Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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Association between A1166C Polymorphism of the Angiotensin II Type-1 Receptor Gene and Type-2 Diabetic Nephropathy in an Indonesian Malay Population
Get PDFBackground: diabetic nephropathy (DN) is the leading cause of blood dialysis worldwide and a major etiology of End-Stage Renal Disease cases in Indonesia. Previous studies showed a relevant link between A1166C polymorphism of Angiotensin II Type-1 Receptor (AT1R) gene and glomerular hyper-filtration as a part of pathogenesis of DN. The aim of this study was to elaborate the association between A1166C AT1R polymorphism and susceptibility of individual with type-2 diabetes to DN in Malay Indonesian population. Methods: a case-control study of 120 consecutive patients with type-2 diabetes mellitus (40 patients in each groups for macro-albuminuria, micro-albuminuria, and normo-albuminuria) was conducted for A1166C AT1R gene polymorphism. The A1166C polymorphism of the AT1R gene was determined based on PCR/RFLP. Results: the mutant C allele was found in 5%, 13.75%, and 12.5% in normo-, micro-, and macro-albuminuria patients respectively. The heterozygote AC genotype was found significantly higher in micro-albuminuria, compared to normo-albuminuria group. Heterozygote AC genotype (OR 3.2 [1.01-10.08], p=0.03) and C allele (OR 2.8[0.95-8.67], p=0.038) were significantly higher in DN, indicating A1166C AT1R gene polymorphism as a risk factor for DN in Malay Indonesian population with type-2 diabetes. Conclusion: there was positive association between A1166C AT1R polymorphism and susceptibility of type-2 diabetics to DN in Malay Indonesian Population. It also indicated that the A1166C AT1R polymorphism could play a role in early pathogenesis of DN
Diagnostic Approach for Thyroid Nodules
Get PDFThyroid nodule is a health problem which commonly found in daily practice, therefore clinical guidance is needed. This guideline was compiled by a multidisciplinary team and expected to be a guideline in diagnosing thyroid nodules on daily clinical practice
Blood Pressure Profile of Young Adults at the Faculty of Medicine Universitas Indonesia
Get PDFBackground: hypertension remains a global burden. Complications of unrecognized hypertension might increase mortality as shown by a WHO 2013 report that hypertension caused 9.4 million deaths worldwide. There is no prior data in Indonesia on blood pressure status in young adults with similar education levels. Medical students are at high risk of developing early hypertension due to modern lifestyle habits. This study aimed to determine the blood pressure profile of medical students as representative of the young adult population. Methods: we measured the prevalence of hypertension in medical students. All medical students who agreed to participate completed a questionnaire. Afterwards, we conducted a physical examination and obtained blood and urine samples to screen for blood pressure, estimated glomerular filtration rate, and the lipid profile. Results: the prevalence of students with prehypertension or hypertension was 29.6%. The mean eGFR was 105.45 ml/min/m2. The mean total cholesterol was within normal limits. Conclusion: the prevalence of hypertension in medical students was high. This study shows that early detection of hypertension is key to treating it early and therefore to reducing morbidity and mortality
The Risk of Developing Non-Alcoholic Fatty Liver Disease in Adult Patients with Subclinical Hypothyroidism Compared to Euthyroid: An Evidence-based Case Report
