Nur I Afriliyantina1, Anna Uyainah2, Evy Yunihastuti3, Anis Karuniawati4, Cleopas M Rumende2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Divisi Alegi dan Imunologi, Departemen Ilmu Penyakit Dalam FKUI/RSCM
4Departemen Mikrobiologi FKUI/RSCM

ABSTRACT
Background: Tuberculosis is one of the most common presenting illness and the leading cause of death among people living with HIV. The clinical features of pulmonary tuberculosis in HIV-infected patients are not typical. The accurate diagnosis of pulmonary tuberculosis in HIV-infected patient remains a clinical challenge. Xpert MTB/RIF® is a new molecular modality for rapid diagnostic of tuberculosis. However, performance-related data from HIV-infected patients are still limited.
Objective: To determine the accuracy of Xpert MTB/RIF® in diagnosing pulmonary tuberculosis in HIV-infected patients from sputum sample.
Methods: This is a cross-sectional study performed in HIV-infected patients who were suspected of having pulmonary tuberculosis during October 2012 to April 2013 in Cipto Mangunkusumo Hospital. We investigated the diagnostic accuracy of Xpert MTB/RIF® compared to liquid media culture from sputum sample
Results: A total of 66 patients were suspected of having pulmonary tuberculosis and 43 patients were confirmed by culture examinations. Most of the patients were 25 - 35 years olds (58%), male (73%), have a low BMI (53%) and low CD4+ (56%). Most of HIV-infected patients were intravenous drugs user (62%). The sensitivity and specificity of Xpert MTB/RIF® were 93.0% (95% CI, 87.0% to 99.0%) and 91.3% (95% CI, 84.5% to 98.1%). The positive and negative predictive values were 95.2% (95% CI, 90.1% to 100%) and 87.5% (95% CI, 79.5% to 95.5%). Positive and negative likelihood ratios were 10.7 and 0.08.
Conclusion: Xpert MTB/RIF® has a good performance in diagnosing pulmonary tuberculosis in HIV-infected patients.
Key words: Tuberculosis, Xpert MTB/RIF®, HIV.,

Anggraini Permatasari1, Ceva W Pitoyo2, Dita Aditianingsih3, Cleopas M Rumende 2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Departemen Anestesi dan Terapi Intensif FKUI/RSCM

ABSTRACT
Background: Critically ill patients are increasing in number with high mortality rates. Prediction model with a good performance is needed to predict their mortalities. Modified Sequential Organ Failure Assessment (MSOFA) is one of the scoring systems which can predict 28 days mortality. It has shown many good results abroad, however it still need to be validated in Indonesia. In order to improve its performance, total serum magnesium is considered too be use as an added variable.
Objective: To evaluate the performance of MSOFA and the value of added magnesium level as predictor of mortality in critically ill patient.
Methods: This is a prospective cohort study. Medical data which consist of physical examination, Glasgow Coma Scale, peripheral oxygen saturation measurement, creatinine and magnesium serum level were obtained from subjects who were admitted to Intensive Care Unit of Cipto Mangunkusumo Hospital during April to July 2013. Subjects were assessed for outcome after 28 days of admission. Calibration performance was evaluated with calibration plot and Hosmer-Lemeshow test. Discrimination value was measured with area under the curve (AUC). Performance of MSOFA and magnesium value were appraised with ROC curve.
Results: A total of 150 critically ill patients was submitted for this study with 33,3% mortality rate. Calibration plot of MSOFA showed r = 0,7 and Hosmer-Lemeshow test showed p = 0,08. Discrimination value was shown by ROC curve with AUC 0,83 (CI 95% 0,76-0,90). With a cut-off value of 1,85 mEq/L, magnesium has shown optimal sensitivity and specificity, 38% and 48% respectively. However, AUC curve do not change after magnesium variable was added. Conclusion: MSOFA has shown a good calibration and discrimination performance in Indonesian people. Magnesium blood level has no added value to MSOFA for predicting mortality in critically ill patients.
Key words: Validation, Modified Sequential Organ Failure Assessment, total serum magnesium, mortality predictior, critically ill patients.

Ridho Adriansyah1, Gurmeet Singh2, Zulkifli Amin2, Anna Uyainah2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM

