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

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

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.

 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

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

TRAKEOSTOMI DILATASIONAL PERKUTAN PADA PASIEN PERAWATAN INTENSIF
Harris Soetanto, Gurmeet Singh
Internal Medicine Department, Universitas Indonesia, Faculty of Medicine. Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

PROGNOSTIC NUTRITIONAL INDEX (PNI) AS A PROGNOSTIC FACTOR IN STAGE IV LUNG ADENOCARCINOMA
Subroto 1, Eko Budiono 2, Sumardi 2
1Resident of Internal Medicine, Department of Internal Medicine Faculty of Medicine Public Health and Nursing Gadjah Mada University/Dr. Sardjito Hospital Yogyakarta
2Division of Pulmonology, Department of Internal Medicine Faculty of Medicine Public Health and Nursing Gadjah Mada University/Dr .Sardjito Hospital Yogyakarta

STUDI KUALITATIF RISIKO KESELAMATAN DAN KESEHATAN KERJA DENGAN METODE JOB SAFETY ANALYSIS PADA TENAGA PERAWAT

Sarah Linda Ginting1, Egi Dahan1, Andi Alim1, Asriani Minarti S2
1Fakultas Kesehatan Masyarakat, Universitas Pejuang Republik Indonesia
2Program Megister Kesehatan Masyarakat, Universitas Muslim Indonesia

ABSTRACT
Occupational safety and health in hospitals as health services is an important thing to consider. Nurses as one of the medical personnel in the hospital have risks and hazards that are quite vulnerable in every process of their work. Data from the PPI (Infection Prevention and Control) committee at DR Tadjuddin Chalid Makassar Hospital found 16 cases of needle stick accidents in the last 5 years. The purpose of this study was to determine the level of occupational safety and health risks that can occur in nurses in the emergency room unit of DR Tadjuddin Chalid Makassar Hospital. The research design used is qualitative with the approach method, namely risk management AS/NZS 4360: 2004 with the instruments of interview guidelines, observation, camera for documentation and JSA (Job Safety Analysis) to identify the risks and hazards of nurses’ work. Risk assessment using the semi-quantitative method of W. T. Fine from AS/NZS 4360:2004. The results of this study indicate that the highest risk in the emergency room with a value of 300 (Priority 1) is at the stage of anamnase and TTV (vital signs) of patients there is a risk of droplet contact hazards infected with infectious diseases of patients and in the installation of infusions there is a risk of needle stick hazards. The conclusion from the research results obtained is that technical improvements are needed, it is hoped that better supervision is expected in the implementation of SOPs for nursing actions and the active role of K3RS in identifying more stages of nurses’ work in the hospital.
Keywords: OHS, Nurses, JSA (Job Safety Analysis), AS/NZS 4360:2004

Pneumonectomy in Congenital Lobar Emphysema: A Case Report

 Susan Hendriarini Mety, I Putu Kokohana Arisutawan, Muhammad Aris Furqon

Staff of Cardiothoracic and Vascular Surgery Department, Persahabatan Hospital, Jakarta, Indonesia

Abstract

Background: Congenital lobar emphysema is a rare congenital disease which caused by anomaly on bronchial cartilage development. Usually, it is limited to a single lobe. It could be treated conservatively or surgically depend on the clinical condition. In this case report we would like to discuss the management strategy for congenital lobar emphysema that affected the whole lung in 17 days old baby.

Case presentation: The patient was admitted to NICU due to respiratory distress. The patient had a difficulty to wean from ventilator. Radiologic examination revealed the whole left hemithorax is filled by multiple bullae which push mediastinal organ contralaterally. Intraoperatively, we found the whole left lung is emphysematous and there is PDA which is not detected preoperatively. Surgeon decided to do pneumonectomy and PDA ligation. After operation, patient recovered on NICU slowly and discharged from hospital 34 days post operation.

Discussion : our case of congenital lobar emphysema which affect one side of lung is a rare case. Our decision to do pneumonectomy was challenging post operatively.

Conclusion: Multidisciplinary team should be involved in treatment of congenital lobar emphysema. Team should be prepared for prolonged intensive care if decision to do lung resection is chosen.

