Terapi Inhalasi Konvensional Pada Pasien Dewasa

 

Fatih Anfasa¹, Gurmeet Singh²

 

 

1 Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo

2 Divisi Respirologi dan Penyakit Medis Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo

Alamat korespondensi: Dr. dr. Gurmeet Singh, SpPD, K-P. Departemen Ilmu Penyakit Dalam FKUI-RSCM. Jl Diponegoro No. 71, Jakarta Pusat.

Alamat email: gurmeetsingh10@yahoo,com

 

Abstrak

Terapi inhalasi konvensional merupakan salah satu terapi penting pada berbagai penyakit saluran nafas, terutama asma dan penyakit paru obstruktif kronik (PPOK). Pemberian obat melalui inhalasi memberikan berbagai keuntungan dibandingkan pemberian obat melalui jalur lainnya terutama untuk penyakit yang melibatkan organ pernapasan. Meskipun demikian, keefektifan terapi akan berkurang jika pasien tidak dapat menggunakan alat inhalasi dengan tepat. Kesalahan pemakaian alat inhalasi berhubungan dengan menurunnya kontrol penyakit asma, prognosis PPOK yang buruk, serta meningkatkan morbiditas dan mortalitas. Sari pustaka ini bertujuan untuk menjabarkan mekanisme terapi inhalasi konvensional dan berbagai modalitas terapi yang ada untuk pasien dewasa.   

Kata Kunci: terapi inhalasi, pasien dewasa

 

 

Abstract

Conventional inhalation therapy is an important therapy for various respiratory diseases, especially asthma and chronic obstructive pulmonary disease (COPD). Administering drugs via inhalation provides various advantages compared to other routes, especially for diseases involving the respiratory organs. However, the effectiveness of therapy will be reduced if the patient cannot use the inhalation devices correctly. Incorrect use of inhalation devices is associated with decreased asthma control, poor COPD prognosis, as well as increased morbidity and mortality. This article aims to describe the mechanism of conventional inhalation therapy and various therapeutic modalities available for adult patients.

Keywords: inhalation therapy, adult patients

KORELASI NYERI DENGAN AGITASI PADA PASIEN YANG TERINTUBASI DI ICU RUMAH SAKIT UMUM PUSAT HAJI ADAM MALIK MEDAN

 

 

Muhammad Syakur1 ,  Tasrif Hamdi ^{2  ,} Andriamuri Primaputra Lubis²

 1Program Studi Magister Kedokteran Klinik / Program Studi Anestesiologi dan Perawatan Intensif, Fakultas Kedokteran, Universitas Sumatera Utara-Rumah Sakit Umum H. Adam Malik Medan, Indonesia

2Program Studi / Departemen Anestesiologi dan Perawatan Intensif, Fakultas Kedokteran, Universitas Sumatera Utara-Rumah Sakit Umum H. Adam Malik Medan, Indonesia

 

ABSTRAK

Latar Belakang: Agitasi umum terjadi pada pasien ICU dan dapat disebabkan oleh faktor-faktor seperti lingkungan baru, paparan obat, kondisi medis, dan kondisi kesehatan mental. Nyeri juga banyak dialami oleh pasien yang diintubasi di ICU yang menerima perawatan medis seperti suctioning ETT, pemasangan kateter urin, nasogastrik, dan tindakan perawatan pasien rutin sehari-hari dapat memperburuk agitasi. Dalam perawatan ICU, penting untuk mempertimbangkan hubungan antara agitasi, nyeri, delirium, dan faktor-faktor lain untuk mengelola dan mengatasi kondisi pasien secara efektif.

Tujuan: Untuk menganalisis korelasi antara nyeri menggunakan CPOT dan agitasi menggunakan RASS pada pasien intubasi di ICU Rumah Sakit Umum Haji Adam Malik.

Metode: Desain penelitian adalah analitik observasional dengan studi cross sectional menggunakan skala CPOT dan RASS sebagai alat ukur selama periode Oktober 2023.

Hasil: Semua data karakteristik (usia, jenis kelamin, BMI, durasi perawatan ICU, dan durasi penggunaan ventilator) tidak menemukan perbedaan dan korelasi (p>0,05) antara kelompok non-bedah dan bedah. Ada perbedaan yang signifikan secara statistik (p<0,001) antara pengukuran pagi dan sore di semua penilaian hemodinamik. Diketahui ada korelasi positif yang signifikan (p<0,001) antara CPOT dan RASS pada pagi hari dengan tingkat korelasi sedang (r = 0,516) dan arah korelasi positif. Tidak ada korelasi yang signifikan secara statistik yang ditemukan antara CPOT malam dan RASS malam. Diketahui bahwa perbedaan nilai CPOT pagi dan RASS pagi dan sore hari signifikan secara statistik (p<0,05), tetapi pada CPOT malam hari tidak ada perbedaan yang signifikan antara kelompok dosis. Diketahui ditemukan perbedaan nilai CPOT pagi pada Golongan 2 dengan 3 (p<0,001) dan Golongan 1 dengan Golongan 3 (p<0,001). Pada pagi hari ditemukan nilai RASS pada Kelompok 2 dengan 3 (<0,001) dan Kelompok 1 dengan Kelompok 3 (<0,001). Pada malam hari RASS, perbedaan signifikan ditemukan pada Kelompok 2 dan Kelompok 3 (p = 0,037).

Kesimpulan: Terdapat korelasi yang signifikan (p<0,001) antara nyeri dan agitasi pada pasien yang diintubasi di ICU Rumah Sakit Umum Adam Malik dengan tingkat korelasi sedang. CPOT dianggap memiliki manfaat untuk digunakan di ICU.

Kata kunci: agitasi, nyeri, ICU, RASS, dan CPOT

Biomarker of Post-COVID-19 Lung Fibrosis: A Systematic Review and Meta-Analysis of Cohort Studies

Gede Ari Mahendra Mardaningrat¹*, Putu Andrika², Isabella Soerjanto Putri¹, I Putu Hendri Aryadi¹

¹ Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia

² Division of Pulmonary and Critical Care, Department of Internal Medicine, Udayana University/Prof. dr. I.G.N.G Ngoerah Hospital, Denpasar, Bali, Indonesia

 

Abstract

Introduction: The World Health Organization (WHO) labeled COVID-19 as a pandemic. On January 7, 2024, an estimated 774,075,242 confirmed cases of COVID-19 had occurred, resulting in 7,012,986 deaths. Pulmonary fibrosis is commonly observed as a consequence of COVID-19 infection, with a reported prevalence of up to 83.3% in individuals who have recovered from the disease. Pulmonary fibrosis that develops after a COVID-19 infection arises from the immune system's reaction to the virus, resulting in inflammation and lung damage.

Objective: This systematic review and meta-analysis were conducted to determine the laboratory biomarker findings in patients with post-COVID-19 lung fibrosis.

Methods: Systematic review and meta-analysis adhering to the PRISMA and MOOSE guidelines. We conducted a literature search on PubMed, EMBASE, and Web of Science from January 1, 2020, to January 31, 2024.