PENDAHULUAN
Tuberkulosis (TB) merupakan penyakit menular melalui droplet udara yang disebabkan Mycobacterium Tuberculosis. Meskipun tingkat penularan TB relatif rendah dibandingkan dengan penyakit menular lainnya dan pengobatan yang efektif telah ditemukan sejak lima dekade lalu, TB masih menjadi masalah kesehatan global yang sulit diatasi. Tidak kurang dari sepertiga populasi dunia terinfeksi TB. Setiap tahun ditemukan sembilan juta kasus baru dan hampir dua juta penderita dilaporkan meninggal dunia. Insidens penularan infeksi HIV ikut berkontribusi terhadap meningkatnya epidemiologi TB secara global, khususnya di Afrika dan Asia. Peningkatan prevalensi tersebut juga diikuti peningkatan resistensi terhadap obat antituberkulosis (OAT). Ada tiga jenis resistensi yang dikenal dengan nama multidrug-resistant (MDR), extensively drug- resistant (XDR), dan total drug-resistant (TDR). Banyaknya jumlah kasus resistensi mencerminkan kegagalan program-program kesehatan yang sudah dijalankan selama ini.1
Indonesia sebagai salah satu negara berkembang di Asia Tenggara pun tidak luput dari masalah- masalah di atas. Indonesia menduduki peringkat ke-4 negara dengan kasus TB terbanyak setelah India, Cina, Afrika Selatan, dan Nigeria. Prevalensi TB di Indonesia cenderung stabil dari tahun ke tahun dengan angka prevalensi yang masih cukup tinggi, yaitu 261 per 100.000 penduduk. Persentase MDR TB saat ini sekitar 1,9 % dari semua kasus TB.2
Sejak tahun 1994, kasus MDR telah banyak dilaporkan oleh 114 negara. Dengan pelaporan dan pelaksanaan program tata laksana MDR TB yang intensif, diharapkan angka insidens MDR TB dapat ditekan. Kesulitan utama dalam tata laksana TB resisten obat baik MDR atau XDR adalah kualitas pemeriksaan sputum. Kualitas pemeriksaan yang baik merupakan salah satu indikasi program tata laksana nasional MDR TB berjalan dengan baik. Hal tersebut dijalankan dengan baik oleh negara-negara yang rutin mengirimkan hasil pemantauan nasionalnya

Borries Foresto1, Eric D Tenda2, Cleopas M Rumende3
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Divisi Alegi dan Imunologi, Departemen Ilmu Penyakit Dalam FKUI/RSCM
ABSTRACT
Upper airway obstruction is an emergency condition that needs to be addressed immediately in order to prevent the consequent irreversible complication. The etiology of obstruction may vary depending on the patient’s age and clinical manifestation. Diagnosis and therapy must simultaneously be attempted in order to optimize patient’s clinical outcome. One of the most effective treatment modality is airway stenting. In this case, a 56-years old male came to Ciptomangunkusumo Hospital, Jakarta with chief complaint of worsening dyspnea after receiving chemotheraphy for non-small cell carcinoma. Physical examination showed tachypnea, inspiratory stridor, and wheezing. Bronchoscopy revealed stricture with intermitten obstruction. Fiberoptic bronchoscopy found stenosis at a distance of 5 cm from vocal cords with severe obstruction (75%)

Hendra Koncoro1, Ida B Suta2
1Departemen Ilmu Penyakit Dalam FK Udayana/RSUP Sanglah Denpasar
2Divisi Pulmonologi dan Ilmu Kedokteran Respirasi, Departemen Ilmu Penyakit Dalam FK Udayana/RSUP Sanglah Denpasar

Penyakit infeksi paru hingga saat ini masih merupakan penyakit yang paling sering dijumpai pada manusia dan penyebab kematian terbanyak setelah penyakit jantung koroner.1 Sekitar 75% penggunaan antibiotik ditujukan untuk infeksi paru yang disebabkan oleh bakteri. Akan tetapi, sebagian besar kasus infeksi ternyata disebabkan oleh virus. Penggunaan antibiotik yang tidak tepat ini merupakan penyebab utama munculnya resistensi antibiotik. Semakin maraknya kasus pemakaian antibiotik yang tidak tepat merupakan masalah yang belum teratasi hingga kini.2
Diferensiasi penyebab infeksi paru menjadi sangat penting guna membatasi penggunaan antibiotik yang tidak bertanggung jawab. Beberapa tes laboratorium dapat mengetahui adanya infeksi seperti hitung leukosit, laju endap darah, C-reactive protein (CRP), tumor necrosis factor, dan interleukin 1 (IL-1) dan IL-6. Namun, berbagai tes tersebut bersifat tidak spesifik sehingga etiologi infeksi paru sulit sekali ditentukan dalam waktu cepat. Diagnosis pasti harus menunggu hasil kultur darah selama beberapa hari. Oleh sebab itu, dibutuhkan suatu penanda spesifik yang mampu mendeteksi infeksi bakteri dengan cepat.3,4
Prokalsitonin (PCT) merupakan suatu biomarker yang lebih spesifik terhadap infeksi bakteri dan dapat dideteksi lebih awal dibandingkan gejala atau tanda infeksi lain, seperti demam, perubahan hitung leukosit, atau kultur darah. Biomarker ini terdiri dari 116 asam amino yang meningkat produksinya pada infeksi bakteri dan beberapa jenis keganasan.5,6 Tulisan ini memberikan gambaran mengenai produksi dan biologi PCT, faktor mempengaruhi kadar PCT, hubungan PCT dengn derajat keparahan infeksi, perbandingan PCT dengan biomarker lain, serta aplikasi PCT dalam kasus pulmonologi.