Keywords: Congenital lobar emphysema, pneumonectomy, neonates

Dampak Ketidaklengkapan Komponen Analisis Kuantitatif Pada Rekam Medis Pasien Rawat Inap Terhadap Tertib Administrasi Rekam Medis Di Rumah Sakit Umum Daerah Sanjiwani Kabupaten Gianyar

The Impact of Incomplete Components of Quantitative Analysis on Inpatient Medical Records on the Orderly Administration of Medical Records at sanjiwani regional general hospital, Gianyar regency

Desak Made Ayu Diah Ardiantari¹, Dr. dr. Bambang Hadi Kartiko, ², I Gusti Ngurah Manik Nugraha ³

Program Studi Perekam dan Informasi Kesehatan, Universitas Dhyana Pura^1,2,3

Email : ayudiahardiantari26@gmail.com

Abstract

                 Based on the observations of patient safety incident reports in 2021, there were 67 incidents and KTD reports, bpjs health cost claims in the first quarter of 2022 were returned totaling 81. The purpose of the study was to determine the impact of the incompleteness of the quantitative analysis component of the medical records of inpatients on the orderly administration of medical records at Sanjiwani Hospital, Gianyar Regency. The research design is descriptive qualitative analytics, with a sample of 8 officers in the Medical Record Installation.The results of the study obtained the impact of incompleteness of the components of the nitatitative analysis of medical records of inpatients, including the impact of incompleteness of identification reviews, namely: delays in the administrative service process for patients, difficulty placing forms on medical record bendels, difficulty distinguishing patients from one another, can result in drug dosage errors, and difficulty determining the ownership of medical records, the impact of incompleteness of important report reviews,  namely: the delay in providing the BPJS claim submission file, and the obstruction of bpjs claim submission, the impact of incomplete review of authentication, namely: medical records do not have legal validity, difficulties of the hospital if there is a lawsuit and there are difficulties if there is an error in the administration of drugs or drug allergies to patients, and the impact of incomplete review documentation, namely: delay in making KLPCM reports, and hampered submission of insurance claims.Based on the results of the study, it was concluded that it was: errors in identifying patients, delays in submitting BPJS claims, medical records could not be used as evidence of defense or legal protection, and the emergence of errors by medical personnel in reading patient medical records.

Keywords: Impact of incompleteness of quantitative components of medical records, orderly administration of medical records.

Perkembangan Precision Medicine di Indonesia

Dr. dr. Telly Kamelia, Sp.PD-KP, FINASIM¹,  dr. Nurul Amelia Rahayu Putri²

¹Pulmonology and Critical Care Division. Internal Medicine Department. Fakultas Kedokteran Universitas Indonesia. Dr. Cipto Mangunkusumo Hospital

2 Research Assistant. Fakultas Kedokteran Universitas Indonesia

Jakarta, Indonesia

ABSTRAK

Latar Belakang dan Tujuan: Kementerian Kesehatan Republik Indonesia (Kemenkes RI) melakukan pengembangan ilmu pengetahuan dan teknologi terutama di bidang genomika biomedis untuk mendukung terapi dan pengobatan yang presisi (precision medicine) dengan memperhatikan keanekaragaman genomika di Indonesia. Precision medicine merupakan sebuah inisiatif untuk mengedepankan pengolahan big data genomika sebagai acuan pelayanan kesehatan yang terintegrasi pada berbagai tingkat kaskade molekuler. Aktualisasi dari precision medicine di Indonesia adalah Biomedical Genome-based Science Initiative (BGSi). Artikel ini mengulas tentang perkembangan precision medicine, terutama di Indonesia.

Metode: Studi ini adalah review literatur. Terdapat 17 (tujuh belas) artikel yang didapatkan dari basis data daring di PubMed, grey literature dari situs web Kementerian Kesehatan, kebijakan yang telah terbit, pedoman nasional, serta Google Scholar.

Hasil: Hasil dari berbagai studi menunjukkan perkembangan precision medicine sebagai kosmologi kedokteran baru. Negara-negara maju di dunia mulai mengembangkan fondasi ekosistem bioteknologi kesehatan baru serta kebijakan terkait untuk mendukung precision medicine, termasuk Indonesia melalui Biomedical Genome-based Science Initiative (BGSi).