Results: Nine eligible studies, including 1,406 patients, were identified. The research results showed that several biomarkers had statistically significant values such as lymphocytes (MD: -0.35; 95% CI: -0.49; -0.21), CRP (MD: 40.73; 95% CI: 27.78; 53.69), D-dimer (MD: 0.76; 95% CI: 0.18; 1.34), lactate (MD: 38.43; 95% CI: 19.73; 57.13), and interleukin-6 (MD: 16.97; 95% CI: 2.57; 31.37). Meanwhile, for biomarkers such as white blood cells (MD: 0.14; 95% CI: -0.54; 0.81) and neutrophils (MD: 3.71; 95% CI: -3.80; 11.23), the values were not statistically significant for the occurrence of lung fibrosis.

Conclusion: The diagnosis of pulmonary fibrosis is generally established using biopsy or CT scans. However, in some hospitals with limitations on healthcare resources and equipment such as CT scans, these biomarkers can be used in diagnosing pulmonary fibrosis, especially in patients after experiencing COVID-19 infection.

 

Keywords: Biomarker, COVID-19, Lung Fibrosis, Sars-Cov2

FACTORS CORRELATED WITH INCREMENTAL SHUTTLE WALK TEST DISTANCE IN SEDENTARY HEALTHY ADULTS

 

Astrid Priscilla Amanda¹, Nury Nusdwinuringtyas¹, Tresia Fransiska Ulianna Tambunan¹, Dewi Friska²

¹Physical Medicine and Rehabilitation Department, Cipto Mangunkusumo Hospital,

Faculty of Medicine, Universitas Indonesia

²Community Medicine Department, Faculty of Medicine, Universitas Indonesia

 

 

Abstract

Background: In carrying out daily activities, it is influenced by a person’s physical fitness. A person’s functional capacity can be assessed by exercise testing distance. One of the exercise tests that currently being applicated nowadays is incremental shuttle walk test (ISWT). There are various factors that affect cardiorespiratory fitness, as well as demographic and anthropometric characteristics such as age, gender, body height, and body weight. This study focused on demographic and anthropometric factors.

Objective: The aim of this study was to determine the factors that correlate with ISWT distance in sedentary healthy adults

Material and Methods: This study was a cross-sectional study conducted on 85 subjects. Subjects performed ISWT twice, with the greatest distance was included in analysis. The independent variables (age, gender, body height, body weight) were analyzed using bivariate analysis to see the correlation with ISWT distance. Furthermore, multivariate analysis was done to see the most influential variable.

Results: Sixty women were participated in this study. Among four variables, multivariate analysis showed gender, body height, and body weight correlated with ISWT distance (p<0,05)

Conclusion: Gender, body height, and body weight correlated with ISWT distance in sedentary healthy adults.

 

Keywords: Incremental shuttle walk test, distance, sedentary, healthy, field test

Low Alveolar Macrophages Function, Low BALF IL-6 Level and High BALF CD4 Cell Count is Associated with Successful Extubation and Survival in Severe Pneumonia Patients: Prospective Cohort Study

 

Gurmeet Singh^1,2, Cleopas Martin Rumende¹, Iris Rengganis³, Zulkifli Amin¹, Tonny Loho⁴, Emmy Hermiyanti Pranggono⁵, Kuntjoro Harimurti⁶, Heri Wibowo⁷, Nova Bornida Fauzi¹, Sudirman Fakhruddin Masse¹, Laila Fakhriyatuz Zakiyah¹

 

¹Division Respirology and Critical Illness, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

²Doctorate Program Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.

³Division of Allergy and Clinical Immunology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

⁴Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

⁵Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr Hasan Sadikin Hospital Bandung, Bandung, Indonesia.

⁶Department of Internal Medicine, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

⁷Head of Integrated Laboratory, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.

A case of concurrent tuberculous pleural effusion and peritonitis

Vanya Utami Tedhy1 , Nurhidayat Mohammad1, Lie Khie Chen2, Mira Yulianti3
1Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia
2Division of Tropical Disease and Infection, Department of Internal Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
3Division of Respirology and Critical Illness, Department of Internal Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
Introduction: Extrapulmonary tuberculosis accounted for about 16% of 7.5 million tuberculosis cases worldwide in 2019 with lymph nodes, pleura, and gastrointestinal system as its most common sites of infection.
Case description: A 36 year-old female patient presented with dyspnea and abdominal distention due to unilateral pleural effusion and ascites. She had accompanying symptoms of weight loss and night sweat since 6 months prior to her presentation. The patient’s medical history was unremarkable, but she had positive contact with tuberculosis patients. Diagnostic approach was taken. Both pleural fluid and ascitic fluid were analysed, revealing exudative fluid with lymphocyte predominance. ADA for both pleural and ascitic fluid was elevated. Abdominal CT scan showed para-aortic lymphadenopathy, omental thickening, and complex ascites. Pleural fluid culture for Mycobacterium was positive for M. tuberculosis. Diagnosis of tuberculous pleural effusion and peritonitis was made and anti-tuberculous treatment was initiated.
Conclusion: The variable manifestation of extrapulmonary TB can make diagnosis difficult, but this diagnosis should always be considered especially in the setting of high TB prevalence. Confirmatory diagnosis with microbiological examination should always be attempted, but clinical feature highly suspicious of TB supported with biological marker can aid in the diagnosis of extrapulmonary TB.
Keywords: tuberculous pleural effusion, tuberculous peritonitis, extrapulmonary tuberculosis

ABSTRA CT
Introduction: Extrapulmonary tuberculosis accounted for about 16% of 7.5 million tuberculosis cases worldwide in 2019 with lymph nodes, pleura, and gastrointestinal system as its most common sites of infection.
Case description: A 36 year-old female patient presented with dyspnea and abdominal distention due to unilateral pleural effusion and ascites. She had accompanying symptoms of weight loss and night sweat since 6 months prior to her presentation. The patient’s medical history was unremarkable, but she had positive contact with tuberculosis patients. Diagnostic approach was taken. Both pleural fluid and ascitic fluid were analysed, revealing exudative fluid with lymphocyte predominance. ADA for both pleural and ascitic fluid was elevated. Abdominal CT scan showed para-aortic lymphadenopathy, omental thickening, and complex ascites. Pleural fluid culture for Mycobacterium was positive for M. tuberculosis. Diagnosis of tuberculous pleural effusion and peritonitis was made and anti-tuberculous treatment was initiated.
Conclusion: The variable manifestation of extrapulmonary TB can make diagnosis difficult, but this diagnosis should always be considered especially in the setting of high TB prevalence. Confirmatory diagnosis with microbiological examination should always be attempted, but clinical feature highly suspicious of TB supported with biological marker can aid in the diagnosis of extrapulmonary TB.
Keywords: tuberculous pleural effusion, tuberculous peritonitis, extrapulmonary tuberculosis

Seorang Laki-Laki 49 Tahun Dengan Tuberkulos Monoresisten Isoniazid (Hr-TB) : Kasus Pertama  Hr-TB di RSUP dr.Kariadi Semarang