ABSTRACT
Background: The number of visits and mortality rates of emergency patients at Emergency Department (ED) have been increasing from time to time. Those patients have a wide spectrum of conditions. Appropriate identification of patients with high mortality risk is crucial. The Hypotension, Oxygen Saturation, Low Temperature, ECG Changes, and Loss of Independence (HOTEL) score is an easy and important tool to be applied in the ED. However, the score has not been validated in Indonesia.
Objective: To evaluate the performance of HOTEL score in predicting the 24-hour mortality of nonsurgical patients in ED of Cipto Mangunkusumo hospital.
Methods: The design is a prospective cohort study. The research subjects were the nonsurgical patients who were admitted to ED of Cipto Mangunkusumo hospital between October-November 2012. We collected systolic blood pressure, peripheral oxygen saturation, body temperature, ECG changes, and loss of independence data. Those data were evaluated based on the HOTEL scoring system. The outcome were evaluated in 24-hour after admission (alive or dead). The calibration was evaluated with the Hosmer-Lemeshow test. The discrimination performance was measured with area under the curve (AUC).
Results: There are 815 non-surgical patients who were admitted to the ED between October until November 2012, but only 804 (98.7%) subjects were included in this study. The 24-hour mortality rate is 3.7% (30 subjects). The calibration performance with the Hosmer-Lemeshow test showed p value of 0.753. The discrimination performance is shown with the AUC score of 0.86 (95% CI 0.781; 0,93).
Conclusion: The HOTEL score has a good calibration and discrimination performance in predicting the 24-hour mortality of the nonsurgical patients in ED of Cipto Mangunkusumo hospital.
Key words: Validation, HOTEL score, mortality, nonsurgical patients, emergency department

ABSTRAK
Latar Belakang: Banyaknya jemaah haji Indonesia memiliki kebiasaan merokok. Kebiasaan merokok tersebut bisa menyebabkan gangguan faal paru. Gangguan faal paru tersebut bisa bersifat obstruktif, restriktif, dan campuran. Banyak studi sebelumnya menunjukkan hubungan kuat antara kebiasaan merokok dengan penyakit saluran napas.
Tujuan: Mendapatkan karakteristik dan gambaran faal paru serta hubungan antara perilaku merokok dengan gambaran faal paru dari jemaah haji perokok di kelompok embarkasi Jakarta-Pondok Gede tahun 2012. Metode: Desain studi ini adalah potong-lintang pada jemaah haji yang menjalani pemeriksaan kesehatan haji di Puskesmas Kecamatan dan Embarkasi Jakarta-Pondok Gede. Penilaian perilaku merokok berdasarkan Indeks Brinkman dan penilaian gambaran faal paru berdasarkan pemeriksaan spirometri. Analisis bivariant menggunakan metode Kolmogorov Smirnov.
Hasil: Pada studi ini, didapatkan 209 subjek jemaah haji perokok. Karakteristik jemaah haji perokok umumnya laki-laki (99,5%), usia <60 tahun (78,0%), kategori IMT overweight (63,2%), tidak disertai komorbid (68,9%), pendidikan kategori tinggi (75,1%), dan Indeks Brinkman kategori sedang (53,1%). Gambaran faal paru ditemukan kategori restriktif 51,2%, obstruktif 8,6%, campuran 8,1% dan normal 32,1%.
Kesimpulan: Penelitian tidak menunjukkan adanya hubungan bermakna antara perilaku merokok dengan gambaran faal paru pada kelompok kategori Indeks Brinkman sedang-berat dibandingkan kelompok Indeks Brinkman ringan.
Kata kunci: Perilaku merokok, gambaran faal paru, jemaah haji perokok.

Dewasa ini penggunaan ventilasi noninvasif semakin berkembang dan membuat penderita merasa lebih nyaman. Perangkat ini menawarkan biaya perawatan yang lebih murah serta waktu perawatan yang lebih singkat dibandingkan dengan ventilasi invasif.1 Saat ini ventilasi noninvasif banyak digunakan pada pasien rawat inap dengan gagal napas akut maupun kronik pada perawatan di rumah.2

SISTEM RESPIRASI
Sistem pernapasan terdiri atas dua bagian, yaitu sistem pertukaran gas (paru) dan sistem ventilasi (pompa pernapasan). Masing-masing bagian dapat terganggu secara independen. Pada gagal paru, terapi oksigen umumnya cukup memadai, kecuali jika disertai dengan gangguan berat pada proses pertukaran gas. Sebaliknya, disfungsi dalam sistem ventilasi biasanya membutuhkan ventilasi mekanis

