Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine 333 Supraclavicular Lymphnodes: Unusual Manifestation of Metastase Adenocarcinoma Colon
Get PDFWe report a patient with supraclavicular lymph node metastasis from an undetectable adenocarcinoma of the transverse colon, who presented with cough and was diagnosed with typhoid fever, bronchitis as well as liver metastasis. There were an abdominal fullness, weight loss, constipation, pencil-like stool with mucous and blood, low-grade fever, bone ache, and tea-color urine. The first colonoscopy revealed lymphocytic ileitis and microscopic findings also showed lymphocytic ileitis. Abdominal USG and CT revealed liver metastasis of unknown origin. Based on the clinical sign and symptoms, we suspected that colorectal carcinoma was the primary site. Then, the second colonoscopy was performed and it revealed a small polyp, which was followed with a biopsy and the result supported a well-differentiated colon adenocarcinoma. Similar result was also revealed by the histopathological evaluation. This is an unusual case of liver and supraclavicular lymph node metastasis arising from a small polyp adenocacinoma of the transverse colon.Key words: liver metastase, colorectal carcinoma, lymph node
Clinical Effectiveness, Safety and Tolerability of Amlodipine/Valsartan in Hypertensive Patients: the Indonesian Subset of the EXCITE Study
Get PDFAim: to assess the effectiveness, safety and tolerability of amlodipine/valsartan (Aml/Val) single-pill combination (SPC) in hypertensive patients in a real-world setting. Methods: the Indonesian subset of the EXCITE (clinical EXperience of amlodIpine and valsarTan in hypErtension) study, which was a multinational, prospective, observational, open study in hypertensive patients treated with Aml/Val SPC for 26 weeks. Aml/Val SPCs (5/80, 5/160, 10/160 mg) were administered as monotherapy or as add-on therapy to other antihypertensive medications in patients not controlled by prior monotherapy. The effectiveness outcomes were (1) mean decrease in sitting systolic blood pressure and diastolic blood pressure (msSBP and msDBP) from baseline to week 26; (2) proportion of patients achieving BP goal (<140/90 mmHg for nondiabetics, or <130/80 mmHg for diabetics); (3) proportion of patients who were responders (achieving BP goal or BP reduction of >20/10 mmHg). The safety variables were the incidence of AEs and SAEs, and the incidence of edema. Results: a total of 500 patients from Indonesia received Aml/Val SPC, 487 patients were analyzed for efficacy (by LOCF), and 464 patients completed the study. At study end (week 26), the overall msSBP and msDBP(95% CI) reductions from baseline were -33.7(-35.2, -32.1) mmHg and -14.8 (-15.7, -13.8) mmHg, respectively. Among the 487 patients, 52.4% achieved BP goal and 80.5% were responders (LOCF). Among 464 patients who completed the study, 53.7% achieved BP goal and 84.5% were responders. Aml/Val SPC was effective in decreasing BP in Indonesian patients. AEs, including SAEs, were reported in 11.4% patients, with SAEs in 1% of patients, and death in 0.8% of patients. SAEs and deaths were considered unrelated to the study drug. Edema was reported by 9.4% of patients atbaseline, and in 3.7% patients at end of study. Effectiveness, tolerability and compliance were rated good and very good in 90.8%, 92.2%, and 89.2% of patients, respectively, according to the investigators. Conclusion: Aml/Val SPC was effective for BP reductions and well tolerated in hypertensive patients, not adequately controlled by monotherapy, in a daily clinical setting in Indonesia.Key words: Aml/Val, single-pill combination, daily clinical, EXCITE study
Prothrombotic Effect of Anti-beta-2 Glycoprotein-1 Antibodies on the Expression of Tissue Factor, Thrombomodulin, and Plasminogen Activator Inhibitor-1 in Endothelial Cells
