Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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Double Culprits in a Patient with ST Elevation Myocardial Infarction: A Challenging But Rewarding Case
Get PDFMyocardial infarction simultaneously involving two or more culprit lesions is extremely rare and usually has a poor clinical outcomes including mortality. Management of this complicated condition is challenging and limited time. Nevertheless, autopsy studies revealed that thrombotic occlusion of more than one major epicardium coronary artery is not uncommon. A 68-year-old woman presented with sudden onset of limited breath and chest discomfort since two hours prior to admission. She also felt exert dyspnoea since one month ago. She has two risk factors that were uncontrolled that is hypertension (HT) and type 2 diabetes mellitus (DM). On admission, she succumbed into cardiogenic shock and pulmonary oedema. ECG revealed a diminished R wave in V2-V4 with ST elevation in V2-V5 and in aVR. Biphasic T wave was seen in V2-V6. The working diagnosis was anterior STEMI, Killip class IV with thrombolysis in Myocardial Infarction (TIMI) score of 8. While being transferred to catheter lab, she gasped, became desaturation, and was intubated prior to procedure. The patient was given double inotropes which run maximally. By Coronary angiography, there were occlusions at the LAD and LCX. Stent was applied at proximal LAD and LCX. Subsequently, patient’s condition improved and post-procedure ECG showed improvement in aVR and precordial leads, and ST elevation was significantly diminished from V5 and aVR, and R wave came back in V2-V4.Previous study found around 50% of STEMI patients had multi-vessels diseases. In this case, ECG suggested LAD region infarction with ST elevation in aVR, commonly associated with left main stenosis (LMS) involvement.Thrombus aspiration in LAD and LCX yielded hemodynamic improvement. V-stenting technique, introduced in 1996, allows delivery and implantation of 2 stents together, and therefore shorten the stent deployment time
Improving Diagnostic of Pulmonary Tuberculosis in HIV Patients by Bronchoscopy: A Cross Sectional Study
Get PDFBackground: diagnostic of pulmonary TB in HIV patients is a problem due to non specific clinical features, or radiological appearance. HIV patients with CD4≤200 cells/mL infected with M. tuberculosis have less capacity in containing M. tuberculosis, developing granulomas, casseous necrosis, or cavities. This condition is caused by weakend inflammatory which later reduced sputum production and may cause false negative result. This study aimed to assess differences in the positivity level of acid fast bacilli (AFB) and cultures of M. tuberculosis from non-bronchoscopic sputum (spontaneous and induced sputum) compared to bronchoscopic sputum (bronchoalveolar lavage) in HIV positive patients suspected pulmonary tuberculosis with CD4<200 cells/μL.Methods: this cross sectional study was conducted in adult HIV patients treated in Hasan Sadikin Hospital with CD4≤200 cells/μL suspected with pulmonary tuberculosis by using paired comparative analytic test. All patients expelled sputum spontaneously or with sputum induction on the first day. On the next day, bronchoalveolar lavage (BAL) was performed. The two samples obtained from two methods were examined by AFB examination with staining Ziehl Neelsen (ZN) and cultured of M. tuberculosis on solid media Ogawa on all patients. Positivity, sensitivity and increased sensitivity of AFB and culture of M. tuberculosis in the non bronchoscopic and bronchoscopic groups were compared.Results: there were differences in the positivity level of AFB with ZN staining between non-bronchoscopic and bronchoscopic groups which were 7/40 (17.5%) vs 20/40 (50.0%) (p<0.001). The differences between the cultures of non-bronchoscopic and bronchoscopic groups were 16/40 (40.0%) vs 23/40 (57.5%) (p=0.039). Bronchoscopic sputum increased the positivity level of the ZN AFB examination by 32.5% (from 17.5% to 50.0%) as well as on culture examination by 17.5% (from 40.0% to 57.5%).Conclusion: Bronchoalveolar lavage can improve the positivity level of smears and cultures in patients suspected of pulmonary TB in HIV patients with CD4<200 cells/μL
Evaluation of Iron Overload Between Age Groups Using Magnetic Resonance Imaging and Its Correlation with Iron Profile in Transfusion-dependent Thalassemia
