Acta medica Indonesiana最新文献

Background: Early prediction of cardiac dysfunction is crucial in preventing the progression to heart failure and associated complications. To achieve this, the utilization of clinical indicators, molecular and pathological markers, and non-invasive evaluation methods has gained significant interest. One potential predictive tool that can be measured through non-invasive imaging modalities is the coronary artery calcium (CAC) score. Recent studies have extensively examined the correlation between coronary atherosclerotic plaque calcium score and cardiac dysfunction. However, data are scarce regarding the usefulness of the calcium score in predicting pulmonary artery hypertension, which is a known consequence of ventricular dysfunction.

Methods: A total of 167 patients with suspected coronary artery involvement were included in the study. Before performing CT angiography, the score of CAC was measured in all patients based on their CT results. The CAC value was calculated using Vitrea software. The CAC score of each coronary artery, as well as the total CAC score (by summing the scores of each artery), was determined based on the Agatston method. Then the patients were subjected to CT angiography, and the value of pulmonary artery pressure or PAP, as well as the pulmonary artery dilatation, was measured based on the results of CT angiography.

Results: The average CAC score in the two groups with and without PAH was 107.57 ± 268.60 and 35.47 ± 93.98, respectively, which indicated a significant difference between the two groups (P value 0.011). Accordingly, the number of cases with a positive CAC score in the two groups with and without PAH was 24 (49.0%) and 47 (39.8%), respectively, which showed a significant difference between the two groups (P = 0.046). There was a significant correlation between CAC score and PAH. Based on the analysis of the area under the ROC curve, CAC score evaluation had a high ability to predict PAH in women and in patients over 50 years old.

Conclusion: The measurement of CAC score could be incorporated as a predictive index for the increase of pulmonary artery pressure and the occurrence of PAH. However, this predictive value is more evident in women and in older patients.

Distal 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.

Continuous 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.

Drug-resistant extrapulmonary tuberculosis (DR-EPTB) represents an escalating global health challenge, complicated by rising rates of rifampicin-resistant (RR-TB) and multidrug-resistant tuberculosis (MDR-TB). Despite growing awareness, DR-EPTB remains underdiagnosed and underreported, often due to presumptive assumptions of drug sensitivity. This case series describes three distinct cases of DR-EPTB: a 34-year-old woman diagnosed with primary MDR-TB involving the lungs and colon; a 41-year-old man with RR-TB-associated arthritis of the elbow joint, following a previous history of pulmonary TB; and a 63-year-old immunosuppressed woman presenting with primary laryngeal and pulmonary RR-TB. These cases highlight the diagnostic complexities and emphasize the necessity of prompt and precise diagnosis facilitated by molecular diagnostics, particularly GeneXpert MTB/RIF. Increased awareness and vigilance for DR-EPTB among clinicians are critical for early detection, effective management, and curbing the spread of drug-resistant strains.

HER2-positive metastatic breast cancer is an aggressive subtype of breast cancer associated with poor prognosis due to high recurrence and mortality rates. The introduction of dual anti-HER2 therapy combined with chemotherapy has significantly improved treatment outcomes.  A 50-year-old woman with a history of left mastectomy in 2019 who initially declined adjuvant chemotherapy and radiotherapy. Three years later, she presented to the clinic with erythematous skin changes, a nodule at the mastectomy site, and left-arm lymphedema. A biopsy confirmed recurrent HER2-positive breast cancer with metastases to lymph nodes, liver, and bones (cT4cN3cM1 ER-, PR-, HER2+). She received initial treatment with dual anti-HER2 (Pertuzumab, Trastuzumab) and Docetaxel every 3 weeks for six cycles, followed by maintenance therapy with Pertuzumab and Trastuzumab. PET scan evaluations showed an excellent response, with complete resolution of the primary lesion and substantial regression of metastases. The CLEOPATRA trial supports the efficacy of a combination of dual anti-HER2 and Docetaxel, showing prolonged progression-free and overall survival. The combination of dual anti-HER2 enhanced antitumor efficacy by providing dual inhibition of HER2. This case highlights the pivotal role of dual anti-HER2 therapy combined with chemotherapy in improving survival outcomes of patients with metastatic HER2-positive breast cancer.