Insidens infeksi jamur, khususnya penyakit jamur invasif, di unit perawatan intensif (UPI) terus meningkat dalam beberapa tahun terakhir. Studi Extended Prevalence of Infections in the ICU (EPIC II) menemukan, jamur berperan dalam 19,4% dari seluruh kasus infeksi di UPI.1 Sistem National Nosocomial Infections Surveillance di Amerika Serikat melaporkan peningkatan kejadian infeksi jamur dari 2,0 infeksi/1000 pasien yang dipulangkan pada tahun 1980menjadi3,8infeksi/1000pasienyangdipulangkan pada tahun 1990. Serupa dengan hal tersebut, Voss dkk. mencatat peningkatan insidens kandidemia di sebuah rumah sakit di Belanda, yaitu dari 4,7 kasus/10 000 pasien/hari pada tahun 1987 menjadi 7,4 kasus /10 000 pasien/hari pada tahun 1994. Penelitian- penelitian saat ini melaporkan bahwa jamur terlibat hingga 17% dari seluruh infeksi-infeksi nosokomial, dan 9-12% dari infeksi darah nosokomial.2
Peningkatan infeksi jamur menggambarkan peningkatan jumlah pasien dengan sistem imunitas rendah yang membutuhkan perawatan intensif, antibiotik yang lebih banyak, perangkat bantuan hidup, dan prosedur invasif yang lebih sering. Kelompok pasien ini memiliki faktor risiko untuk infeksi jamur, termasuk pembedahan abdomen, nutrisi parental, dan kondisi imunosupresi.2
Morbiditas dan mortalitas yang bermakna dilaporkan pada pasien UPI dengan penyakit jamur invasif. Pemberian terapi antijamur yang tepat dan cepat adalah penentu utama prognosis pasien. Meski demikian, diagnosis penyakit jamur invasif sangat sulit dilakukan pada populasi ini karena tidak adanya metode diagnostik noninvasif yang akurat.
Selain itu, tidak terdapat rekomendasi jelas berbasis bukti mengenai waktu dan metode deeskalasi terapi antijamur. Akibatnya, terapi antijamur empiris sering kali digunakan untuk periode yang lama di UPI.
Terapi antijamur berkepanjangan berkontribusi dalam pembengkakan biaya perawatan di rumah sakit dan dapat mendorong terjadinya resistansi antijamur.1 Walaupun Aspergillus dan Candida masih menjadi patogen paling umum, spektrum mikosis invasif berubah dengan munculnya jamur patogen oportunistik lainnya, seperti Fusarium, Zygomicetes, dan Scedosporium. Infeksi patogen baru tersebut berpotensi mengancam jiwa jika terjadi bersamaan dengan mold (aspergillosis).3

Background: Mortality due to air pollution reached 1,2 million deaths worldwide in 2004 and had been linked to a range of adverse health effects, including respiratory diseases. Microbus drivers are constantly exposed to air pollution and therefore at high risk of lung function deterioration.
Objectives: To assess the magnitude of lung function deterioration and to determine both primary and secondary prevention approaches on microbus drivers.
Methods: This is a cross sectional study among microbus drivers at Kampung Melayu station in October 2014. Data were obtained from interview, body height and weight measurement, spirometry and random capillary blood glucose test. Descriptive analysis was performed to obtain proportion of each variable and to determine the mean or median value.
Results: A total of 101 subjects were recruited by purposive sampling. There were 69.3% microbus drivers who had been working for more than ten years, 76.2% smokers, 8.9% with history of tuberculosis, 44.6% with random capillary blood glucose >140 mg/dl and 34.7% with obesity. There were 30.7% subjects with lung function deterioration, consisting of 90.3% restrictive diseases and 9.7% obstructive diseases. Deterioration was more prominent in those who had been working for more than ten years or had history of tuberculosis.
Conclusion: Deteriorating lung function was found in 30.7% microbus drivers at Kampung Melayu station, East Jakarta, consisting of 90,3% restrictive and 9,7% obstructive diseases. Deterioration was found mostly in subjects working for more than 10 years or having history of tuberculosis.
Key words: Microbus drivers, lung function deterioration, air pollution

Background: The comparation of survival rate between elderly patients with advanced non-small cell lung carcinoma (NSCLC) who underwent chemotherapy and those who did not had been studied in other countries, but had yet to be covered in Indonesia. The influence of confounding factors such as comorbidity, histopathology, body mass index, functional status, age and stage of cancer were seldom considered in earlier studies. Objective: To determine the difference of one-year survival rate in elderly patients with advanced NSCLC who received chemotherapy and those who did not receive chemotherapy.
Methods: Retrospective cohort followed by survival analysis were done on 232 elderly patients with stage IIIB/IV NSCLC and ECOG performance status 0-2 who visited Cipto Mangunkusumo Hospital and Dharmais Cancer Hospital Jakarta between January 2007 and April 2013. Patients were divided into chemotherapy and non-chemotherapy group. Kaplan-Meier curve was used to evaluate one-year survival rate of each group. Bivariate analysis was conducted using log-rank test while multivariate analysis was conducted using Cox proportional hazard regression. The relationship between chemotherapeutic approaches and survival rate was expressed in crude HR with 95% CI and adjusted HR with 95% CI after adjustment for confounding factors.
Results: As much as 232 elderly patients with advanced NSCLC were divided into chemotherapy group (118 subjects) and non-chemotherapy group (114 subjects). One-year mortality percentage were 93.9% and 57.6% for non- chemotherapy and chemotherapy group, respectively. Survival median were 2 months in non-chemotherapy group and 9.73 months in chemotherapy group (HR 3.45, 95%CI 2.52-4.71; p< 0.001). Bivariate analysis showed statistically significant relation between chemotherapy and one-year survival rate. Multivariate analysis showed that stage of cancer was a confounding factor regarding the relationship of chemotherapeutic approach to survival rate.
Conclusion: One-year survival in elderly patients with advanced NSCLC who received chemotherapy was better compared to those who did not receive chemotherapy.
Key words: Lung cancer, chemotherapy, survival rate, elderly.