Kesimpulan: Sebagai kosmologi kedokteran baru, precision medicine menjembatani kosmologi kedokteran sebelumnya. Indonesia meluncurkan Biomedical Genome-based Science Initiative (BGSi) sebagai pendukung program pelayanan kesehatan berbasis data genomik. Terdapat berbagai tantangan dalam pengembangan precision medicine. Maka dari itu, diperlukan kerjasama antar pihak, baik pusat peneliti, pembuat kebijakan, politisi, klinisi, perusahaan obat, dan masyarakat, untuk mendukung keberhasilan BGSi di Indonesia.

Kata Kunci: precision medicine, big data, Biomedical Genome-based Science Initiative (BGSi), Indonesia

DIAGNOSTIK DAN MANAJEMEN TERKINI GANGGUAN PERNAPASAN SAAT TIDUR Obstructive sleep apnea (OSA) merupakan salah satu jenis gangguan napas saat tidur yang sering terjadi pada 14% pria dan 5% wanita. Penyakit OSA terjadi akibat episode berulang hambatan jalan napas atas, baik secara total (apnea) maupun parsial (hipopnea). OSA berhubungan erat dengan obesitas, hipertensi, gangguan fungsi dan struktur jantung dan vaskular, dan diabetes melitus. Diagnosis dapat ditegakan menggunakan hasil polisomnografi (PSG) yaitu: jika terdapat 5 atau lebih kejadian obstruksi pernapasan (apnea obstruktif dan campuran, hipopnea, atau respiratory effort-related arousals/RERA) per jam tidur pada pasien dengan satu atau lebih gejala: rasa kantuk berlebihan, tidur non-restoratif, kelelahan, atau muncul gejala insomnia; bangun tidur dengan tahanan napas, terengah-engah, atau tersedak; kebiasaan mendengkur, gangguan napas, atau keduanya yang disadari oleh orang lain yang tidur bersama atau orang lain; hipertensi, gangguan mood, gangguan kognitif, penyakit arteri koroner, stroke, gagal jantung kongesti, atrial fibrilasi, atau diabetes melitus tipe 2. Penyakit OSA merupakan penyakit kronik yang membutuhkan manajemen jangka panjang dan melibatkan multidisiplin. Pasien yang terdiagnosis OSA perlu diberikan edukasi komprehensif terkait penyakit, faktor risiko, gejala, dan komplikasi dari OSA. Modifikasi gaya hidup perlu dilakukan untuk mengontrol faktor risiko yang dapat memperberat gejala OSA.

PROFIL KARAKTERISTIK KLINIS PASIEN COVID-19 VARIAN OMICRON PADA RUMAH SAKIT DARURAT COVID-19 WISMA ATLET KEMAYORAN

Background : According to WHO, B.1.1529 or omicron has been found as a variant of SARS-CoV-2 with high num-ber of mutations and is easily transmitted. In a month, 108 countries have reported 151.368 cases. This study aims to determine the clinical characteristics of patients with confirmed Covid-19 Omicron variant being treated at Wisma Atlet Kemayoran Hospital. Methods : This research method is descriptive using retrospective data. Secondary data was taken from medical re-cords of patients with Covid-19 Omicron variant who were hospitalized on December 16 – January 16 2022 at Wisma Atlet Kemayoran Hospital. Inclusion criteria was all patients with confirmed mild to moderate COVID-19 Omicron variant. The data were processed by statistical software and analyzed univariately. Results : We reported a total of 227 patients in this study. Majority of samples were women (53.1%), the age average was 19 – 39 years (56.6%), 96.1% had no comorbidities. The majority are foreign travelers (88.2%), with traveler from Asia as much as 70.6%. A total of 96.1% have never had Covid-19 before. As many as 82% have received 2 doses of the vaccine. 56.6% of patients were asymptomatic with symptomatic patients mostly complaint of cough (31.1%). The lowest Hb value was 5.60, the highest leukocyte was 14.39μL, the highest SGOT was 208 U/L, the highest SGPT was 406 U/L and the highest D-Dimer was 8290 ng/mL. A total of 82.5% did not have lung abnormalities seen on x-ray. Conclusion : Covid-19 Omicron variant patients in this study are mostly female, with transmission from foreign trav-elers, the majority are asymptomatic and without pulmonary abnormalities on x-ray, and mostly do not need antibiotic nor antiviral therapy.
Keyword: Clinical characteristic; Covid-19; Omicron