Hepatic encephalopathy (HE) is one of the serious complications of liver cirrhosis, characterized by a broad spectrum of neuropsychiatric symptoms, ranging from subtle cognitive impairment to coma, due to brain dysfunction associated with acute or chronic liver failure and/or portosystemic shunting. Globally, the prevalence of hepatic encephalopathy (HE) is reported to range from 20% to 80% in patients with liver cirrhosis, depending on whether the assessment includes minimal (MHE) or overt (OHE) forms. In Indonesia, determining the true prevalence of HE is challenging due to diagnostic difficulties, with estimates ranging from 30% to 84%. At Cipto Mangunkusumo General Hospital, the prevalence of HE in 2009 was 63.2%. In recent years, evidence has highlighted the role of the gut microbiota in the pathogenesis of hepatic encephalopathy (HE), a concept now widely referred to as the "gut-liver-brain axis."  Short-chain fatty acids (SCFAs) are gut microbial-derived metabolites that provide numerous health benefits. SCFA has been demonstrated to impact gut barrier function, immunomodulation, and glucose homeostasis.  In this issue, Ferdianto et al. conducted a cross-sectional observational study comparing the amount and composition of fecal SCFA in cirrhotic patients with and without HE. The study revealed no significant difference in SFA levels between HE and non-HE groups; however, the HE groups demonstrated higher levels of total SCFA, acetate, and butyrate compared to the non-HE groups. While this study contributes valuable early evidence from an Indonesian cohort, several important limitations should be acknowledged. First, the diagnostic approach for covert or minimal HE requires clarification. The authors did not explicitly state the neuropsychological tools and specific criteria used. Clear definitions are essential, as minimal and covert HE is susceptible to the choice of diagnostic method and can substantially influence group classification. Second, although SCFAs represent key microbial metabolites, the study did not explore the underlying microbiome composition. Without bacterial taxonomy or species-level data, it remains difficult to determine whether differences in SCFA levels truly reflect gut dysbiosis or altered microbial diversity. SCFA concentrations may be influenced by multiple factors, and therefore, inclusion of metagenomic or sequencing data would strengthen the mechanistic interpretation and allow linking specific bacterial taxa with cognitive impairment. Future studies that include larger and more heterogeneous cohorts, alongside integrated analyses of microbiome composition and validated neurocognitive testing, will be crucial to validate the role of SCFAs in HE development.

Influenza remains a significant global health problem. The risks of complication and death from influenza are greater in comorbid groups, such as those suffering cardiovascular diseases. The true economic and social costs of influenza are far greater in these groups compared to healthy ones as these groups are vulnerable to complications and even death. Cardiovascular disease is the leading cause of death, both globally and in Indonesia. The relationship between cardiovascular events and seasonal influenza has been established. Influenza vaccination is one of the prevention methods that has proven effective in preventing influenza infection and reducing the risk of major cardiovascular events. In addition to being effective, influenza vaccination is also safe and well-tolerated by adults and the elderly. This review outlines the impacts of influenza and the benefits of influenza vaccine in groups with cardiovascular disease.

Background: Short-chain fatty acids (SCFA) are the main metabolites of the intestinal microbiota, which play a role as colonocyte trophic factors and maintain the integrity of the gastrointestinal tract and blood-brain barrier. Microbiota dysbiosis that occurs in cirrhosis reduces SCFA production and plays a role in the pathogenesis of hepatic encephalopathy (HE). This study aims to compare the amount and composition of fecal SCFA in patients with cirrhosis, with and without HE.

Methods: This research is a cross-sectional study at the Hepatobiliary Clinic and Integrated Procedure Room, Dr. Cipto Mangunkusumo Hospital, Jakarta, in 2023. Patients with cirrhosis underwent a flicker or Stroop test, fecal SCFA examination (acetate, butyrate, and propionate), and a questionnaire with a food recall technique to assess dietary patterns.

Results: A total of 86 patients with cirrhosis participated in this study, with a mean age of 53 ± 8.10 years, and the majority were male (68.6%). Hepatic encephalopathy (HE) was identified in 20 patients (23.25%). Multivariable analysis of SCFA profiles showed no statistically significant associations with HE. The absolute SCFA proportion had an adjusted prevalence ratio (PR) of 1.98 [95% CI: 0.75-5.24; p = 0.171], the absolute acetate proportion had an adjusted PR of 2.06 [95% CI: 0.40-10.62; p = 0.388], and the butyrate proportion had an adjusted PR of 2.02 [95% CI: 0.76-5.39; p = 0.158].

