Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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Complicated Pregnancy in a Patient with Distal Renal Tubular Acidosis, Systemic Lupus Erythematosus, and Antiphospholipid Syndrome: A Rare Case and Management Strategies
Full text linkDistal renal tubular acidosis (dRTA) is a rare disorder characterized by impaired acid excretion leading to metabolic acidosis and hypokalemia. Its occurrence during pregnancy, particularly alongside systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), poses significant challenges for both maternal and fetal outcomes. This case report describes the successful management of a 23-year-old woman with secondary dRTA, SLE, and APS during pregnancy. The patient, with a history of recurrent hypokalemia and previous preterm deliveries, was closely monitored by a multidisciplinary team. Throughout her pregnancy, she required significant potassium and bicarbonate supplementation to maintain electrolyte and acid-base balance. Additionally, hydroxychloroquine, methylprednisolone, aspirin, and unfractionated heparin were continued to manage SLE and APS. Despite the complexity of her condition, she delivered a healthy baby girl at 37 weeks via cesarean section. This case provides valuable insights into managing dRTA during pregnancy, highlighting the importance of customized approaches to the management of electrolyte and acid-base abnormalities, as well as that of autoimmune disease
Risk Factors of Coronary In–Stent Restenosis in Drug-Eluting Stent: A Systematic Review and Meta-Analysis
Full text linkBackground: In-stent restenosis (ISR) is an event of coronary atherosclerosis re-budling following the stent implantation in percutaneous coronary intervention. The events of ISR have been significantly reduced since the introduction of drug-eluting stents. However, ISR could still occur, and factors affecting the incident have not yet been discovered. This study aims to evaluate the risk factors of coronary in-stent restenosis in drug-eluting stents. Methods: Studies on the factors and risks of ISR in patients with drug-eluting stents were systematically searched in databases (PubMed, ScienceDirect, Springer, Google Scholar, and ProQuest) on September 20th, 2023. The odds ratio (OR) and mean difference (MD) were analyzed using Review Manager 5.4. Results: Diabetes mellitus (OR 1.73 [95%CI 1.56, 1.91] p < 0.00001) and smoking (OR 1.24 [95%CI 1.13, 1.36] p<0.0001) are the patients' clinical characteristics that are associated with ISR in DES. It is closely related to the contribution of diabetes mellitus in promoting platelet adhesion and smoking in enhancing intimal hyperplasia. As in the angiography characteristics, stent lesion at LAD (OR 1.20 [95%CI 1.07, 1.35] p = 0.002) and stent length (MD 3.61 [95%CI 1.81, 5.42] p < 0.0001) are correlated with the events of ISR. Every millimeter excess of stent length significantly increases the risk of ISR. Therefore, reducing the excess stent length may contribute to the reduced risk of ISR in DES. Conclusion: The identification of risk factors contributing to ISR in DES may help cardiologists modify the attributable factors and prevent the occurrence of ISR
The Impact of Palliative Care on Quality of Life and Cortisol Levels in HIV/AIDS Patients with Anxiety
Full text linkBackground: Individuals with HIV/AIDS often experience significant physical and mental burdens. Palliative care has emerged as a means to improve the quality of life for people living with HIV/AIDS (PLWHA). This study aims to determine the effect of palliative care on the quality of life and psychoneuroimmunoendocrine aspects in PLWHA, particularly those suffering from anxiety, as indicated by cortisol hormone levels. Methods: A total of 30 PLWHA with anxiety were selected based on inclusion and exclusion criteria. This study employed a quantitative design with a quasi-experimental one-group pre-test and post-test approach. The data were analyzed using descriptive statistics and a paired t-test to assess the impact of the intervention on quality of life and cortisol hormone levels. Results: The findings indicated a significant improvement in quality of life following palliative care (p = 0.000, p < 0.05). The cortisol levels in PLWHA with anxiety decreased following palliative care; however, the reduction was not statistically significant, suggesting that palliative care had no measurable impact on cortisol levels post-intervention (p = 0.845, p > 0.05). Conclusion: Palliative care significantly enhances the quality of life in PLWHA. However, it does not lead to a statistically significant reduction in cortisol hormone levels before and after the intervention. Factors such as patient compliance with the palliative care plan and the influence of efavirenz on cortisol levels in PLWHA are likely contributing to these results
The Diagnostic Utility of Brain Natriuretic Peptide in Heart Failure Patients Presenting with Acute Dyspnea: A Systematic Review and Meta-analysis