Get PDFBackground: hypothyroidism is a common concomitant disease of non-alcoholic fatty liver disease (NAFLD). Previous studies regarding the relationship between subclinical hypothyroidism and NAFLD showed conflicting results, ranging from a strong association to not significant one. This case report aimed to investigate the risk of developing NAFLD in subclinical hypothyroidism patients. Methods: literature searching used ScienceDirect, PubMed, ProQuest, and Scopus. Filtering process of titles and abstracts by using inclusion and exclusion criteria yielded 4 eligible articles (1 systematic review, 1 prospective cohort, 1 retrospective cohort, and 1 case-control study) for answering the clinical question. Critical appraisal was conducted by using worksheets from Centre for Evidence-Based Medicine, University of Oxford. Results: the systematic review was considered invalid due to its less comprehensive search for relevant studies, inappropriate article selection to find a causal relationship between diseases, and statistical heterogeneity. The retrospective cohort was decided unimportant because it possessed a relative risk of 0.85 (95% confidence interval [CI], 0.72--1.00) which the upper limit of its CI included 1.00. The rest were valid and had important risk relative and odds ratio (1.27 [95% CI, 1.09--1.47], 3.41 [95% CI, 1.16--9.98]; respectively). The number needed to harm (5—17) indicated the clinically meaningful harm of the exposure since only a few patients with subclinical hypothyroidism is needed to obtain one additional NAFLD incidence. Those two articles were also suitable to be applied in our case. Conclusion: patients with subclinical hypothyroidism, compared to euthyroid patients, are at higher risk of developing NAFLD
Cardiac Performance by Echocardiography, Cardiovascular Biomarker, Kidney Function, and Venous Oxygen Saturation as Mortality Predictors of Septic Shock
Get PDFBackground: cardiac function in patients with septic shock at the cellular level can be assessed by measuring troponin I and NT Pro BNP levels. Venous oxygen saturation is measured to evaluate oxygen delivery and uptake by organ tissue. Our study may provide greater knowledge and understanding on pathophysiology of cardiovascular disorder in patients with septic shock. This study aimed to evaluate the roles of echocardiography, cardiovascular biomarkers, venous oxygen saturation and renal function as predictors of mortality rate in patients with septic shock. Methods: this is a prospective cohort study in patients with infections, hypotension (MAP < 65 mmHg) and serum lactate level of > 2 mmol/L. On the first and fifth days, septic patients underwent echocardiography and blood tests. Statistical analysis used in our study included t-test or Mann-Whitney test for numeric data and chi-square test for nominal data of two-variable groups; while for multivariate analysis, we used Cox Regression model. Results: on 10 days of observation, we found 64 (58%) patients died and 47 (42%) patients survived. The mean age of patients was 48 (SD 18) years. Patients with abnormal left ventricular ejection fraction (LVEF) had 1.6 times greater risk of mortality than those with normal LVEF (RR 1.6; p = 0.034). Patients with abnormal troponin I level showed higher risk of mortality as many as 1.6 times (RR: 1.6; p = 0.004). Patients with impaired renal function had 1.5 times risk of mortality (RR 1.5; p = 0.024). Patients with abnormal troponin I level and/or impaired renal function showed increased mortality risk; however, those with normal troponin I level and impaired renal function also showed increased mortality risk. Multivariate analysis revealed that left ventricular ejection fraction and troponin I level may serve as predictors of mortality in patients with septic shock. (HR 1.99; 95% CI: 1.099 ̶ 3.956 ; p = 0.047 and HR: 1.83 ; 95%CI: 1.049 ̶ 3,215 ; p = 0.043). Conclusion: left ventricular ejection fraction and biomarkers such as troponin I level are predictors of mortality in septic shock patients
Fragmented QRS (fQRS) in Acute Coronary Syndrome: Is It a More Potential Marker Than Predicted?