Get PDFBackground: routine blood transfusion in transfusion-dependent-thalassemia (TDT) causes iron accumulation in various organ. Serum markers of iron overload, serum ferritin and transferrin saturation, are sensitive but not specific. MRI T2-star (T2*) is valuable for detecting iron level in organs. This study aimed to explore the degree of iron overload in various organs, iron deposition difference between children and adults, also its correlation with serum marker of iron overload. Methods: this was a cross-sectional study of TDT patients who had been evaluated by MRI T2* examination in Cipto Mangunkusumo Hospital from 2014 to 2018. Results: a total of 546 subjects was included in this study. The number of subjects between children and adults was almost equal. Most of subjects had normal cardiac iron deposition. The difference of cardiac iron overload between children and adults was significant (p=0.009). Liver evaluation showed that most of subjects had moderate to severe iron overload. This difference between children and adults was significant (p=0.017). Pancreas evaluation showed that either children or adults mostly had mild pancreatic iron overload. Analysis of T2* showed that pancreatic iron deposition progressed with increasing age. Serum ferritin had weak correlation with heart T2* MRI, moderate correlation with pancreas and liver T2* MRI. Relationship between transferrin saturation and T2* MRI was extremely weak. Conclusion: cardiac and hepatic iron deposition between children and adults differ significantly. Liver has the greatest iron overload, followed by pancreas and heart. Iron deposition in liver and pancreas has been started from earlier age. Pancreatic iron deposition rises with increasing age. Serum ferritin and transferrin saturation should not be used solely to predict iron overload in various organs. We suggest that MRI evaluation must be conducted at least once to assess iron deposition in organs
Meta-analysis of Optimal Management of Lower Pole Stone of 10 - 20 mm: Flexible Ureteroscopy (FURS) versus Extracorporeal Shock Wave Lithotripsy (ESWL) versus Percutaneus Nephrolithotomy (PCNL)
Get PDFBackground: the optimal management of lower calyceal stones is still controversial, because no single method is suitable for the removal of all lower calyceal stones. Minimally invasive procedures such as extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureteroscopy (fURS) are the therapeutic methods for lower calyceal stones. The aim of this study was to identify the optimal management of 10-20 mm lower pole stones. Methods: a meta-analysis of cohort studies published before July 2016 was performed from Medline and Cochrane databases. Management of 10-20 mm lower pole stone treated by fURS, ESWL and PCNL with follow-up of residual stones in 1-3 months after procedure were include and urinary stone in other location and size were excluded. A fixed-effects model with Mantzel-Haenzel method was used to calculate the pooled Risk Ratio (RRs) and 95% Confidence Interval (CIs). We assessed the heterogeneity by calculating the I2 statistic. All analyses were performed with Review manager 5.3. Results: we analized 8 cohort studies. The stone free rate from 958 patients (271 PCNL, 174 fURS and 513 ESWL), 3 months after operation, was 90.8% (246/271) after PCNL; 75.3% (131/174) after fURS; and 64.7% (332/513) after ESWL. Base on stone free rate in 10-20 mm lower pole stone following management, PCNL is better than fURS (overall RR was 1.32 (95% CI 1.13 – 1.55); p<0.001 and I2=57%) and ESWL (overall risk ratio 1.42 (95% CI 1.30 – 1.55); p=<0.001 and I2 = 85%). But, if we compare between fURS and ESWL, fURS is better than ESWL base on stone free rate in 10-20 mm lower pole stone management with overall RR 1.16 (95% CI 1.04 – 1.30; p=0.01 and I2=40%). Conclusion: percutaneus nephrolithotomy provided a higher stone free rate than fURS and ESWL. This meta-analysis may help urologist in making decision of intervention in 10-20 mm lower pole stone management
The Autoimmune Mechanism in Dengue Hemorrhagic Fever
Get PDFThe immune response of dengue fever/dengue hemorrhagic fever is a series of immunopathogenesis processes starting from viral infection to the target on monocytes and macrophages. It may consequently cause a cascade of viremia in the circulation that stimulates the afferent, efferent, and effector mechanism by the interaction of the humoral and complement system. The cascade results in inflammatory substance that will affect capillary permeability and activate coagulation factors leading to further effects on endothelial level. The mechanism involving pathogenesis of DHF/DSS is still vague. So far, a theory of heterologous infection has been developed, which explains that on second infection, there is subneutralization that induce viral replication. The autoimmune mechanism development leads to the better understanding of DHF. It also explains the autoimmune response of the viral infection, which consists of molecular mimicry, bystander activation and viral persistence. The development of the autoimmune pathomechanism is related to the role of autoantibody and endothelial dysfunction that may have role in worsening DHF
Comparison of Deferiprone to Deferasirox and Deferoxamine to Cardiac and Hepatic T2* MRI in Thalassemia Patients: Evidence-based Case Report