Background: Prevalence of extrapulmonary tuberculosis (TB) increases along with escalated number of Human Immunodeficiency Virus (HIV) infection. Patients with extrapulmonary TB and HIV infection are at risk of rapid deterioration and higher death rate. Identifying clinical characteristics of extrapulmonary TB is important to initiate early management.
Objective: To find out the proportion of HIV-positive in extrapulmonary TB patients, to recognize the demographic pattern of extrapulmonary TB patients and to identify clinical characteristics of EPTB in HIV-positive and negative patients.
Methods: This is a cross-sectional study using medical record data of extrapulmonary TB patients from all units in Cipto Mangunkusumo Hospital, Jakarta during 2008 to 2012. All adult extrapulmonary TB patients who had complete medical record data and their anti-HIV ELISA examined were included. Data were processed descriptively
using SPSS 17.0 software.
Results: This study obtained data from 620 extrapulmonary TB patients, 75.97% of which were HIV-positive. Most patients were between 18-40 years old, 76.6% were male, 57.7% graduated from high school or equivalent and 46.13% were unemployed. The most common extrapulmonary TB in HIV-positive subjects was lymphadenitis (42.59%) and in HIV-negative was meningitis (36.18%). Major systemic clinical presentations include weight loss, prolonged fever and fatigue. Clinical characteristics of each extrapulmonary TB type were similar in HIV-positive and HIV-negative patients.
Conclusion: Extrapulmonary TB was more common in HIV-positive patients. Most extrapulmonary TB patients were male, 18-40 years old, high school or equivalent graduates and unemployed. Clinical characteristics of each extrapulmonary TB type were similar in HIV-positive and HIV-negative patients.
Key words: Clinical characteristics, extrapulmonary tuberculosis, HIV.

Background: Community-acquired pneumonia (CAP) remains a major cause of death from infectious disease. Knowing its prognostic factors is important to tailor patient management. Previous studies overseas about predictors of mortality were mostly done on elderly. Only one previous study in Indonesia was found but it was limited on the elderly.
Objectives: To determine the mortality predictors in patients with CAP in Cipto Mangunkusumo Hospital, Jakarta. Methods: A retrospective cohort was conducted on hospitalized patients with CAP in Cipto Mangunkusumo Hospital between 2010-2014. Clinical data, laboratory results and outcome (all-causemortality and survival)were collected from medical records. Bivariate analysis using chi-Square test was performed on age group, loss of consciousness, comorbidity (represented as Charlson Comorbidity Index/CCI >5), sepsis, respiratory failure, severe pneumonia, hemoglobin level <9 g/dl, leucocyte count <4000/μl or >20000/μl, albumin level <3 g/dl and blood glucose level >200 mg/dl. Missing data were handled with multiple imputation. Multivariate logistic regression analysis was performed to identify independent predictors of mortality.
Results: A total of 434 patients were evaluated. In-hospital mortality rate was 23.9%. There were 237 (54.6%) female patients. Median age of population was 58 (18-89) years old and median length of stay was 8 (1-63) days. The most common pathogen was Klebsiella pneumoniae (28%). Multivariate analysis revealed severe pneumonia (OR 29.42; 95%CI 20.81-41.58), sepsis (OR 3.65; 95%CI 2.57-5.19), respiratory failure (OR 3.2; 95%CI 1.9-5.37), CCI score >5 (OR 2.25; 95%CI 1.6-3.15) and albumin level <3 g/dl (OR 1.42; 95%CI 1.04-1.95) as independent mortality predictors.
Conclusion: Severe pneumonia, respiratory failure, sepsis, CCI score >5 and albumin level <3 g/dl were independent predictors of in-hospital mortality among hospitalized patients with CAP in Cipto Mangunkusumo Hospital.
Key words: Community-acquired pneumonia, mortality predictors

Background: Anti-tuberculosis regiments have been reported to cause drug-induced liver injury (DILI) which interferes with the therapy itself and thus increases morbidity and mortality in tuberculosis patients. There has been no medication aimed specifically to prevent DILI related to anti-tuberculosis regiments. Objective: To look for scientific evidences regarding hepatoprotective property of N-acetylcysteine (NAC) to prevent DILI related to anti-tuberculosis medication.
Methods: Clinical question had been formulated before relevant scientific articles were sought in online databases using keywords extracted from the clinical question. Articles were then sorted based on the inclusion criteria, exclusion criteria and relevance.
Results: Two relevant articles in regards of the clinical question were found. Both provide scientific evidences that NAC reduced the occurrence of DILI related to anti-tuberculosis medications. Outcome indicators include good cell viability, prevention of DNA damage and decrease in hepatic enzymes and plasma bilirubin. Conclusion: Administration of NAC has hepatoprotective effect to prevent DILI related to anti-tuberculosis medications.
Key words: Tuberculosis, drug-induced liver injury, N-acetylsysteine, hepatoprotective