Get PDFFragmented QRS (fQRS) complexes are electrocardiographic (ECG) findings which reflect impaired ventricular depolarization due to heterogeneous electrical activation of ischemic and or injured myocardium. Therefore, it had been associated with many cardiovascular diseases both ischemic and non-ischemic origin. To date, fQRS is considered a novel and convenient marker of myocardial scar or fibrosis. Thus, it has gained more interest to investigate the potential use of fQRS in cardiac disease, especially in acute coronary syndrome (ACS)
Late Diagnosis of Congenital Hypothyroidism in Young Adult
Get PDFCongenital hypothyroidism is the most treatable cause of mental retardation. It is also the most prevalent congenital endocrine disorder in childhood. A dramatic improvement can be made by early detection, diagnosis, and adequate treatment of levothyroxine in patients with congenital hypothyroidism. Severe cognitive impairment is associated with persistent disease in patients who have delayed or no treatment at all. In a modern era with complete healthcare facilities in a big city like Jakarta, the prevalence late-diagnosed congenital hypothyroidism is supposed to be very low. Since many districts have their own public healthcare facilities to screen and diagnose congenital hypothyroidism in children at very young age, a delayed diagnosis in adulthood is actually a rare case.In this medical illustration, we report a case of 21 year-old woman who came to our hospital with abdominal pain. She had mental retardation with no capability to communicate well with other person. She had a short stature (her height was less than 1 meter). She also had mongoloid face with big lips and a very big tongue. There was no goiter or lump on her neck. Her motoric performance was very weak and frail. During abdominal examination, we could see an umbilical bulging on her abdominal wall and on palpation, we could feel an umbilical hernia. By abdominal ultrasound, we could see the umbilical hernia. Unfortunately, no diagnosis of congenital hypothyroidism had been made when she was a newborn, there was also no past or known history of thyroid disease of her and her family. She had a diagnosis of mental retardation with no specific etiology since she was 5-years old. Based on the results of her laboratory examination, we had a confirmed diagnosis of primary hypothyroidism with T4 10.56 nmol/L (normal 60-120 nmol/L) and TSH > 100 mIU/mL. We provided her treatment using levothyroxine based on her body weight (25 mg daily). We arranged her to have abdominal CT Scan and digestive surgery as further management for her umbilical herniation.Some defects are correlated with congenital hypothyroidism when the disease is not treated properly and adequately. Neurocognitive, neuromotoric, growth, and development are some areas which can be disrupted by long-term hypothyroidism condition for patients who had the disease since their early years of life. Congenital hypothyroidism appears to be associated with an increased risk of congenital malformations. Several congenital malformations associated with congenital hypothyrodism are umbilical hernia, congenital heart disease, neurologic abnormalities, genitourinary malformations, cleft palate, and Down’s syndrome.Studies concluded that severity of the congenital hypothyroidism has more important role than timing of treatment initiation on long-term cognitive and motor outcomes. Detrimental effects on developmental outcomes in congenital hypothyroidism patients may persist over time; however, early treatment for patients at very early ages may bring the best cognitive outcomes and neuromotoric development.Regardless of the treatment options, we can say that it is a loss case and a very late diagnosis and treatment of congenital hypothyroidism. The unusual age of detection, delayed diagnosis and treatment are some reminders for primary care physicians in our society to pay greater attention to screening programs.6 Early detection and prompt treatment is an essential part of measures to reduce burden of mental retardation in our society. Delayed diagnosis of congenital hypothyroidism case, which is diagnosed at adulthood, indicates failure in screening program. Early diagnosis and treatment are necessary to prevent long-term catastrophic effects. This a wake-up call of attention and awareness for general public and primary care physicians in our country
The Need for a New Cut-off Value to Increase Diagnostic Performance of Bioelectrical Impedance Analysis Compared with Dual-Energy X-ray Absorptiometry to Measure Muscle Mass in Indonesian Elderly
Get PDFBackground: the use of bioelectrical impedance analysis (BIA) is affected by the population setting, the type of BIA, and the cut-off point being used. The aim of this study was to determine the diagnostic performance of BIA to measure muscle mass in Indonesian elderly outpatients aged 60 years or more. Methods: a cross-sectional study was conducted at the Geriatric Clinic of Cipto Mangunkusumo Hospital from April to June 2018. The muscle mass was measured using BIA Tanita MC-780MA (Tokyo, Japan) with dual-energy x-ray absorptiometry (DXA) as the reference test. Analysis on the cut-off point was performed based on the Asian Working Group of Sarcopenia (AWGS) criteria and the new cut-off point. Results: from 120 subjects, 74 were female (61.7%). The diagnostic performance of BIA based on AWGS criteria only showed sensitivity and specificity of 79.2% and 66.7%. The diagnostic performance of BIA based on the new cut-off point showed sensitivity and specificity of 75% and 92.7%. The new cut-off point using BIA was found to be <6.9 kg/m2 in males (sensitivity 70.6%; specificity 82.8%) and <5 kg/m2 in females (sensitivity 85.7%; specificity 97%). Conclusion: the diagnostic performance of BIA Tanita MC-780MA (Tokyo, Japan) was good to measure muscle mass in Indonesian elderly outpatients using a new cut-off point of <6.9 kg/m2 for males and <5 kg/m2 for females
Diagnostic Tools for Sarcopenia: Can We Get Less Expensive and Accurate Methods?