Arif Wicaksana1, Fathur Nur Kholis2, Banteng Hanang Wibisono2
1Resident of Internal Medicine, Department of Internal Medicine, Faculty of Medicine, Diponegoro University
2 Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine,
Diponegoro University
Introduction : Drug Resistance Tuberculosis still become one of biggest burden on Global TB Control. Isoniazid Resistance Tuberculosis (Hr-TB) is one form of Drug Resistance TB. Although Hr-TB cases is commonly found worldwide, yet this case is the first case to be reported in Kariadi Hospital Semarang.
Case Illustration : A 49-year-old male come with productive cough, sub-febris fever and weight loss within 1 month with history of Complete Drug Sensitive TB treatment 10 years ago. Patient had decreasing of vesicular sound and crackles in lower part of right lung. On chest radiographic evaluation found consolidation on lower base of right lung and image of tuberculosis. Sputum evaluation found Acid-fast Bacteria with Nucleic acid amplification tests (NAAT) detected M. Tuberculosis with rifampicin sensitive, Line Probe Assay (LPA) stated resistance of Low Dose and High Dose Isoniazid. Patient was given treatment regimen of 6RHZE-Lfx. Evaluation was done in second month of treatment that given no identification of Acid-fast bacteria, improvement on chest radiographic, and bodyweight.
Discussion : Hr-TB was found in 156 countries from 2003 until 2017, prevalence of Hr-TB is 7.6% of Newly Diagnosed TB and 11.4% of patient TB on treatment. Mechanism of resistance in Hr-TB are identified the mutation of katG ang inhA that decrease the antimicrobial function of Isoniazid. Diagnostic of Hr-TB based on WHO guideline is using NAAT and LPA to rule out resistance of INH and other line of regimen. WHO 2017 recommendation for Hr-TB treatment is RHZE-Lfx for 6 months. Addition of Fluoroquinolone to the regimen for Hr-TB strengthen treatment regimens since bactericidal effect of Isoniazid replaced by Lfx and became core drug for Drug Resistance TB. Adding Lfx shows improvement on results, and there is no evidence of including Isoniazid on regimen giving poor outcome on therapy.
Conclusion : Hr-Tb need to be identified on high-risk group to have proper diagnosis and therapy and give better prognosis and improve TB elimination.
Keyword : Tuberculosis, Isoniazid, Resistance
ABSTRAK
Pendahuluan : Tuberkulosis resisten obat masih menjadi salah satu permasalahn pada ELiminasi TB secara global. Tuberkulosis mnoresisten isoniazid (Hr-TB) adalah salah satu bentuk TB Resisten Obat. Walaupun kasus Hr-TB banyak ditemukan secara global, tetapu kasus ini adalah kasus pertama yang dilaporkan di RSUP dr. Kariadi Semarang
Ilustrasi Kasus : Seorang laki-laki 49 tahun dating dengan batuk produktif, demam sub febris dan penurnan berat badan dalam 1 bulan dengan Riwayat pengobatan TB Sesitif Obat lengkap 10 tahun yang lalu. Pada pasien ditemukan penurunan suara vesikuler pada dan ronki kasar pada basal paru kanan. Pada pemeriksaan ronsen thoraks didapatkan konsolidasi pada basal paru kanan dan gambaran yang mendukun tuberculosis. Pada pemeriksaan dahak ditemukan BTA dan TCM mendeteksi M. Tuberkulosis dengan sensitive rifampisin. PEmeriksaan Line Probe Assay (LPA) menyatakan resisten dari Isoniazid dosis rendah dan dosis tinggi. Pasien diberikan regimen pengobatan ^RHZE-Lfx. Evaluasi dilakukan pada bulan kedua dari pengobatan dan didapatkan BTA negative dan perbaikan pada ronsen thorakas dan berat badan.
Diskusi : Hr-TB ditemukan pada 156 negara dari 2003 hingga 2017, prevalensi dari Hr-TB adalah 7.6% dari TB kasus baru dan 11.4% pada pasien yang sedang pengobatan TB. MEkanisme reistensi dari Hr-TB diidentifikasi pada mutasi gen katG dan inhA yang menurunkan fungsi antimicrobial dari Isoniazid. Diagnosis dari Hr-TB berdasarkan Guideline WHO menggunakan TCM dan LPAuntuk menemukan adanya resistensi Isoniazid dan regimen lain. Rekomendasi WHO 2017 untuk pengobatan Hr-TB adalah RHZE-Lfx untuk 6 bulan. Penambahan FLuoroquinolon pada regimen untuk Hr-TB memperkuat efek bakterisidal dan menggantikan efek bakterisidal dari Isoniazid dan menjadi core drug untuk TB Resisten Obat. PEnambahan Lfx menunjukan perbaikan pada hasil dan melibatkan Isoniazid pada terapi tidak membuktikan perburukan luaran dari terapi.
Kesimpulan : Hr-TB perlu diidentifikasi pada kelompok resiko tinggi dan mendapatkan diagnosis dan tatalaksana yang tetap untuk mendapatkan prognosis yang lebih baik dan meningkatkan angka eliminasi TB.
Kata Kunci : Tuberkulosis, Isoniazid, Resitensi

Hubungan Penyakit Komorbid dan Faktor Prognostik dengan Mortalitas pada Pasien COVID-19 Critical ill Bulan Juni - Desember 2021 di Ruang Intensive Care RSUP Prof. DR. I.G.N.G Ngoerah Denpasar

Ni Wayan Eka Satyawati1, Putu Andrika2
1Program Studi Spesialis Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Udayana/RSUP Prof. Dr. I.G.N.G. Ngoerah Denpasar, Bali, Indonesia
2Staf Divisi Pulmonologi dan Penyakit Kritis, Departemen/KSM Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Udayana/ RSUP Prof. Dr. I.G.N.G. Ngoerah Denpasar, Bali, Indonesia

