termasuk karakteristik klinis, gejala, komorbiditas, multimorbiditas dan luaran mortalitas pasien.HasilDi populasi pasien lansia (n=44), mayoritas berusia di antara 60-69 tahun (68%), berjenis kelamin laki-laki (66%), dan tidak memiliki riwayat kontak erat dengan pasien COVID-19 sebelumnya (86%). Gejala tersering ialah demam, batuk, dan sesak yang merupakan gejala khas COVID-19, sedangkan penyakit kronis tersering adalah diabetes melitus, hipertensi, dan keganasan. Multimorbiditas ditemukan hanya di 14% pasien lansia, dan para pasien tersebut bertahan hidup pasca infeksi virus SARS-CoV-2. Angka kematian pasien lansia rawat inap dengan COVID-19 di studi ini adalah 23%, dan 90% dari kasus kematian berjenis kelamin laki-laki.KesimpulanPasien laki-laki mendominasi kasus terkonfirmasi dan kasus kematian lansia dengan COVID-19. Gejala khas COVID-19 hanya ditemukan di sekitar setengah pasien penelitian. Pasien yang meninggal dunia memiliki persentase gejala khas lebih tinggi. Gejala tidak khas pun mungkin ditemukan di pasien lansia. Immunosenescence dan fungsi imunoregulasi jenis kelamin tertentu dihipotesiskan memiliki peran penting dalam menyebabkan kematian lansia di studi ini.Kata Kunci: Profil Klinis, Lansia, Pasien Geriatri, COVID-19, Indonesia ABSTRACTBackgroundOlder people contributed to 38.6% of death cases related to COVID-19 in Indonesia. Data regarding clinical profile of hospitalised elderly with COVID-19 in Indonesia were still lacking. Older people are at-risk population in the pandemic, whom we should pay attention to.MethodsThis single centre descriptive study utilised complete data of elderly inpatients with COVID-19 in Indonesia’s national general hospital from April to late August 2020. The data consisted of clinical characteristics, symptoms, comorbidities, multimorbidity, and mortality outcome.ResultsAmong elderly patients (n=44), a majority of patients were aged 60-69 years (68%), were male (66%), and had no history of close contact with COVID-19 patient (86%). The most common symptoms were fever, cough and shortness of breath (classic symptoms of COVID-19), whereas the most common chronic diseases were diabetes mellitus, hypertension, and malignancy. Multimorbidity was only found in 14% of patients, all of whom remained alive following SARS-CoV-2 infection. The death rate among elderly inpatients with COVID-19 in this study was 23%, and male older adults contributed to 90% of death cases.ConclusionMale patients dominated both confirmed cases and death cases among elderly with COVID-19. Classic symptoms of COVID-19 were only found in about half of the study patients. Non-survivors had higher percentage of the classic symptoms of COVID-19 than survivors. Atypical COVID-19 presentations are possible in older adults. We postulated that immunosenescence and sex-specific immunoregulatory function play an important role in causing death in this study cohort. Keywords: Clinical Profile, Elderly, Geriatric Patient, COVID-19, Indonesi