Full text linkBackground: Patients with heart failure are often diagnosed based on clinical signs and serological markers. Finding biomarkers with greater sensitivity and specificity for heart failure patients who also have episodic dyspnea is a challenge for researchers. Thus, we conducted a systematic review and meta-analysis of previous research to determine the diagnostic value of B-type natriuretic peptide as a potential biomarker in heart failure patients experiencing acute dyspnea. Methods: By searching PubMed/Medline, Scopus, and Google Scholar up to March 2023, all cross-sectional and cohort studies were selected according to the PRISMA guidelines and assessed by the Deeks’ funnel plot asymmetry test for bias. Results: A total of thirty-five qualifying studies had their data extracted. In 26 investigations (n=16002), the precision of B-type natriuretic peptide was evaluated. There were significant differences in the reported sensitivity and specificity between trials. One research study yielded the lowest sensitivity of 0.76 (0.68, 0.82), with a prevalence of 46% for heart failure and a BNP level of ≥500 pg/ml. Specificity grew but stayed variable as the threshold rose, whereas sensitivity declined. A diagnostic meta-analysis was carried out on 14 trials (n=6313) to determine the accuracy of N-terminal probrain natriuretic peptide. When the threshold is raised, the pattern in NTproBNP is similar to that of B-type natriuretic peptides, with sensitivity falling and specificity increasing. Following the final analysis, the confidence areas surrounding the pooled sensitivity and specificity for BNP vs NTproBNP showed a distinct overlap. The overlap indicated that there was no statistically significant difference between the tests at the <100 pg/ml and ≤300 pg/ml rule-out levels, respectively (P>0.05). Conclusion: The meta-analysis reveals a substantial degree of congruity in the sensitivity and specificity between the levels of BNP and NTproBNP as biomarkers. Nevertheless, it's worth noting that, in the end, there exists a potential for overlooking heart failure diagnoses. Larger future studies, overcoming past limitations, could likely establish a consensus
Critical Management of Haemodynamically Unstable Acute Pulmonary Embolism in COVID-19
Full text linkThrombotic events occur in up to one-third of patients with COVID-19, predominantly manifesting as pulmonary emboli (PE), which are associated with higher morbidity and mortality. Acute PE should therefore be one of the main differential diagnoses of COVID-19 patients who develop hemodynamic instability. Early systemic thrombolysis remains the first line of treatment for hemodynamically unstable PE in those infected with COVID-19, particularly considering the risks of infection to other personnel during catheter-directed thrombolysis procedures. This report aims to describe a typical case of hemodynamically unstable acute PE with COVID-19 management in our center. A 66-year-old male presented to ER with shortness of breath and desaturation was suspected of having COVID-19. Despite unremarkable physical examination, he was later confirmed to be COVID-19 positive. While in the isolation ward, he experienced a cardiac arrest. 12-lead ECG showed sign of right ventricular strain and subsequently bedside echocardiography showed a fresh thrombus in the right atria with signs of acute right ventricular dysfunction. The diagnosis of acute PE with hemodynamic instability was made, and systemic thrombolysis was immediately initiated. Despite the bleeding complication, his symptoms and hemodynamic improved and he was discharged safely with oral anticoagulant. Our case demonstrates how early recognition and prompt treatment of acute PE especially in COVID-19 patients with hemodynamic instability, can be life saving. Recognizing the subtle signs of acute PE during emergency improves patients outcome considerably
Current Diagnosis and Therapeutic Approach of Functional Mitral Regurgitation
Full text linkFunctional mitral regurgitation is characterized by normal structures of the mitral valve and chordae tendinea, but the regurgitation occurs due to geometric changes in the left atrium and left ventricle. This condition can contribute to heart failure progression and lead to a poor prognosis. Functional mitral regurgitation is found in approximately one-third of patients with heart failure with a decreased ejection fraction. Echocardiography is the primary work-up for assessing the anatomy and function of the left ventricle, mitral valve, and severity of functional mitral regurgitation. Additionally, for the latter, an integrated qualitative and quantitative assessment is essential to determine the optimal therapeutic strategy. According to the current guidelines, medical therapy remains the main treatment for functional mitral regurgitation. Yet, transcatheter intervention is a safe and effective treatment option in selected patients. While the effect of surgery on improving mortality in patients with functional mitral regurgitation is not established yet, recent guidelines recommend considering surgery for patients who have undergone coronary artery bypass surgery or other cardiac procedures
Continuous Glucose Monitoring Use in Rural Area: An Evidence-Based Case Report