Background : Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV2). The spread of COVID-19 occurs globally and designated as a pandemic with clinical manifestations of COVID-19 mainly affect the respiratory system. COVID-19 there is often an increase in inflammatory response, thrombosis, coagulopathy, and the presence of comorbid chronic diseases which is associated with increased degree of disease severity, morbidity and mortality. In this study, aimed that there will be a relationship between the presence of comorbid diseases (Diabetes Mellitus, hypertension, and chronic kidney disease) as well as prognostic factors (platelet levels, neutrophil lymphocyte ratio (NLR), procalcitonin and D-dimer) with mortality in critically ill COVID-19 patients in the Intensive Care Unit (ICU) Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar.
Methods : This research is an analytical study with a retrospective approach using secondary data from medical records with a purposive sampling method. The population was all medical record data for critically ill COVID-19 patients in the ICU Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar period June - December 2021 as many as 397 patients. The analysis performed was univariate and bivariate analysis with the Chi-Square statistical test using the SPSS 26.0 application for windows.
Results : In this study, based on data from patients critical ill period June - December 2021 were treated in the ICU Prof. Dr. I.G.N.G Ngoerah Hospital Denpasar obtained that the predominant age was 45-59 years for 214 patients (53.9%), with a mortality rate of 133 patients (50.6%). The gender factor was more in males, 229 patients (57.7%) with a mortality rate of 154 patients (58.6%) The bivariate test results found no significant relationship between age and mortality and between gender and mortality in critically ill COVID-19 patients, with a p-value of 0.148 and 0.62. In the comorbid factor data, more patients with hypertension were found, namely 154 patients (38.8%), while type II DM was 141 patients (35.5%) and chronic kidney disease 84 patients (21.2%). Based on the results of the bivariate test, there was no significant association with mortality in critically ill COVID-19 patients with comorbid factors, with p-values of 0.31 and 0.67, respectively. Whereas in the comorbid factors of chronic kidney disease, the results of bivariate tests found a significant relationship with mortality in critically ill COVID-19 patients, p-value 0.03. In terms of platelet levels, there were more platelets with normal platelet levels, namely 308 patients (77.6%) with bivariate test results, there was no significant relationship with mortality in critically ill COVID-19 patients, p-value 0.23. The factor of NLR levels was higher with an increase in NLR in 365 patients (91.9%), procalcitonin levels was higher with increased procalcitonin in 283 patients (71.3%), D-dimer levels with increased D-dimer levels in 370 patients (93.2%), with the results of bivariate tests there is a significant relationship with mortality in critically ill COVID-19 patients, p-value 0.001 for NLR, p-value 0.000 for procalsitonin and p-value 0.013 for D-dimer.
Conclusion : In this study it was found that the age and gender factors did not have a significant relationship with mortality in critically ill COVID-19 patients who were treated in the June-December 2021 period at Prof. Dr. IGNG Ngoerah Denpasar. While the comorbid factors studied were mostly hypertension, followed by type II DM and chronic kidney disease. However, comorbid chronic kidney disease has a significant relationship with mortality in critically ill COVID-19 patients. As for the levels of routine investigations carried out in patients with COVID-19, they are a complete blood count (in this study including NLR and platelet values) as well as procalcitonin and D-dimer levels. In this study it was found that elevated NLR, procalcitonin and D-dimer levels had a significant relationship with mortality in critically ill COVID-19 patients.
Keyword : COVID-19 critical ill, comorbid, D-Dimer, procalcitonin

Diagnostic Accuracy and Prediction of COVID-19 Outcome Using Artificial Intelligence Based on Radiological Data, Clinical and Laboratory Parameter at Dr. Sardjito General Hospital, Yogyakarta

Harik Firman Thahadian 1 Ika Trisnawati1 Eko Budiono1 Bambang Sigit Riyanto 1 Heni Retnowulan1 Nur Rahmi Ananda1 Sarah Ulfa 1 Tani Prima Auladina1 Imam Manggalya Adhikara 1 Sumardi
1 Department of Internal Medicine of Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada Yogyakarta
Introduction: The application of the “color heat-map” method through identifying and analyzing chest X-ray images transferred into AI (artificial intelligence) to generate scores. The aim of this research to was to evaluate the diagnostic accuracy of artificial intelligence scores of Chest X-Ray for predicting the clinical outcome of COVID-19 patients and establishing a scoring system using predictor variables based on AI scoring data based on chest X-rays, clinical parameters, and laboratories of COVID-19 patients.
Methods: A retrospective study collected data from hospitalized COVID-19 patients in Dr. Sardjito General Hospital, Yogyakarta, between 2020 and 2022. The data collected is clinical, laboratory parameters, patient outcomes, and values from AI Chest X-Ray readings. Artificial intelligence was used to detect radiographic abnormalities using CAD4COVID-Xray software (Thirona, Nijmegen, Netherlands). Receiver operator curve (ROC) to evaluate the predictive value of the AI probability score and AI Affected Lung Area score. Multiple logistic regression analysis selected some variables to develop the scoring model.
Results: Four hundred forty-nine (449) patients were included in the study: 237 males (52,8%), median age 56 years (IQR = 45-65). ROC analysis shows that the AI probability score (AUC = 0.875, CI 95% 0.801-0.948) and AI ALA score (AUC = 0.836, CI 95% 0.766-0.906) have sufficient discrimination ability to determine the degree of disease severity of COVID-19 confirmed subjects. Multiple logistic regression analysis from clinical, laboratory, and clinical outcomes showed that this scoring system uses seven variables (5 clinical and two laboratory variables) and has a good prognostic ability to predict the severity of COVID-19 patients. Based on the stratification of scoring results, we found that the scoring value of low-risk patients (1-2 points) had a mortality proportion of 7.8.%, moderate risk ((3-5) points) had a mortality proportion of 38.7%, and high-risk ((6-9) points) had a mortality proportion of 76.9%.
Discussion: Using an AI-based score derived from radiographic, clinical, and laboratory parameters may be beneficial to estimate prognosis in confirmed COVID-19 patients.

Thymoma Presenting as Superior Vena Cavaa Syndrome
Putri Indah Permata1, Fauzar2, Roza Kurniati2 Eifel Faheri3
1. Peserta Program Pendidikan Dokter Spesialis Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Andalas,
RSUP Dr. M. Djamil Padang, Indonesia
2. Divisi Pulmonologi, Program Studi Penyakit Dalam, Fakultas Kedokteran Universitas Andalas RSUP Dr. M. Djamil Padang, Indonesia
3. Divisi Hematologi Onkologi Medik, Program Studi Penyakit Dalam, Fakultas Kedokteran Universitas Andalas
RSUP Dr. M. Djamil Padang, Indonesia
Pendahuluan
Timoma adalah neoplasma yang jarang terjadi yang berasal dari sel epitel timus dengan prevalensi 0,5-1,5% dari semua keganasan di Amerika Serikat. Pada 2018-2023 ditemukan 20 kasus pasien timoma yang dirawat di RSUP M Djamil. Gejala klinis dapat berupa nyeri dada, dispnea, batuk, atau sindrom vena kava superior akibat efek pendesakan pada organ yang berdekatan.
Ilustrasi Kasus
Laki-laki, 28 tahun dirawat di Bagian Penyakit Dalam RSUP Dr. M. Djamil Padang mengeluhkan sesak nafas yang hebat sejak 3 hari sebelum masuk RS disertai dengan bengkak pada leher, wajah, dan tangan kanan. Pemeriksaan fisik didapatkan keadaan umum berat, takipneu, dan pemberton sign positif. Pada pemeriksaan laboratorium didapatkan hasil dalam batas normal. Pemeriksaan CT Scan thoraks dengan kontras didapatkan tumor mediastinum anterior yang menekan vena kava superior. Dilakukan pemberian kortikosteroid dan radioterapi cito untuk keadaan emergency sindroma vena kava superior (SVKS). Setelah sesak berkurang, dilakukan pemeriksaan transthoracic needle aspiration (TTNA) dan trans thoracic biopsy (TTB) dengan hasil timoma. Selanjutnya pada pasien dilakukan kemoterapi sebagai terapi primer timoma karena massa tumor yang non-resectable.
Diskusi
Kasus ini menarik karena keberhasilan terapi pada pasien. Radioterapi dapat memberikan perbaikan klinis pada pasien SVKS kemudian dilakukan kemoterapi menggunakan regimen cisplatin, doxorubicin, siklofosfamid karena tumor non-resectable. Pada follow up setelah kemoterapi didapatkan perbaikan klinis dan pengecilan massa tumor pada pasien secara radiologis.
Kesimpulan
Timoma adalah tumor yang jarang dengan mortalitas tinggi. Pengobatan timoma harus dilakukan oleh tim multidisiplin untuk menentukan strategi perawatan yang tepat. Pilihan pengobatan kemoterapi memberikan perbaikan klinis pada pasien dengan massa yang non-resectable
Kata kunci: timoma, SVKS, radioterapi, kemoterapi