Conclusion: Changes in SCFA composition may be associated with the presence of HE in patients with cirrhosis. Although no statistically significant relationships were found, these findings suggest that SCFA profiles warrant further investigation concerning dysbiosis and HE in cirrhosis.

Background: A coronary artery bypass graft is a complex procedure that can cause various physiological responses, including inflammation, oxidative stress, apoptosis, and endothelial dysfunction. Nevertheless, the correlation between these responses and organ function after CABG has not yet been established. This study aims to investigate the correlation between inflammation, oxidative stress, apoptosis, endothelial dysfunction markers, and postoperative organ function assessment as evaluated by the Cardiac Surgery Score (CASUS).

Methods: A prospective cohort study was conducted on patients undergoing coronary artery bypass graft from two hospitals in Jakarta. IL-6, MDA, caspase-3, and syndecan-1 levels were measured at three points in time: before surgery, on ICU Day-1, and ICU Day-2. Postoperative organ function was assessed on ICU Day 2 by Cardiac Surgery Score (CASUS).

Results: Fifty-one patients were included in the study. There was a positive correlation between IL-6 measured before surgery (r = 0.325, p = 0.020) and at the time of admission to the ICU (r = 0.374, p = 0.007). Positive correlation was also found between syndecan-1 levels on ICU day 1 (r = 0.304, p = 0.030) with CASUS. MDA correlated with CASUS on ICU day 2 (r = 0.392, p = 0.004); meanwhile, no significant association was found between caspase-3 and postoperative organ function assessment.

Conclusion: Interleukin-6 levels pre-surgery and on ICU day 1, syndecan-1 levels on ICU day 1, and MDA levels on ICU day 2 were correlated with CASUS.

Background: Acute cholangitis is associated with high mortality, necessitating prompt diagnosis and intervention. The Tokyo Guidelines 2018 (TG18) are a crucial diagnostic tool, but their sensitivity and specificity require evaluation. Moreover, factors influencing acute cholangitis mortality in Indonesia remain unidentified. This study evaluates the diagnostic accuracy of TG18 and identifies mortality predictors in adult patients with acute cholangitis in Indonesia.

Methods: A retrospective cohort study was conducted using the medical records of acute cholangitis patients at Cipto Mangunkusumo Hospital from 2019 to 2022. TG18 was compared with endoscopic retrograde cholangiopancreatography (ERCP). Bivariate and multivariate analyses were employed to identify mortality predictors.

Results: The study involved 163 individuals (male: 51.5%; mean age: 51.0 ± 12.81 years). The in-hospital mortality rate was 11.6%. TG18 demonstrated a sensitivity and specificity of 84.05% (95% confidence interval (CI):77.51%-89.31%) and 95.65% (95%CI: 78.05%-99.89%), respectively, compared with ERCP. Significant mortality predictors in univariate analysis included TG18 grade III (risk ratio (RR): 13.85; 95%CI: 3.31-57.89; p<0.001), history of malignancy (RR: 4.40; 95%CI: 1.52-12.68; p=0.006), noncompliance with antibiotic guidelines (RR: 3.27; 95%CI: 1.36-7.85; p=0.008), and procalcitonin levels ≥ 2.0 ng/dL (RR: 2.44; 95%CI: 1.056-5.63; p=0.037). Multivariate analysis revealed that significant predictors included TG18 grade III (RR: 10.67; 95%CI: 2.50-45.56; p<0.001), non-compliance with antibiotic guidelines (RR: 2.92; 95%CI: 1.34-6.36; p=0.007), and procalcitonin levels ≥ 2.0 ng/dL (RR: 2.37; 95%CI: 1.18-4.75; p=0.015).

Conclusion: TG18 demonstrates favorable sensitivity for diagnosing acute cholangitis. Independent predictors of acute cholangitis mortality include TG18 grade III, noncompliance with antibiotic guidelines, and procalcitonin levels ≥ 2.0 ng/dL.