Background: Community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality in elderly patients. Vitamin C as an antioxidant agent may prevent excessive pulmonary inflammation and assist the resolution of CAP. A systematic review mentioned vitamin C as potential adjunctive therapy for mild CAP in vitamin C-deficient elderly patients but evidences are still scarce.
Objective: To obtain the prevalence of vitamin C deficiency in elderly patients with CAP and to determine the role of vitamin C status in the resolution of CAP in elderly patients.
Methods: A prospective cohort was conducted on 65 patients above 60 years old who were diagnosed with CAP, received therapy according to guidelines and were not in immunosuppressive therapy in the emergency unit and wards of Cipto Mangunkusumo Hospital, Jakarta during April to June 2012. Subjects were assigned into vitamin C-deficient group and non-deficient group. Resolution and median resolution rate of each group were calculated. The differences between groups were examined using log-rank test. Hazard ratio was determined using Cox regression models. Multivariate analysis of confounding variables was carried out with Cox regression test.
Results: The prevalence of vitamin C deficiency in elderly CAP patients was 76.92% (95%CI 66.68-87.16%). The rate of resolution on tenth day in vitamin C-deficient group was 56% and in non-deficient group was 53%, while the rate of resolution on fourth day in deficient group was 20% and in non-deficient group was 40%. Median resolution rate in deficient and non-deficient group was 9 days and 5 days, respectively. Log-rank test did not reveal statistically significant difference in resolution rate between both groups with crude HR 1.18 (95%CI 0.54-2.58; p=0.69). Conclusion: The prevalence of vitamin C deficiency in elderly CAP patients in Cipto Mangunkusumo Hospital was
76.92% (95%CI 66.68-87.16%). There was no significant difference in the resolution of CAP between vitamin C-deficient and non-deficient elderly patients.
Key words: Vitamin C deficiency, community-acquired pneumonia, resolution, elderly.

Background: The severity of tuberculosis (TB) disease and its appropriate treatment is determined by bacillary load, extent of disease and anatomical site. A case of pulmonary TB is classified as severe when parenchymal involvement is extensive or miliary disseminated. Meanwhile, extra-pulmonary TB is classified as severe when it manifests as meningeal, pericardial, peritoneal, bilateral or extensive pleural effusion, spinal, intestinal and genitourinary TB. Severe TB patients have higher risk of death.
Objective: To assess the profile of hospitalized severe TB patients in Cipto Mangunkusumo Hospital, Jakarta.
Methods: A descriptive study was performed on hospitalized severe TB patients in Cipto Mangunkusumo Hospital between January 2008-September 2013. Data of inpatients at admission and in-hospital mortality status were assessed.
Results: A total of 78 patients were evaluated. In-hospital mortality rate was 34,6%. There were 52 (66.7%) male and median age of the sample was 30 (range 18-80) years old. Miliary TB was found in 40 (51,3%) subjects, whereas meningeal TB was found in 38 (48,7%) subjects. A major part (65,8%) of the patients were malnourished with BMI <18,5 kg/m2. Fifty percent subjects were HIV-positive. Chronic liver disease was the most common comorbidity (20,5%).
Conclusion: Most hospitalized severe TB patients in Cipto Mangunkusumo Hospital were male at 18-80 years old. Most of the patients had military TB. Most of the patients were malnourished. Chronic liver disease was the most common comorbidity. In-hospital mortality rate was high.
Key words: In-hospital mortality, profile, severe tuberculosis.

Background: Initial phase of sepsis is marked by hyperinflammation, while later phase is related to immunosuppression. Cumulative deaths are more common during late phase. To date there has been no specific study to determine prognostic factors and develop a prediction model to predict mortality in late-phase sepsis. Objective: To discover prognostic factors of mortality in late-phase sepsis patients in intensive care units and to develop a mortality prediction model.
Methods: A retrospective cohort was performed on adult patients with severe sepsis who survived for more than
72 hours in Intensive Care Unit of Cipto Mangunkusumo Hospital, Jakarta during October 2011 to November 2012. Independent predictors were identified using Cox’s proportional hazard. Statistically significant predictors were quantified in a prediction model. Callibration model was evaluated using Hosmer-Lemeshow test, while discrimination ability was assessed by area under the curve of receiver operating curve. Results: A total of 220 subjects were recruited. The 28-day mortality in late-phase severe sepsis was 40%. Statistically significant prognostic factors include the reason of ICU admission (medical HR 2,75; CI95% 1,56-4,84 or emergent surgery HR 1,96; CI95% 0,99-3,90), Charlson’s comorbidity index >2 (HR 2,07; CI95% 1,32-3,23), and MSOFA score >4 (HR 2,84; CI95% 1,54-5,24). Prediction model has good ability in discrimination (AUC 0,844) and calibration (Hosmer-Lemeshow test p=0,674). Based on the model, mortality risk was classified into low risk (score 0, mortality 5,4%), moderate risk (score 1-2,5, mortality 20,6%), and high risk (score >2,5, mortality 73,6%). Conclusion: Medical and emergent surgery as reasons of ICU admission, Charlson’s comorbidity index >2 and MSOFA score >4 are prognostic factors of mortality in late-phase severe sepsis patients in ICU of Cipto Mangunkusumo Hospital. A model was developed to predict and classify risk of mortality. Risk of mortality was classified into low (score 0), moderate (score 1-2.5) and high (score >2.5).
Key words: Prognostic factors, prediction model, mortality, late-phase severe sepsis.