Predictors of Hair Zinc Deficiency and Its Association with the Severity of Community-Acquired Pneumonia in Dr. Cipto Mangunkusumo National General Hospital

 

Rosatya Imanuela¹, Gurmeet Singh², Nurul Ratna Mutu Manikam³, Kuntjoro Harimurti¹, Juferdy Kurniawan¹, Cleopas Martin Rumende², Sally Aman Nasution¹, Noto Dwimartutie¹

 

¹Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo National General Hospital

²Divison of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo National General Hospital

³Department of Nutrition, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo National General Hospital

 

Corresponding Author:

Gurmeet Singh, MD, PhD

Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital

Jalan Diponegoro 71, Central Jakarta, Indonesia

Email: gurmeetsingh10@yahoo.com

 

Abstract

 

Background: Zinc deficiency can cause immune disorders that can increase the severity of community-acquired pneumonia (CAP). One of the potential biomarkers of zinc deficiency is hair zinc levels because they are more stable. However, because zinc levels are not routinely tested, clinical predictors are needed to determine the profile of patients at risk of zinc deficiency, especially in CAP patients.

Methods: This study is a cross-sectional study using primary data. Ninety-three adult patients who were hospitalized with CAP at Cipto Mangunkusomo National General Hospital in July-August 2023 were included in this study. Sampling used the consecutive sampling method. Hair zinc levels were analyzed using spectrophotometry. Zinc intake during the last month was assessed using a semiquantitative food frequency questionnaire (FFQ). Medical history was obtained from hospital medical records and laboratory examinations. Bivariate tests using chi-square tests were performed on age, sex, nutritional status, diabetes mellitus, malabsorption, chronic kidney disease, liver cirrhosis, HIV/AIDS, and malignancies with hair zinc deficiency. Identification of predictors for hair zinc deficiency was carried out using a multivariate logistic regression test. A bivariate test was also performed using chi-square to assess the association between hair zinc deficiency and the severity of CAP, and then a multivariate analysis was performed on confounding variables.

Results: 10.75% of patients experienced hair zinc deficiency. Predictors for hair zinc deficiency in community-acquired pneumonia patients were diabetes mellitus (PR 4.800; 95% CI 1.339 – 17.199) and HIV/AIDS status (PR 6.000; 95% CI 1.356 – 26.544). There was no significant relationship between hair zinc deficiency and the severity of CAP.

Conclusion: The prevalence of hair zinc deficiency in this study population was 10.75%. Predictors for hair zinc deficiency in community-acquired pneumonia patients are diabetes mellitus and HIV/AIDS. However, there was no association between hair zinc deficiency and the severity of CAP in this study population.

 

Keywords: predictors, hair zinc deficiency, community-acquired pneumonia

PREDICTOR FACTORS FOR LENGTH OF STAY BASED ON SERUM BIOMARKERS IN MODERATE TO SEVERE COMMUNITY-ACQUIRED PNEUMONIA PATIENTS

Efata Polii¹, Gurmeet Singh², Yulia Rosa Saharman³, Jufferdy Kurniawan⁴

Martin Rumende², Arif Mansjoer⁵, Hamzah Shatri^6, Irsan Hasan⁷

 

¹Departement of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

²Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

³Departement of Clinic Microbiology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

⁴Clinical Epidemiology Unit, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

⁵Division of Cardiology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

⁶Division of Psychosomatic and Palliative, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

⁷Division of Hepatobilier, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

 

Corresponding Author: Efata Polii, 085256183214, efata.md@gmail.com

 

ABSTRAK

Latar belakang : Pneumonia komunitas (PK) merupakan penyakit dengan insiden morbiditas dan mortalitas global yang tinggi. Serum biomarker dapat digunakan sebagai prediktor untuk lama rawat pada pasien PK. Studi ini bertujuan untuk mendapat sistem skoring menggunakan beberapa serum biomarker seperti prokalsitonin, C-reactive protein (CRP), leukosit, asam laktat, D-dimer dan albumin terhadap lama rawat pasien PK sedang berat.

Metode : Studi ini menggunakan desain kohort prospektif pasien PK sedang berat yang dirawat di IGD/ICU/HCU RSUPN dr. Cipto Mangunkusumo periode Mei 2022 s/d Juli 2023. Variabel-variabel prediktor lama rawat pasien PK sedang berat didapatkan dari hasil analisis multivariat dengan regresi logistik.

Hasil : Dari total 360 subjek yang memiliki lama rawat >14 hari sebanyak 204 subjek (56,67%) dan ≤14 hari sebanyak 156 subjek (44,44%). Variabel prediktor yang secara konsisten mempengaruhi lama rawat adalah asam laktat dengan RR 1,305 (IK 95% 1,097 – 1,551, p=0,003) dan albumin dengan RR 2,234 (IK 95% 1,164– 2,156, p=0,003). Analisis kurva ROC menunjukkan kemampuan prediksi lemah (AUC=0,629). Performa kalibrasi dengan uji Hosmer-Lemeshow test menunjukkan validasi baik (0,562). Biomarker lain yang dianggap signifikan dalam analisis bivariat yaitu prokalsitonin dengan RR 1,481 (IK 95% 1,121-1,954, p=0,006) dan CRP dengan RR 2,465 (IK 95% 1,141-5,326). Leukosit tidak dinilai signifikan sebagai biomarker PK sedang berat (p = 0,947).

Kesimpulan : Terdapat hubungan antara prokalsitonin, CRP, asam laktat dan albumin  dengan lama rawat pasien PK sedang berat.  Tidak terdapat model skoring lama rawat pasien PK sedang berat.

 

Kata Kunci : pneumonia, lama rawat, serum biomarker

Comparison of Enteral and Parenteral Nutrition in Cancer Patients with Dyspnea: Evidence-Based Case Report

Ni Putu Menganti Harum Putrinata1 Gurmeet Singh2
1Faculty of Medicine, Universitas Indonesia
2Pulmonology Division, Internal Medicine Department, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia

Abstract

Background: The role of nutritional support for cancer patients in palliative care still become a controversial topic, because an ambiguity in choosing between enteral and parenteral treatment were still found in clinical practice, yet a comparison of effectiveness between enteral and parenteral nutrition in cancer patients with dyspnea still remain scarce.

Objective: The purpose of this evidence-based case report is to identify the effectiveness of enteral nutrition compared to parenteral nutrition in adult patients with cancer and dyspnea.

Methods: Literature searching were performed on Pubmed, Cochrane, and Google Scholar database to obtain RCT studies. Searches were made with keyword “enteral nutrition”, “parenteral nutrition”, “dyspnea” “cancer” and “dyspnea score”. Selecting the studies were further based on exclusion and inclusion criteria by results, title, abstract, and full-text screening.