Get PDFBackground: there are currently three iron chelator readily available for patients Indonesia; deferiprone/DFP (branded as Ferriprox), deferasirox/DFX (branded as Exjade) and deferoxamine/DFO (branded as Desferal). This study aims to determine which iron chelator is the most efficient in reducing cardiac and hepatic iron overload (measured by means of T2* MRI). Methods: journal search with determined MeSH term was done in PubMed and Scopus. Studies that looked upon thalassemia major patient in all ages with usage of monotherapy iron chelation and its effect on myocardial T2* MRI and/or liver T2* MRI was included. Appraisal of studies was done using Oxford’s CEBM appraisal tools and Joanna Brigs Institute critical appraisal tools. Results: total of 11 studies with grand total of 611 samples were included. Mean T2* MRI value or (when available) mean changes in T2* MRI value after usage of specific iron chelator was gained from all the studies included. Comparison study and individual studies shows better control and increase of myocardial T2* MRI in those with DFP, and of liver T2* in those with good adherence to DFO chelation. Conclusion: DFP is superior in controlling or reducing myocardial iron load (as proven by mT2* MRI) and DFO had better capabilities in controlling or reducing hepatic iron load (as proven by liver T2* MRI). Studies with longer observation and larger samples is needed to see a significant changes of T2* MRI in DFX
Clinical Outcomes of Geriatric Care in Cipto Mangunkusumo Hospital, Before and After the Implementation of National Health Insurance Program
Get PDFBackground: the National Health Insurance (NIH/JKN) has been enacted since January 2014. Various outcomes of geriatric patient care, such as improved functional status and quality of life have not been evaluated. Prolonged hospitalization and re-hospitalization are potentially affecting the efficiency care of this vulnarable group. This study aimed to identify the differences of functional status improvement, quality of life improvement, length of stay, and hospitalization of geriatric patients admitted to CMH between prior to and after NHI implementation.Methods: a cohort study with historical control was conducted among geriatric patients admitted to Acute Geriatric Ward CMH Hospital on two periods of time: January-December 2013 (pre-NHI implementation) and June 2014-May 2015 (after NHI implementation). Patients who died within 24 hours of hospital admission, those with APPACHE II score >24, advance stage cancer, transfer to other wards before they were discharged or have incomplete record were excluded from the study. Data on demographical and clinical characteristics, functional status, quality of life, length of stay, and re-hospitalization were taken from patient’s medical record. The differences of studied outcomes were analyzed using t-test or Mann-Whitney test.Results: there were 102 subjects in pre-NHI and 135 subjects in NHI groups included in the study. Median lengths of stay were not different between two groups (12.5 days in pre-NHI and 10 days in NHI groups, p=0.087), although the proportion of patients with in-hospital stay less than 14 days was higher in NHI group. The difference of functional status of discharged patients in pre-NHI and NHI groups were 3 and 3 (p=0.149) respectively, whereas for health-related quality of life, although NHI group in the beginning showed a lower quality of life compared to the pre-NHI (0.163 [0.480] vs. 0.243 [0.550]; p=0.012). However, after incorporating comprehensive geriatric assessment (CGA) the quality of life improved significantly by the end of in-hospital care in both groups. Re-hospitalization incidence in NHI group was lower compared to pre-NHI (7 [5.2%] vs. 13 [12.7%]; p=0.038).Conclusion: our study shows that there was no significant difference regarding length of stay, functional status, and health-related quality of life between prior to and after national health insurance implementation on admitted geriatric patients. Rehospitalization incidence showed better results in NHI group and hence NHI implementation is favored
Obesity as the Sequel of Childhood Stunting: Ghrelin and GHSR Gene Polymorphism Explained
Get PDFStunting or short stature in children is a significant nutritional problem in developing and underdeveloped countries. Stunting during childhood might affect brain development and impair development cognitive function. Additionally, this condition associated with the increased risk for obesity during adulthood. Several studies have shown that the increment risk of obesity and overweight in children with a short stature was due to their metabolic efficiency. Children with stunting have lower resting energy expenditure compared to non stunting children. Additionally, stunted children has higher respiratory quotient and carbohydrate oxidation but lower fat oxidation compared to non-stunting children. These results might explain why stunted children easily become obese, which is due to lower fat oxidation and leading to tendency to store fat.This review discussed the current status on studies in the nutrigenetic aspects of the relationship between stunting in the childhood and obesity in adulthood. I hypothesized that stunted children are more likely to become obese in their later life because they have lower metabolic rate and higher tendency of fat storage. There are several candidate genes and pathway involved in obesity and I suspected that ghrelin and its receptor growth hormone secretague receptor (GHSR) were responsible