Background: Community-acquired pneumonia (CAP) severity assessment is crucial to determine disease severity and provide better management to decrease 30-day mortality rate. Antithrombin III (AT-III) as a biomarker of coagulation may play a role in determining the diagnosis and prognosis of patients with CAP. Objective: To determine the association between the level of AT-III at hospital admission with 30-day mortality in patients with CAP.
Methods: This is a prospective cohort study. A total of 55 subjects who met CAP criteria in the emergency department of H. Adam Malik Hospital, Medan during February to May 2013 were examined using CURB-65 score. The level of ATIII was measured. Chi-square test was used to determine the association between AT-III level and 30-day mortality. Results: Among 55 subjects, all 9 subjects with low levels of AT-III had severe CAP based on CURB-65 score. Of 20 (36,4%) subjects who died, 8 (88,9%) subjects had low level of AT-III. There is a significant relationship between low levels of AT-III and 30-day mortality (p=0,0001).
Conclusion: Antithrombin-III levels at hospital admission in patients with CAP is associated with 30-day mortality. The lower AT-III level is, the higher 30-day mortality will be.
Keywords: Community-acquired pneumonia, CURB-65, antithrombin-III, 30-day mortality.

Mediastinal chondrosarcoma is an exceedingly rare case, particularly in posterior mediastinum. In this case, a 28 years old male was referred to Cipto Mangunkusumo Hospital, Jakarta with chief complaint of worsening dyspnea since one month complementedwith mild cough and fever. Thorax rontgen and CT scan revealed mediastinal mass and pneumothorax. More thorough EBUS TBNA, bronchoscopy, esophagoscopy, EUS and biopsy were performed. From EBUS TBNA an image of a mass similar to thymoma was discovered, but immunohistochemistry test could not be carried out due to inadequate sample. Later EUS imaging revealed chondrosarcoma. The diagnosis of this tumor was difficult because small biopsy or needle biopsy usually warranted only small amount of tissue leading to false interpretation of chondrosarcoma as type A thymoma, solitary fibrous tumor or synovial sarcoma. The patient went through five sessions of radiotherapy, however thoracotomy was not performed because endotracheal intubation was not feasible to execute. The patient was let out with plans of chemotherapy.
Key words: Diagnosis, chondrosarcoma.

Background: End-stage renal disease (ESRD) can lead to pulmonary complications, especially pulmonary edema due to increased permeability of capillary and also intravascular and interstitial volume overload. These conditions lead to altered physiological and mechanical function of the lungs and subsequent increase in airway resistance. Objective: To determine the impact of hemodialysis on pulmonary function in ESRD patients undergoing regular hemodialysis.
Methods: An analytical-descriptive cross-sectional study was conducted on 90 ESRD patients on sustained HD in HD Unit of H. Adam Malik Hospital and Pirngadi Hospital, Medan during March to April 2013. Spirometry testing was applied on subjects before and after one session of HD, measured using a single device and independent operator. Results: Of the 90 samples 55 were male (61.1%) and 35 were female (38.9%) with mean age 50.18 ± 12.51 years old, duration of HD 21.27 ± 17.87 months, mean hemoglobin level 9.48 ± 1.21 mg/dl, ureum 110.17 ± 38.40 mg/dl and creatinine 11.50 ± 3.39 mg/dl. After hemodialysis, there were a significant increase in FEV1, FCV and FEV1/ FVC (p<0.01) and also a significant decrease in body weight (p<0.01). After HD, there was a significant correlation between decrease in body weight and improvement in FVC (p=0.006).
Conclusion: Hemodialysis is associated with significant improvement in spirometry parameters in ESRD patients undergoing regular HD.
Key words: End-stage renal disease, hemodialysis, pulmonary edema, spirometry

Background: Infections, including pneumonia, become most common etiology of lung diseases in Indonesia. Procalcitonin (PCT) level endocrine response to bacterial infections. Procalcitonin level may distinguish bacterial and viral infections and is also on par with bacterial load, giving it prognostic value.
Objective: To assess the correlation between quantitative procalcitonin (PCT) levels with patients’ responses to therapy of community-acquired pneumonia (CAP).
Methods: This is an analytic-observational prospective study. The study was conducted in Wahidin Sudirohusodo Hospital, Makassar from September 2014 to January 2015. Procalcitonin level in plasma samples from in-hospital CAP patients was measured quantitatively using immunoluminometric method before and 72 hours after administration of empirical antibiotic. The correlation between PCT level and responses to therapy was analyzed using Wilcoxon signed ranked test.
Results: A total of 30 plasma samples were collected and examined. Initial PCT level in CAP subjects with negative response to therapy was higher than in subjects with positive response (mean 8.86 vs. 3.43; p=0.49). Procalcitonin level at 72 hours post-treatment in subjects with negative response to therapy was higher than in subjects with positive response (mean 9,36 vs 1,52; p=0,01). The difference between the levels of initial PCT and PCT level 72 hours post-treatment was larger in CAP subjects with positive response to therapy compared to subjects with negative response (mean 1,09 vs. -0,51; p=0,004).
Conclusion: There is a correlation between quantitative PCT levels and responses to CAP therapy. Procalcitonin level
72 hours after treatment was higher in subjects with negative response to therapy while the difference of initial and
72 hours post-therapy was higher in subjects with positive response to therapy.
Key words: Procalcitonin, response to therapy, community-acquired pneumonia.