No full textAim: to analyse the effects of immunoglobulin (Ig)G and IgM anti-beta-2 glycoprotein-1 (anti-β2GP1) on the expression of tissue factor (TF), thrombomodulin (TM), and plasminogen activator inhibitor-1(PAI-1) of endothelial cells in the messenger RNA level. Methods: laboratory experimental study in human umbilical vein endothelial cells (HUVEC) was done at Cipto Mangunkusumo Hospital/Faculty of Medicine, Universitas Indonesia. Samples are purified IgG anti-β2GP1 from six antiphospholipid syndrome (APS) patients serum and IgM anti-β2GP1 from six APS patients serum. For controls, purified IgG from six normal human serum (IgM-NHS) and purified IgM from six normal human serum (IgM-NHS) were used. HUVEC were treated with purified IgG anti-β2GP1, IgM anti-β2GP1, IgG-NHS, IgM-NHS for four hours of incubation. We measured TF, TM, and PAI-1 of HUVEC in mRNA relative expression levels (before and after treatment) by real time reverse transcription polymerase chain reaction. Results: the mean value of TF, TM, and PAI-1 mRNA levels in HUVEC after treated with IgG anti-β2GP1 compared to Ig-NHS were 3.14 (0.93)-, 0.31 (0.13)-, 5.33 (2.75)-fold respectively. In other hand, after treated with IgM anti-β2GP1 compared to IgM-NHS, mRNA levels of TF, TM, and PAI-1 were 4.33 (1.98)-, 0.33 (0.22)-, 5.47 (2.64)-fold respectively. Before and after treatment with IgG anti-β2GP1 showed significant differences of TF mRNA levels {1.09 (0.76) versus 3.14 (0.93), p=0.003}, TM mRNA levels {0.91 (0.11) versus 0.31(0.13), p=0.001}, and PAI-1 mRNA levels 0.93 (0.13) versus 5.33 (2.75), p=0.013}. Before and after treatment with IgM anti-β2GP1 showed significant differences of TF mRNA levels {1.03 (0.11) versus 4.33 (1.98), p=0.008}, TM mRNA levels {0.93 (0.08) versus 0.33 (0.22, p=0.003}, and PAI-1 mRNA levels {1.02 (0.10) versus 5.47 (2.64), p=0.01}. Conclusion: IgG anti-β2GP1 and IgM anti-β2GP1 increased TF and PAI-1 mRNA levels. However, IgG anti-β2GP1 and IgM anti-β2GP1 decreased TM mRNA levels. It proved that the mechanism of thrombosis in APS occurs through coagulation activation, reduction of fibrinolysis activity, and reduction of anticoagulant activity.Key words: APS, IgG/ IgM, anti-β2GP1, TF mRNA, TM mRNA, PAI-1 mRNA
The Role of Ursodeoxycholic Acid in Acute Viral Hepatitis: an Evidence-based Case Report
Get PDFAim: to review the role of ursodeoxycholic acid in acute viral hepatitis. Methods: following literature searching according to the clinical question on Pubmed and Cochrane Library. After filtered with our inclusion and exclusion criteria, one meta-analysis and two randomized clinical trials are obtained. Through critical appraisal, it was concluded that the articles meet the criteria for validity and relevance. Results: the article found that there is a positive effect of ursodeoxycholic acid on the activity of serum transaminases and cholestasis indexes. However, there is insufficient evidence to support or to refute effects of ursodeoxycholic acid on disease’s course as well as the viral load. Conclusion: better method of clinical trials are needed to obtain a valid and applicable result for daily practice.Key words: ursodeoxycholic acid, acute viral hepatiti
Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine 253 Extended Dual Antiplatelet for Diabetic Elderly Patients After Drug-eluting Stent Implantation: an Evidence-based Clinical Review
Get PDFAntiplatelet is an important drug for patients with coronary heart disease undergoing drug-eluting stent implantation. Current guidelines recommend dual antiplatelet with aspirin and a P2Y12 inhibitor for at least 12 months. Continuation of DAPT beyond 12 months may be considered for preventing very late stent thrombosis. Several patient-related factors that contribute to stent thrombosis have been recognized, including diabetes and advanced age, but the optimal DAPT duration for these patients is still controversial. This article reviews the efficacy of extended (>12 months) compared to standard (12 months) DAPT for reducing myocardial infarction and stent thrombosis rates, especially in diabetic elderly patients. Literature screening was conducted at PubMed and Cochrane database using “dual antiplatelet”, “duration”, “adult-onset diabetes mellitus”, “elderly” and, “drug-eluting stent” as keywords. Article types were limited to meta-analysis, systematic review, randomized clinical trial, or clinical trial that compared the efficacy of extended to standard duration of DAPT. Clinical outcomes used were myocardial infarction and stent thrombosis. The initial search was done to find relevant studies specifically assessing diabetic and