Result: Two studies were found to be relevant according to the criteria. These studies showed that enteral nutrition showed more effectiveness compared to parenteral nutrition in reducing dyspnea score.  Study by Cotogni P et al showed enteral nutrition was more significant in giving lower Modified Borg Dyspnea Score [p =0.01], similarly to the results of study by Kao et al [p=0.05]. However, included study patients is different than patients in clinical practice settings. Therefore, there is a consideration regarding the applicability.

Conclusion: Based on two articles that have been reviewed, enteral nutrition has a positive effect on reducing Modified Borg Dyspnea Score in patients with cancer compared to parenteral nutrition.

 

Keywords: enteral nutrition, parenteral nutrition, dyspnea score, cancer

COMPARING THE EFFECTIVENESS OF FIXED-DOSE COMBINATIONS AND SEPARATE-TABLET REGIMENS ON 2-MONTH PULMONARY TUBERCULOSIS SPUTUM CONVERSION
Ichsan Fauzi Triyoga1, Mira Yuliarti2
1Program Studi Profesi Dokter, Fakultas Kedokteran Universitas Indonesia
2Divisi Pulmonologi, Departemen Gastroenterohepatobilier, Rumah Sakit Umum Pusat Nasional Cipto
Mangunkusumo, Fakultas Kedokteran Universitas Indonesia

ABSTRACT

Background: Tuberculosis (TB) is one of the leading causes of death amongst other non-communicable diseases, accounting for up to 845 thousand cases in 2020 in Indonesia alone. Currently, the WHO recommends the use of anti-tuberculosis fixed dose combinations (FDCs) for treating lung TB. However, before the existence of FDCs, patients rely on the use of anti-TB separate tablets (STs). Both forms offer excellent effectiveness and could be measured objectively through bacterial smear conversion, but different dosages and compliance in each individual may alter the outcomes they offer.
Methods: 5 online databases (Cochrane Central Registers of Trials, Cochrane Database of Systematic Review, Embase Classics, MEDLINE(R) ALL, and Pubmed) were used in finding potential studies. Studies were appraised using the Oxford Center for Evidence-Based Medicine (CEBM) Tool, specifically in the validity, importance, and applicability of the studies.
Result: 24 articles were acquired from literature search, and 3 randomized controlled trials (RCTs) were reviewed. All studies found statistically insignificant results between FDCs and STs in 2-month sputum smear conversion. The negative percentage of patients with a negative 2-month sputum conversion result using FDCs ranges from 88% - 96% and those using STs ranges from 89% - 96%. Relative risk results for all studies are within the 95% CI range, hence precision of results are more certain.
Conclusion: In conclusion, all studies reported FDCs nor STs to have significant effectiveness difference in 2-month sputum smear conversion rate. Future studies should consider doing individual analysis of these forms of anti-TB treatment on bacterial smear conversion with factors that could influence conversion time.
Keywords: fixed dose combinations, separate tablets, 2-month sputum smear conversion, lung tuberculosis

Frailty As A Predictor of Mortality Among Elderly Patients With Pneumonia: A Systematic Review and Meta-Analysis

RA Tuty Kuswardhani¹, I Desak Putu Agung Krisdanti², Christina Permata Shalim³

 

¹Division  of  Geriatric  Medicine,  Department  of  Internal  Medicine,  Faculty  of  Medicine,  Udayana University/Prof Dr. I.G.N.G. Ngoerah Hospital, Bali, Indonesia

²Department of Pulmonology and Respiratory, Faculty of Medicine, Udayana University/Udayana University Hospital, Bali, Indonesia

³Siloam Hospitals Kebon Jeruk, Jakarta, Indonesia

ABSTRACT

Introduction: Pneumonia is a significant cause of morbidity and mortality among elderly patients.
Assessing the prognostic factors associated with pneumonia outcomes is crucial for clinical decision-making. This systematic review and meta-analysis aimed to evaluate the impact of frailty on mortality in elderly patients with pneumonia.
Methods: We performed a systematic search on the electronic databases PubMed, Cochrane Library, and Science Direct up to June 12th, 2023. Studies reporting the association between frailty and mortality in elderly patients with pneumonia were included. Quality assessment of the included studies was appraised using a Newcastle-Ottawa Scale. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using random-effects models.
Results: Seven studies involving a total of 376,170 elderly pneumonia patients were included in the meta-analysis. The pooled results demonstrated a significant association between frailty and mortality in this population (pooled OR = 2.76, 95% CI: 2.22-3.44; p<0.00001). Frailty was also significantly associated with prolonged hospitalization (pooled OR = 2.74, 95% CI: 1.90-3.96; p<0.00001).
Conclusion: Frailty is significantly associated with increased mortality and prolonged
hospitalization in elderly patients with pneumonia.
Keywords: elderly, frailty, mortality, pneumonia

SUSPECT HEPATOPLEURAL FISTEL INITIATED BY LUNG ABCESS BECOMES
HYDROPNEUMOTHORAX WITH THE COMPLICATION OF LIVER ABCESS
Sri Indah Indriani1*, Indra Yovi1, Aulia Rezha Yomitra1, Elvando Tunggul Maulite Simatupang1, Heri Krisnata Ginting2, Hariadi Hatta3
1Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Riau University - Arifin Achmad General Hospital Pekanbaru
2Department of Internal Medicine, Faculty of Medicine, Riau University - Arifin Achmad General Hospital Pekanbaru 3Department of Thoracic Cardiovascular Surgery, Faculty of Medicine, Riau University - Arifin Achmad General Hospital Pekanbaru

ABSTRACT
Background: A liver abscess is an inflamed liver lesion that can migrate into the pleural cavity and cause lung abscess and empyema. Hepatopleura fistulas are one of the reasons why cancer might spread to the pleural cavity.
Case: A 25-year-old man complains of sudden shortness of breath, exacerbated by strenuous activity. An x-ray was performed showing a lung abscess. after 6 days, a repeat x-ray showed a hydropneumothorax, and a Water Sealed Drainage was performed. An abdomen ultrasound was carried out and found a picture of a liver abscess. In the patient’s condition, repeated abdominal ultrasounds were done to determine the size of the liver abscess and repeated chest X-rays were done to examine the WSD. No hepatopleural fistula was discovered in this patient, and the liver abscess was less than 5 cm, therefore drainage was not necessary. Antibiotics were administered to the patient. The patient was treated for 40 days and it was found that the lungs had not expanded an open pleural window was performed.
Conclusion: This patient was then consulted for thoracic and cardiovascular surgery for further management of the lungs that had not yet expanded and fluid production was still ongoing, a decision was made with further intervention.
Keywords: Hydropneumothorax, Lung Abscess, Liver Abscess

THE USE OF INDWELLING PLEURAL CATHETER
FOR MALIGNANT PLEURAL EFFUSION
Sri Indah Indriani*, Indra Yovi, Elvando Tunggul Mauliate Simatupang
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Riau University, Pekanbaru, Riau