Ultrasonografi (USG) adalah modalitas pemeriksaan radiologi yang menggunakan gelombang ultrasound, yaitu gelombang suara di atas ambang dengar manusia (>20.000 Hz). Frekuensi gelombang yang digunakan pada USG transabdominal atau jantung adalah 2-5 MHz. Pada pemeriksaan kulit, frekuensi dapat mencapai 100 MHz.1
Selama bertahun-tahun, USG tidak digunakan untuk evaluasi paru karena udara dianggap menghambat gelombang yang dipantulkan.2 USG toraks seolah-olah terbatas penggunaannya untuk massa atau efusi pleura dan tindakan yang berhubungan dengan keduanya. Dewasa ini, penggunaan ultrasonografi khususnya USG toraks mengalami perkembangan yang pesat baik untuk kondisi akut maupun kronik, mulai dari edema paru hingga acute lung injury, dari pneumotoraks hingga pneumonia, dan dari penyakit paru interstisial hingga kontusio dan infark paru.3
Pemeriksaan USG toraks amat bermanfaat karena mudah dipelajari, tekniknya lebih sedikit dibandingkan USG lainnya, dapat dilakukan dengan cepat, portabel, aman diulang, dan juga tidak memiliki efek radiasi. Ultrasonografi toraks memiliki jendela akustik yang khas dan sangat sesuai untuk evaluasi dalam kondisi rawat jalan maupun rawat inap, akut maupun kronik.3

Background: End-stage renal disease (ESRD) can lead to pulmonary complications, especially pulmonary edema due to increased permeability of capillary and also intravascular and interstitial volume overload. These conditions lead to altered physiological and mechanical function of the lungs and subsequent increase in airway resistance. Objective: To determine the impact of hemodialysis on pulmonary function in ESRD patients undergoing regular hemodialysis.
Methods: An analytical-descriptive cross-sectional study was conducted on 90 ESRD patients on sustained HD in HD Unit of H. Adam Malik Hospital and Pirngadi Hospital, Medan during March to April 2013. Spirometry testing was applied on subjects before and after one session of HD, measured using a single device and independent operator. Results: Of the 90 samples 55 were male (61.1%) and 35 were female (38.9%) with mean age 50.18 ± 12.51 years old, duration of HD 21.27 ± 17.87 months, mean hemoglobin level 9.48 ± 1.21 mg/dl, ureum 110.17 ± 38.40 mg/dl and creatinine 11.50 ± 3.39 mg/dl. After hemodialysis, there were a significant increase in FEV1, FCV and FEV1/ FVC (p<0.01) and also a significant decrease in body weight (p<0.01). After HD, there was a significant correlation between decrease in body weight and improvement in FVC (p=0.006).
Conclusion: Hemodialysis is associated with significant improvement in spirometry parameters in ESRD patients undergoing regular HD.
Key words: End-stage renal disease, hemodialysis, pulmonary edema, spirometry.

Rongga toraks dan jaringan atau organ di dalamnya sering menjadi lokasi metastasis kanker dari dalam ataupun luar toraks. Lesi dapat ditemukan di parenkim paru, pleura, perikardium, otot jantung, kelenjar getah bening di hilus atau mediastinum, tulang iga, maupun vertebra torakal. Penting diketahui apakah keganasan yang ditemukan merupakan tumor primer atau sekunder karena tata laksananya akan berbeda.

INSIDENS
Kanker paru pada satu sisi dapat bermetastasis ke sisi lainnya, menjadikan klasifikasi tumor tersebut M1a. Kadang metastasis berbentuk ekskavasi sehingga harus dibedakan dengan kavitas akibat infeksi kronik. Kanker organ lain yang sering bermetastasis ke parenkim paru, di antaranya melanoma maligna, karsinoma genitourinaria, sarkoma jaringan lunak dan osteogenik, serta neoplasma sel germinal. Berdasarkan satu laporan autopsi, metastasis ke paru ditemukan pada 30-40% pasien kanker primer ekstratorakal, namun hanya 10-30% yang terdeteksi sebelum pasien meninggal.

Kanker paru adalah tumor yang tumbuh dari epitel respiratori (bronkus, bronkiolus, dan alveoli). Adenokarsinoma merupakan tipe yang kerap terjadi pada bronkioloalveoli. Karsinoma bronkioloalveolar meliputi permukaan alveolar tanpa menginvasi atau merusak jaringan paru. Faktor risiko utamanya adalah tembakau. Akan tetapi, pada individu berisiko rendah (bukan perokok, wanita, dewasa muda), kanker paru tetap dapat ditemukan dengan adenokarsinoma sebagai predominasi. Pada kasus ini, seorang wanita berusia 59 tahun memiliki keluhan sesuai gejala karsinoma paru tanpa ada faktor risiko. Foto polos toraks memperlihatkan massa pada paru sebelah kiri, kemudian CT scan memperjelas adanya massa paru dengan gambaran ireguler. Biopsi dengan bantuan CT scan mendapat gambaran adenokarsinoma. Staging memberikan hasil T1bN0M0 sehingga dilakukan reseksi massa paru. Pemeriksaan jaringan pasca-reseksi menunjukkan staging T3N0M0 sehingga dilakukan prosedur kemoterapi ajuvan dengan sisplatin dan paklitaksel.