elderly patients, then widened to diabetic and non-diabetic patients of any age above eighteen years. A total of 5 clinical trials and 1 meta-analysis were reviewed, showing an overall risk reduction of stent thrombosis and myocardial infarction. This review has several limitations, such as its potential selection bias and underrepresented proportion of diabetic and elderly patients. High-risk subgroups like diabetes mellitus has a tendency of increased ischemic risk, while advanced age could have both increased ischemic risk and bleeding risk. This review suggests that it is better to reserve extended dual antiplatelet therapy for patients with high ischemic risk and low bleeding risk (tailored therapy).Key words: adult-onset diabetes mellitus, drug-eluting stent, extended dual antiplatelet, elderly, myocardial infarction, stent thrombosis
Model and Effectiveness of Endurance Exercise to Increase Physical Fitness in Intellectual Disability Subjects with Obesity: A Randomized Controlled Trial
Get PDFAim: to design a model and assess the effectiveness of endurance exercise to increase physical fitness in intelectual disability (ID) patients with obesity. Methods: a randomized-controlled clinical trial was performed in ID patients with obesity aged 10-30 years old from all Special School in DKI Jakarta, which were randomly allocated into 3 groups and then given 3 different type of exercises: lower extremity muscles endurance exercise for 20 RM followed by cardiorespiratory endurance exercise for 24-25 minutes (type I), lower extremity muscles endurance exercises for 10 RM followed by cardiorespiratory endurance exercises for 26-27 minutes (type II), and threw a tennis ball with 10 m distance for 10 minutes as control (type III). These program was performed 3 times a week for 4 months. Assesment of the exercise effectiveness was done by measuring maximum load that can be lifted and six-minutes walking test on rectangular track which was converted with the VO2 max prediction formula. Analysis was perfomed with Kruskal Wallis test. Results: two hundred and twelve (212) subjects were included in the study, randomly allocated into three types (I, II, and III) of exercises groups. The type II of endurance exercise model was proved to be more effective in increasing lower extremity muscles endurance level compared to type I and III for ID patients with obesity (p<0.05). Meanwhile, type I of endurance exercise model was proved to be more effective in increasing cardiorespiratory endurance level compared to type II and III for ID patients with obesity (p<0.05). Conclusion: lower extremity muscles endurance exercise followed by a cardiorespiratory endurance exercise can be used to increase physical fitness in ID patients with obesity. Key words: intelectual disability patient, obesity, lower extremity muscles and cardiorespiratory endurance exercise, lower extremity muscles endurance level, cardiorespiratory endurance level
Angiogenesis, Inflammation, Platelets Count, and Metastatic Status as a Predictor for Thrombosis Risk in Nasopharyngeal Carcinoma Patients
Get PDFAim: to assess the use of of angiogenesis, inflammation, platelets count, and metastatic status as predictors for thrombosis risk represented by soluble P-selectin level in nasopharyngeal carcinoma (NPC) patients. Methods: a cross sectional study was conducted on NPC patients at the Hematology and Oncology Clinic of Cipto Mangunkusumo Hospital, Jakarta, during Mei to October 2012. Data regarding angiogenesis (CD105 and VEGFR-2), inflammation (IL-6), platelets count, and metastatic status were assessed at enrollment, as well as soluble P-selectin levels in all eligible patients. Bivariate analysis continued with multiple linear regression analysis were done to identify independent predictors for soluble P-selectin levels. Results: sixty NPC patients were enrolled in the study. There was correlation between platelet counts (r=0.389; p=0.002), IL-6 (r=0.595; p<0.001) and number of metastatic sites (r=0.542; p<0.001) with soluble P-selectin level, and a linear regression analysis showed that these three variables can predict soluble P-selectin levels with adjusted R-square 65%. There was no correlation between VEGFR-2 and CD105 levels with soluble P-selectin levels.Conclusion: platelet counts, IL-6 level, and number of sites of metastasis can be used as predictors of soluble P-selectin level as parameter of thrombosis risk in NPC patients. Key words: nasopharyngeal carcinoma (NPC), thrombosis risk, soluble P-selectin