ABSTRACT

Malignant Pleural Effusion (MPE) is one of the metastatic processes that occur due to lung cancer. MPE condition can be used as one of the parameters to assess the degree of disease and prognosis of lung cancer patients. Shortness of breath is the most common symptom experienced by lung cancer patients. Indwelling Pleural Catheter (IPC) are recommended as effective management for shortness of breath in patients. The use of IPC also has a pleurodesis effect on problems in the pleura. Palliative therapy with the use of IPC can reduce the length of hospitalization and drainage treatment can be done on an outpatient basis. The development of IPC selection as the first line in MPE cases is also supported by several recent studies so its use is more recommended to be applied to MPE. Some other studies mentioned that IPC is rarely used due to limitations for installation techniques and long-term care is needed after IPC installation.
Keywords: Procedure, Indwelling Pleural Catheter, Malignant Pleural Effusion

 Dampak Keterlambatan Pengembalian Rekam Medis Pasien Rawat Inap Terhadap Pelaporan RS Dan Pengajuan Klaim BPJS Kesehatan Di RSU Ganesha Kabupaten Gianyar

I Gusti Ayu Dina Lasmi Putri1, Bambang Hadi Kartiko, 2, Dylla Hanggaeni Dyah Puspaningrum 3

Program Studi Perekam dan Informasi Kesehatan, Universitas Dhyana Pura1,2,3

ABSTRACT

 In accordance with the standard operating procedures set by the Ganesha General Hospital, the late return of inpatient medical records is defined as the return of medical records from the inpatient room to the medical record unit beyond the time limit of 3 x 24 hours from the time of collection. The aim of this research is to determine the impact of late returns on home reporting of pain and claims from the Social Security Administration (BPJS).The research is based on a descriptive qualitative analysis of 224 overdue medical records and a sample of 10 officers at the Medical Record Installation. returned in July-December 2022. The results of the analysis showed that data from July 2022 through December 2022 showed that out of 510 inpatient medical records, 138 (27%) had medical records. returned not timely before the 25th of the current month, and there are 86 (17%) medical records that were returned not on time after the 25th of the current month. The impact of the late return of inpatient medical records is the delay in reporting RL 4a and RL.5.3 to the Department of Central Health, the increased workload of reporting officers, and the decreased ability of hospital management to make informed decisions. Aside from that, it has an effect on the time it takes for BPJS insurance documents to be sent in with claims, on the time it takes to give health services to patients, especially for repeat visits, on the amount of work that medical record keepers have to do, and on the amount of money that hospitals make. Based on the results of the study, it can be concluded that: late reports on hospital activities (RL 4a and RL.5.3) to the Department of Central Health; the increased workload of reporting officers and medical record officers; and delays in providing BPJS insurance documents have had an impact on hospital income.

Keywords: Impact of late return of Medical Records, Hospital Reporting RL4a and RL.5.3, BPJS Claims

 

 

HYPOXEMIA DURING BRONCHOSCOPY PROCEDURE:
WHAT WE NEED TO UNDERSTAND AND HOW TO ANTICIPATE IT
Sri Indah Indriani*, Chyntia Triana Putri, Elvando Tunggul Mauliate Simatupang,
Arya Marganda Simanjuntak, Adelia Pratiwi
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine,
Riau University, Pekanbaru, Riau

ABSTRACT

By inserting a Diagnostic Sign (bronchoscope) into the airway, bronchoscopy is an invasive medical treatment that allows tracheobronchial viewing in order to evaluate pathological abnormalities that develop in the lung. The importance of bronchoscopy is growing as lung disease cases become more complex and the demand for minimally invasive diagnostic methods rises. Use of bronchoscopy as a diagnostic and therapeutic tool are its two primary indications. With a low morbidity rate (0.1–2.5%) and a very low fatality rate (0.05%), bronchoscopy is a surgery that is generally considered to be safe. The risk of consequences from bronchoscopy still exists, one of which being hypoxemia. One of the most frequent side effects brought on by several variables is hypoxemia. Due to the use of sedation during bronchoscopy, hypoxemia frequently happens. This situation is often transient and is reversible. The operator must take into account the possibility of hypoxemia while doing the process in order to know when to stop. Hypoxemia should be anticipated, therefore monitoring and oxygen supplementation should be priorities during the process.
Keywords: Hypoxemia, Complications, Bronchoscopy

 EDITORIAL

Sub-spesialis Konsultan Pulmonologi dan Medik Kritis

Seorang Konsultan Pulmonologj dan Medik Kritis (KPMK) merupakan seorang yang telah menjadi spesialis penyakit dalam dan melajutkan pendidikan subspesialis/konsultan di bidang pulmonologi. Seorang KPMK adalah anggota Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI) dan juga anggota komunitas seminat Perhimpunan Respirologi Indonesia (PERPARI). Subspesialis ini memiliki kompetensi yang lebih dalam dan dapat menangani kasus-kasus yang lebih kompleks atau yang membutuhkan tindakan di bidang Respirologi dan Penyakit Kritis. Adapun kompetensi SpPD-KMPK yaitu respirologi, intervensi pulmonologi, ventilasi mekanik (di HCU/ICU), dan juga penyakit kritis. Sekitar tahun 1952, ilmu penyakit kritis/medik kritis baru dikembangkan sebagai suatu ilmu tersendiri.

 

Acute Digitalis Toxicity presenting as Bradycardia in patient with Atrial Fibrillation with Heart Failure         

 RaymondPranata1,Emir Yonas2, Veresa Chintya3

1General Practitioner, Tabanan General Hospital, Tabanan, Bali, Indonesia 2Faculty of Medicine, YARSI University, Jakarta, DKI Jakarta, Indonesia 3General Practitioner, Sanjiwani General Hospital, Gianyar, Bali, Indonesia

ABSTRACT

 

INTRODUCTION: Digitalis is used for atrial fibrillation to reduce the ventricular rate and has narrow therapeuticwindow. Mortality associated with unrecognized digitalis intoxication is high and often unacknowledged.

CASE ILLUSTRATION:A86 years old male presented with fatigue since 1 day before admission. PMH of AF, HHD, CHF and CKD.PE: BP 90/60, HR: 48 bpm, RR: 20x/minute. ECG: AF SVR 40-50x/minute ‘reverse tick sign’ ST depression, LAD. Lab: Hyperkalemia andeGFR 22.92 mL/min. Previous echocardiography: Grade III diastolic dysfunction + LVH. IV hydration was given using normal saline 200 mL initially, insulin and glucose were administered to reduce potassium level.

DISCUSSION:Digitalis cause an increase in vagal activity and prolong conduction in the AV node, excessive effect in this patient cause reduced ventricular rate. ST-segment depression resembling a ‘reverse tick’ signified digitalis effect not necessarily toxicity. Digitalis toxicity can emerge even when the serum digitalis concentration is within the therapeutic range.The narrow therapeutic index of and pharmacokinetic changes associated with aging increases the risk of toxicity. The elimination of digitalis is mainly by renal clearance and is prolonged inCKD. This patient was an elderly and has eGFR of 22.92 mL/min, hence in high risk of digoxin toxicity.Ideally, digitalis Fab fragments is indicated for a K + level greater than 5 mmol/L. CONCLUSION:Atrial fibrillation is the most common sustained arrhythmia and digoxin is widely used as rate control especially in those with heart failure.Digitalistoxicity is important to recognize and receive prompt treatment should toxicity arises.