Penatalaksanaan TB Diseminata dan Pneumonia Pada Pasien Gangguan Hati Kronis : Sebuah Laporan Kasus

Iis Widiayati¹, Jesica Supriadi¹, Nenny Agustanti², Pandji Irani Fianza³

¹Departemen Penyakit Dalam, Rumah Sakit Umum Hasan Sadikin, Fakultas Kedokteran, Universitas Padjadjaran, Bandung, Indonesia.

²Divisi Gastroenterohepatologi, Departemen Penyakit Dalam, Rumah Sakit Umum Hasan Sadikin, Fakultas Kedokteran, Universitas Padjadjaran, Bandung, Indonesia.

³ Divisi Hematoonkologi Medik, Departemen Penyakit Dalam, Rumah Sakit Umum Hasan Sadikin, Fakultas Kedokteran, Universitas Padjadjaran, Bandung, Indonesia.

ABSTRAK

     Frekuensi tuberkulosis meningkat empat belas kali lipat pada pasien dengan penyakit hati kronis dan sirosis hati (SH). Pemilihan obat anti tuberkulosis (OAT) pada pasien SH perlu memperhatikan derajat fibrosis hati. Pneumonia merupakan penyebab kedua tersering yang menyebabkan Acute on Chronic Liver Failure (ACLF) setelah Secondary Bacterial Peritonitis (SBP). CLIF Consortium Organ Failure Score  (CLIF-SOFA) dapat dipakai untuk memprediksi mortalitas SH dengan pneumonia.

     Seorang laki-laki berusia 53 tahun datang ke instalasi gawat darurat (IGD) dengan keluhan buang air besar hitam. Keluhan disertai adanya batuk lama, penurunan berat badan, demam, serta keringat malam. Pasien sudah diketahui menderita hepatitis B dan mendapatkan terapi Tenofovir sejak April 2022. Pasien didiagnosa dengan TB diseminata (TB milier dan peritonitis TB) dan terkonfirmasi dengan ditemukannya Mycobacterium tuberculosis (MTB) pada  hasil Tes Cepat Molekuler (TCM) sputum dan cairan asites. Pasien diterapi dengan regimen RHES. Pada hari perawatan kelima pasien didiagnosa dengan Hospital Acquired Pneumonia dan mendapatkan terapi Ceftazidime dan Levofloxacine. Pasien meninggal pada hari perawatan kesembilan karena repiratory failure.

     Pasien dengan Child-Turcotte-Pugh score  13 sebaiknya pasien diterapi dengan menggunakan obat yang tidak hepatotoksik selama 18-24 bulan. Pasien mengalami pneumonia pada hari perawatan kelima dengan skor CLIF-SOFA 10. Pneumonia mencetuskan terjadinya ACLF pada pasien. Semakin tinggi skor CLIF-SOFA, maka akan meningkatkan mortalitas pasien SH dengan pneumonia.

     Pemilihan OAT pada pasien dengan sirosis hati harus disesuaikan dengan derajat fibrosis hati. Deteksi infeksi pneumonia dan perhitungan CLIF-SOFA pada pasien SH dalam perawatan harus dilakukan sedini mungkin karena pneumonia merupakan penyebab ACLF kedua tersering dan meningkatkan mortalitas pada pasien sirosis hati.

Kata kunci: TB diseminata, pneumonia, sirosis hepatis, obat anti tuberkulosis

ABSTRACT

     Tuberculosis incidence increases fourteenfold in chronic liver disease and cirrhotic patients. The degree of liver fibrosis must be considered when selecting anti-tuberculosis drugs in cirrhotic patients. After Secondary Bacterial Peritonitis (SBP), Pneumonia is the second most common cause of Acute on Chronic Liver Failure (ACLF). CLIF Consortium Organ Failure Score (CLIF-SOFA) can predict mortality in cirrhotic and pneumonia patients.