Relationship Between Salted Fish Consumption and Nasopharyngeal Carcinoma: An Evidence-based Case Report
Get PDFAim: to know the relationship between salted fish consumption and nasopharyngeal carcinoma (NPC). Methods: we searched for the articles from PubMed® and ScienceDirect® based on our clinical question. After filtered with our in- and exclusion criteria, we had six articles about this topic, all of them were case-control studies. All articles were then critically appraised for their validity, importance, and applicability. Results: there was no consistent relationship between salted fish consumption and NPC. Worth to note that those studies wo showed the firm relationship were conducted in Southern China, where the incidence of NPC was extremely high and related to specific Chineese-style salted fish consumption. Conclusion: there was an inconsistent relationship between salted fish consumption and NPC.Key words: salted fish, risk factor, nasopharyngeal carcinoma
Combination of Aspartate Aminotranferase and Tumor Necrosis Factor-alfa as Non Invasive Diagnostic Tools for Non Alcoholic Steatohepatitis (NASH)
Get PDFAim: to develop a non-invasive diagnostic test for non-alcoholic steatohepatitis NASH. Methods: this is a cross-sectional study on non-alcoholic fatty liver disease (NAFLD) subjects. Sample was taken by consecutive sampling method. Diagnostic criteria of NAFLD were confirmed by liver biopsy. Clinical variables include metabolic syndrome, aspartate aminotransferase (AST), alanine aminotransferase (ALT), adiponectine, TNF-alfa, insulin, homeostatic model assessment insulin resistance (HOMA-IR) index and liver biopsy. Patients were divided into two groups based on their liver biopsy, group 1: Non-NASH (NAFLD activity score <3) and group 2: NASH (NAFLD activity score of >4). Statistical analyses were performed using Student’s t-test, Mann Whitney U, chi-square, the ROC curve, sensitivity and specificity test. Results: fifty NAFLD patients were recruited, 30 males and 20 females. Among these patients, 12 (24%) had type 2 diabetes, 36 (72%) had metabolic syndrome, the remaining 2 (4%) did not fulfilled metabolic syndrome. Liver biopsy confirmed 21 (42%) non- NASH and 29 (58%) NASH respectively. Level of AST and ALT, plasma level of adiponectine and TNF-alfa were statistically different between two groups. The AST level (>25 U/L) in combination with TNF-a (>3.28 pg/cc) demonstrated a good diagnostic accuracy for NASH (Accuracy 82%, Sensitivity 76%, Specificity 90%, PPV 92%, and NPV 73%). Conclusion: the combined diagnostic tests of AST and TNF-alfa plasma levels demonstrated a good accuracy for the detection of NASH among NAFLD patients. This combination test can be used as a noninvasive method to diagnose NASH.Key words: AST, TNF-a, diagnostic test, NASH
A Patient With Plaque Type Morphea Mimicking Systemic Lupus Erythematosus
Get PDFMorphea is an uncommon connective tissue disease with the most prominent feature being thickening or fibrosis of the dermal without internal organ involvement. It is also known as a part of localized scleroderma. Based on clinical presentation and depth of tissue involvement, morphea is classified into several forms, and about two thirds of adults with morphea have plaque type. Overproduction of collagen production by fibroblast is the cause of abnormality in morphea, and the hyperactivity mechanism of fibroblast is still unknown, although there are several mechanisms already proposed. Plaque type morphea is actually a benign and self limited. Plaque type morphea that mimicking systemic lupus erythematosus in clinical appearance, such as alopecia and oral mucosal ulcers, is uncommon. A case of plaque type morphea mimicking systemic lupus erythematosus in a 20 year old woman was discussed. The patient was treated with local and systemic immunosuppressant and antioxydant. The patient’s condition is improved without any significant side effects. Key words: morphea, plaque type