Get PDFSarcopenia, as defined by the European Working Group on Sarcopenia (EWGSOP) in Older People is “a progressive and generalized skeletal muscle disorder that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability, and mortality”. The first EWGSOP and Asian Working Group for Sarcopenia used muscle mass to define sarcopenia, which is diagnosed by using Dual-energy X-Ray absorptiometry (DXA). However, the cut-off from several countries in Asian showed different cut-off value for different age groups and BMI. In addition, not all hospitals and countries can afford DXA to be used as daily diagnostic routine for sarcopenia.In 2018, EWGSOP made a revision regarding sarcopenia, as well as the diagnostic test and cut-off value (EWGSOP2). EWGSOP2 recommends using self-questionnaire, known as SARC-F as sarcopenia screening, especially in community-dwelling elderly. SARC-F consisted of 5 questions regarding patient’s perception of his or her limitations in strength, walking ability, rising from a chair, stair climbing and experiences with falls. This is more feasible to be done in countries without advanced muscle mass measurement tools. Several parameters in sarcopenia are muscle strength, muscle quantity, and physical performance. In muscle strength, measuring grip strength can be done as predictor for patients’ outcomes, such as hospitalization and quality of life. For muscle quantity, the gold standards are Magnetic resonance imaging (MRI) and computed tomography (CT). However, since both are expensive, and the cut-off points have not been defined yet, DXA and Bioelectrical impedance analysis (BIA) can be a substitute. Current evidence showed that DXA still does not give consistent results and not yet portable for the use in the community. On the other hand, BIA measure muscle mass using the whole-body electrical conductivity and less expensive than the other tools, thus can be used in the community setting. However, there is no specific cut-off for BIA especially in elderly. For physical performance, several tests can be done, such as gait speed and Timed-Up and Go test (TUG)
Risk Factors for Poor Pregnancy Outcome in Systemic Lupus Erythematosus Patients
Get PDFBackground: systemic lupus erythematosus (SLE) is still a challenging autoimmune disease, especially in pregnancy setting. An early risk factors awareness of poor pregnancy outcome is important to optimize the outcome of pregnancy in SLE patients. This study was conducted to describe pregnancy outcome and determine the risk factors associated with poor pregnancy outcome in SLE patients. Methods: a retrospective case-control study of SLE patients with poor and normal pregnancy outcome was performed. Pregnancy histories were reviewed from Dr. Hasan Sadikin General Hospital lupus registry study. The case group was pregnancy with poor outcome, defined as abortion, premature birth, stillbirth, intrauterine growth restriction (IUGR) and neonatal death. The control group was pregnancy with good outcome, defined as live birth and full term. Results: a total of 84 SLE patients were enrolled in this study with 109 pregnancies after SLE diagnosis. The median age of subjects at the time of pregnancy was 28 (25-32) years old. Poor pregnancy outcome comprising 22.9% abortion, 14.7% premature birth, 5.5% stillbirth, 1.8% IUGR and 4.6% neonatal death. There was a significant difference in the number of planned pregnancy (P=0.011) between groups with poor and good outcome. Clinical variables significantly associated with poor pregnancy outcome were lupus nephritis (OR = 4.813, 95% CI 1.709 – 13.557, P = 0.003) and neuropsychiatric SLE (OR = 5.045, 95% CI 1.278 – 19.920, P = 0.021). Conclusion: the pregnancy in SLE patient should be planned to have better outcome. Lupus nephritis and neuropsychiatric (NP) SLE were risk factors for poor pregnancy outcome in SLE patient