     A 53-year-old man arrived at the emergency department complaining of black stools, a long cough, weight loss, fever, and night sweats. The patient had been treated for hepatitis B with Tenofovir since April 2022. He was diagnosed with disseminated tuberculosis (miliary and peritonitis tuberculosis). His sputum and ascites fluid contained Mycobacterium tuberculosis (MTB). He received RHES regimen treatment. He was diagnosed with Hospital Acquired Pneumonia on the fifth day and was given Ceftazidime and Levofloxacine. He died on the ninth day due to respiratory failure.

     Patients with a Child-Turcotte-Pugh score of 13 should be treated for 18-24 months with non-hepatotoxic drugs. On the fifth day, the patient developed pneumonia, and his CLIF-SOFA score was 10. In this patient, pneumonia can trigger ACLF. The higher the CLIF-SOFA score, the greater the mortality in a cirrhotic patient with pneumonia.

     We must consider the degree of liver fibrosis when selecting anti-tuberculosis drugs for patients with liver cirrhosis. Early detection of pneumonia is critical and the calculation of CLIF-SOFA score in cirrhotic patients must be performed as early as possible because pneumonia is the second most common cause of ACLF and it might increase mortality risk in cirrhotic patients.

Keywords: Disseminated TB, pneumonia, cirrhosis, anti-tuberculosis drugs

IMPLEMENTASI KEPERAWATAN POLA NAPAS TIDAK EFEKTIF PADA KASUS ASMA BRONKIAL

Lily Marleni¹, Mardiah², Lia Pitriani³

^1,2,3Sekolah Tinggi Ilmu Kesehatan Siti Khadijah Palembang

Email : lilyasheeqa@gmail.com

Abstrack

Asma adalah suatu keadaan dimana saluran napas mengalami penyempitan karena hiperaktivitas terhadap rangsangan tertentu, yang menyebaabkan peradangan/inflamasi, penyempitan ini bersipat sementara. Peradangan pada saluran pernapasan disebabkan oleh allergen, yang tampil dalam bentuk ingesta dimana allergen masuk ke dalam tubuh melalui mulut terutama makanan dan obat-obatan. Selain itu juga bisa dalam bentuk inhalan yaitu allergen yang masuk kedalam tubuh melalui hidung seperti debu atau polusi , bulu binatang, serbuk bunga yang menimbulkan gejala sesak napas, mengi, dada terasa nyeri,batuk. Tujuan penelitian ini adalah untuk memberikan Asuhan keperawatan pola napas tidak efektif pada Tn.R dengan kasus Asma Bronkial. Waktu penelitian dilakukan pada tanggal 28 April 2022 di ruang rawat inap Rumah Sakit Bhayangkara M.Hasan Palembang. Metode penguumpulan data dilakukan dengan metode deskriftif dengan cara wawancara dan observasi. Hasil studi kasus pada Tn.R didapatkan pengkajian yaitu kesadaran conpos mentis, pasien tampak sesak, batuk dan mengi, tekanan darah 130/80 mmHg, nadi 80x/menit, Respiration rate 28x/ menit,dan suhu tubuh 36,5 ^OC. Diagnosa yang ditegakkan yaitu pola napas tidak efektif berhubungan dengan hambatan upaya napas.Adapun implementasi keperawatan yang dilakukan mengatur posisi semi flowler, memberikan O2,meng observasi tanda-tanda vital, memonitor kemampuan batuk efektif, memonitor pola napas, mengajarkan batuk efektif, mengajarkan relaksasi napas dlam, memberikan minum air hangat, dan menganjurkan pasien istirahat yang cukup..Evaluasi keperawatan dengan metode SOAP dengan masalah pla napas tidak efektif masalah teratasi. Dengan demikian diharapkan kepada pasien olahraga yang tidak berlebihan, hindari asap rokok,yang menyebabkan sesak napas dan batuk menjaga lingkuangan yang nyaman dan bersih

Kata Kunci : Asma Bronkial,  Implementasi Keperawatan, Pola Napas Tidak Efektif