Full text linkContinuous Glucose Monitoring (CGM) provides real-time glycemic variability data, surpassing traditional methods like HbA1c. CGM data, also known as glucometrics, provide a comprehensive assessment of glycemic variability rather than a single point estimate like HbA1c, CGM data, or glucometrics. It provides a comprehensive assessment of glycemic variability rather than a single point estimate like HbA1c. CGM enables clinicians to understand dysglycemia patterns better by continuously tracking the patient’s glucose levels, therefore allowing for individualized adjustments to antidiabetic therapy. By continuously tracking glucose levels, a CGM enables clinicians to understand dysglycemia patterns better, allowing for individualized adjustments to antidiabetic therapy. While costly, CGM enables long-distance monitoring, addressing healthcare inaccessibility in remote rural areas. This case reportstudy examines a 24-year-old Indonesian female patient diagnosed with young-onset diabetes with limited access to specialized care, a history of macrosomia at birth, high blood glucose, and a body mass index (BMI) of 27.7. The patient's abdominal circumference was 86 cm, which is above normal for women and within the range of obesity. In this patient, CGM recorded a mean glucose level of 145 mg/dL. Studies indicate that when at least 70% of CGM data is available over a 10–14-day period, an estimated HbA1c can be calculated. CGM is vital for diabetes management in rural settings. Further, integrating telemedicine can help bridge healthcare gaps. Expanding access to CGM and genetic testing is crucial for improving outcomes in underserved communities
Resistance-Associated Substitutions (RAS) and Clinical Factors as Determinants of Sofosbuvir-Daclatasvir Treatment Outcomes in Chronic Hepatitis C Patients
Full text linkBackground: Direct acting antivirals (DAAs) have demonstrated remarkable efficacy, in achieving hepatitis C viral (HCV) elimination rates higher than 90%. One particular concern associated with treatment failure is the emergence of resistance associated substitutions (RASs) in the genome. The occurrence of RASs highlights the adaptability and resilience of the HCV. This highlights the importance of RASs mutation, enabling the development of new therapeutic strategies to combat these resistant strains. This study aims to determine the presence of early HCV mutations in chronic hepatitis C in Indonesia and the association between this mutation to the efficacy of sofosbuvir-daclatasvir. Methods: We conducted a prospective longitudinal study in naïve hepatitis C patient population. The virus was examined for RAS by RNA sequencing before starting treatment. RAS mutations were determined through the cut-off value of RAS mutations that contributed in the successful therapy. All patients were followed up until 12 weeks after completion of treatment to determine the sustained virological response 12 (SVR12). Results: Out of the 58 patients, 9 patients (15.51%) did not achieve SVR. Only 14 patients was further analyzed to provide the association between the mutation and SVR-12 failure after sofosbuvir-daclatasvir therapy. Specifically, 2 patients with L31 mutation and one patient with L31/Y93 mutation achieved SVR. Only one patient with failure to achieve SVR and the mutation was found in Y93H region. Conclusion: The mutation of Y93H may contribute to treatment failure while L31A may increase the susceptibility to DAAs treatment
Outcome Prediction in Infectious Disease
Full text linkSepsis is a critical, life-threatening condition that demands precise prediction to mitigate adverse outcomes. The heterogeneity of sepsis leads to variable prognoses, making early and accurate identification increasingly difficult. Despite ongoing advancements, no single gold standard has emerged for sepsis prediction. Current research explores a range of prognostic tools, from traditional scoring systems and biomarkers to cutting-edge omics technologies and artificial intelligence. These tools can differ significantly across patient populations and clinical settings, such as the emergency department (ED) and intensive care unit (ICU). This review aims to critically evaluate the development and application of outcome prediction modalities in sepsis and other infectious diseases, highlighting the progress made and identifying areas for further research
Telemedicine-assisted Directly Observed Therapy (DOTS) for Tuberculosis: An Evidence-based Case Report
Full text linkBackground: Tuberculosis is a high-burden infectious disease requiring long-term treatment. Compliance is the key to cure; however, directly observed therapy (DOTS) is not always feasible. Telemedicine use in DOTS offers improved accessibility; however, its effectiveness has not been established. We aimed to investigate the effectiveness of telemedicine-based DOTS on treatment compliance in patients with tuberculosis. Methods: Databases including MEDLINE, Scopus, EMBASE, PubMed, and Cochrane were searched for studies implementing telemedicine-based DOTS until November 2nd, 2023. Studies were appraised for validity, importance, and applicability using the Oxford Centre of Evidence-Based Medicine tool, and the outcomes were graded based on their levels of evidence (LOE). Results: Our search yielded six systematic reviews. Telemedicine-based DOTS yielded favourable effects in improving adherence (LOE: I), treatment completion (LOE: II-III), and cure rates (LOE: II-III). Other outcomes, in terms of bacteriological resolution (LOE: II) and mortality (LOE: IV), were estimated to be non-inferior to those of DOTS. In terms of the telemedicine mode, the VDOTS yielded the highest LOE in improving adherence (LOE: I), followed by short messaging services (LOE: III) and medication monitors (LOE: III), which yielded similar effects. Results for phone reminders were contradictory, with the highest evidence suggesting that it might be ineffective for treatment completion (LOE: I-III) but may increase the cure rate (LOE: III). Conclusion: Telemedicine-based DOTS may improve adherence, treatment completion, and cure rate, and is non-inferior in terms of bacteriological resolution and mortality. Telemedicine-based DOTS can be considered for implementation; however, further high-quality studies in limited-resource settings are needed to strengthen the evidence