Keywords:digitalis, digoxin, toxicity, atrial fibrillation

 

 

A Case of Spontaneous Hemorrhagic Transformation in a patient with Cardioembolic Stroke due to Atrial Fibrillation

Raymond Pranata1, Veresa Chintya2, Emir Yonas3

1General Practitioner, Tabanan General Hospital, Tabanan, Bali, Indonesia 2General Practitioner, Sanjiwani General Hospital, Gianyar, Bali, Indonesia 3Faculty of Medicine, YARSI University, Jakarta, Indonesia

ABSTRACT

INTRODUCTION: Hemorrhagic transformation (HT) refers to aspectrum of ischemia-related brain hemorrhage and is associated with increased morbidity and mortality of acute ischemic stroke.

CASE ILLUSTRATION: An 83 years old female presented with loss of consciousness 30 minutes before admission. Her past medcal history of congestive heart failure, hypertension, atrial fibrillation (AF), and stroke. Physical examination showed GCS 7 andBP 190/100 mmHg. Electrocardiography showed Atrial Fibrillation NormoVentricular Response and Left Ventricular Hypertrophy. Laboratory examination showed thrombocytopenia, hypokalemia,and INR of 1,8. National Institutes of Health Stroke ScaleScore: 16CHA₂ DS₂ -VASc: 7, HAS-BLED: 4.Thorax Xray revealed cardiomegaly and Thorax CT Scan depicted characteristic of hemorrhagic transformation of an ischemic infarct. The patient was treated with hemorrhagic stroke protocol and mannitol.

DISCUSSION: Atrial fibrillation is associated with greater volumes of more severe baseline hypoperfusion, leading to higher infarct growth, more frequent severe HT and worse stroke outcomes. This patient has massive infarction andAFwhich were independent predictors of HT risk. In patients with AF probability of bleeding was about 95% if the volume of infarction edema >10 cm3.Hemorrhagic transformations may occur in patients with acute ischemic stroke who received thrombolytic, however, it may also occur spontaneously in 12.3 % of patients with ischemic stroke. Warfarin has been associated with increased HT riskirrespective of INR and aPTT values. Hemorrhage risk stratification score might be used to predict HT in acute ischemic stroke.Anticoagulant may be reinitiated after 4-8 weeks. Long-term anticoagulation with NOAC (similar efficacy with lower bleeding risk compared to VKA) or Left atrial appendage occlusion.

CONCLUSION: One-third of ischemic stroke patient may experience hemorrhagic transformation.Physician must strike a balance between stroke recurrence and HT.

Keywords:Atrial Fibrillation, Stroke, Anticoagulant

 

 

Difficulty in Controlling Malignant Pleural Effusion

Ignatius B Prasetya1, Eric D Tenda2
1Department of Internal Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
2Division of Respirology and Critical Care, Department of Internal Medicine, Universitas Indonesia, Cipto
Mangunkusumo Hospital, Jakarta, Indonesia

ABSTRACT

Malignant pleural effusion is the second leading cause of exudative pleural effusions, usually recurrent and represents advanced malignant disease. Treatment options were restricted to symptomatic purpose in order to increase functional capacity and quality of life. In this case, a 35-years old woman with history of breast cancer was admitted with worsening dyspnea since 4 months prior. The patient was told that there was fluid in her left lung. She underwent thoracocentesis twice, pleuroscopy and pleurodesis with little success. The treatment option switches to placement of pleural catheter to control the effusion. This option, however, may leave the patient and caregivers with routine task of aspiration of the fluid and with greater risk of infection.
Key words: Malignant pleural effusion

The Role of Chronic Inflammation in the Development of Depression in COPD Patients

Vania Tryanni 1 , Hamzah Shatri1,3, Dika Sinulingga1, Vinandia Irvianita1, Edward Faisal1, Rudi Putranto1, Gurmeet Singh2, Ceva W. Pitoyo2
1 Psychosomatic and Palliative Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
2 Respirology and Critical Care Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
3 Clinical Epidemiology in Department of Internal Medicine, Faculty of Medicine Universitas Indonesia- Cipto Mangunkusumo Hospital, Jakarta, Indonesia

ABSTRACT

COPD is one of the most prevalent disease and the prevalence is still increasing. Depression is one of the most prevalent comorbid found in COPD and associated with increase mortality and reduced quality of life. The linked between booth of them can’t be fully elucidated. One of the theories is chronic inflammation. Increase inflammatory state is associated development of depression to some pathway, and there is direct link between serotonin-inflammation. COPD is a well-known inflammatory state with same increasing inflammatory state. There are also similar characteristics between depression with inflammatory stated and depression in COPD such as atypical symptom and resistance to therapy. Studies also proved that there were increase in cytokine especially IL-6 , IL-2 and IFN gamma in COPD -Depression.
Keyword: COPD, Depression, Chronic Inflammation

GAMBARAN EFEK SAMPING PANDUAN STANDAR JANGKA PENDEK DAN PANJANG PADA TUBERKULOSIS RESISTEN OBAT
Annisa Nurfaujiah1, Ferdy Ferdian2, Basti Andriyoko3
1Program Studi Pendidikan Dokter, Fakultas Kedokteran, Universitas Padjadjaran
2Divisi Respirologi, Departemen Penyakit Dalam, Rumah Sakit Umum Hasan sadikin, Fakultas Kedokteran Universitas Padjadjaran, Bandung.
3Departemen Patologi Klinik, Rumah Sakit Umum Hasan sadikin, Fakultas Kedokteran Universitas Padjadjaran, Bandung

ABSTRACT

Drug resistant TB treatment requires more drugs, longer duration and more side effects. In 2020 WHO introduced an all-oral combination with a higher success rate but with additional side effect challenges. It is a descriptive observational study with a cross-sectional study design. The data used are medical records of patients aged over 18 years who have been declared complete treatment of TB-RO in January 2020 – June 2022 with an oral regimen of short-term and long-term treatment. Abnormal data results at the initial examination before starting treatment and incomplete or missing medical record data were not included in the study. The number of samples is determined by the total sampling method. The result from 69 patients who received short-term treatment combinations, nausea was the most common side effect (76.19%), followed by hyperuricemia (69.8%), vomit (55.56%), and QTc interval prolongation (44.44%). Out of 16 patients who received a combination of long-term treatment, the highest incidence was nausea (75%), arthralgia (62.5%) rash, itching, and headache (56.25%).The incidence of gastrointestinal disturbances, QTc prolongation, skin discoloration, hyperuricemia, hepatotoxicity, chest pain and tightness, and psychiatric disorders was higher in the short-term group. Meanwhile in the long-term regimen, tachycardia, itching and rash, arthralgia, visual and hearing impairment, neurological disorders, and neuropathy. Peripheral anemia and anemia were more common.
Keywords: Side Effects; Drug Resistant Tuberculosis; STR; LTR