Current Approach to Post-COVID-19 Pulmonary Fibrosis

Mawin Mahen*, Gurmeet Singh**
*Department of Internal Medicine, Faculty of Medicine Universitas Indonesia
**Division of Respirology & Critical Care, Department of Internal Medicine, Faculty of Medicine
Universitas Indonesia

ABSTRAK

Jumlah pasien yang pulih dari COVID-19 terus meningkat di seluruh dunia, namun ada kekhawatiran mengenai konsekuensi jangka panjang pada organ paru pasien penyintas COVID-19. Fibrosis paru pasca-COVID-19 (post-COVID-19 pulmonary fibrosis, PCPF) telah diketahui sebagai komplikasi COVID-19, dapat terjadi pada sejumlah besar penyintas COVID-19, dan dapat bertahan berbulan-bulan setelah awitan infeksi. Patogenesis PCPF belum sepenuhnya dipahami dan kemungkinan bersifat multifaktorial, melibatkan beberapa jalur seperti inflamasi, hipoksia, dan tromboemboli. Pasien dengan penyakit yang lebih parah, usia lebih tua, dan memiliki komorbiditas berisiko lebih besar terkena PCPF. Pasien PCPF mungkin asimtomatik atau bergejala, paling sering berupa sesak napas pada berbagai tingkat keparahan, dan pemeriksaan paling baik dilakukan dengan CT resolusi tinggi. Saat ini tidak ada terapi yang sudah terbukti efektif untuk PCPF, dan banyak uji klinis sedang berlangsung. Prognosis jangka panjang PCPF juga masih perlu dipelajari lebih lanjut.
Kata kunci: COVID-19, fibrosis paru, fibrosis paru pasca-COVID-19

The Role of External Validation Studies of Clinical Predictive Models (CPMs) in Acute Respiratory Distress Syndrome (ARDS)

Hasna Afifah1, Asri C Adisasmita1, Fitriana Nur Rahmawati2, Zulkifli Amin2
1 Department of Epidemiology, Faculty of Public Health, Universitas Indonesia
2 Division of Respirology and Critical Care Internal Medicine, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital

ABSTRAK

Model prediktif klinis atau sistem skoring saat ini makin populer dan mengakibatkan terlalu banyak model skoring yang ada namun studi yang melakukan validasi eksternal terhadap model-model tersebut masih sangat kurang. ARDS merupakan salah satu sindrom penyakit yang memiliki mortalitas dan morbiditas yang tinggi. Model skoring biasanya digunakan dalam memprediksikan luaran pada populasi yang memiliki risiko tinggi seperti pada ARDS. Pada telaah ini kami ingin memberikan gambaran tentang bagaimana studi eksternal harus dilakukan dan dilaporkan khususnya pada area ARDS. Pada area penelitian ARDS, sebagian besar studi validasi eksternal yang telah dilakukan memberikan laporan yang inadekuat, yaitu biasanya hanya menyebutkan diskriminasi saja dan tidak melaporkan kalibrasi. Kami merekomendasikan peneliti untuk mengikuti panduan TRIPOD yang merupakan panduan telaah kritis yang paling relevan dalam menilai dan melaporkan penelitian terkait model skoring. Studi validasi eksternal yang dilakukan dengan baik dan transparan dapat memudahkan klinisi dan peneliti lain dalam melakukan penilaian mengenai perfoma dan tingkat akurasi suatu model.
Kata kunci: acute respiratory distress syndrome, clinical predictive models, external validation, TRIPOD

SEMI RECUMBENT POSITIONING FOR PREVENTING VENTILATOR ASSOCIATED
PNEUMONIA IN ADULTS REQUIRING MECHANICAL VENTILATION
Harris Soetanto1, Gurmeet Singh2
1.Internal Medicine Dept., Universitas Indonesia, Faculty of Medicine. Dr. Cipto Mangunkusumo National General Hospital,
Jakarta, Indonesia.
2.Respirology and Critical Illness Division, Internal Medicine Department, Universitas Indonesia, Faculty of Medicine.
Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia.

Background:

Ventilator associated pneumonia (VAP) is term to describe pneumonia that develops in a patient who has been on mechanical ventilation for more than 48 hours. VAP has been associated with increased mortality, morbidity, length of intensive care unit stay and duration of mechanical ventilation. VAP can be prevented with put patients in a right postion. Based on the literature, semi recumbent positioning has the advantage of convenience and almost no cost to implement. The purpose of this study is to conduct a evidence based case report to date comparing semi recumbent positioning with supine positioning to clarify their current role in the prevention of VAP.
Method: Literature search was performed on the PubMed, Cochrane library, Proquest, Elsevier, and EBSCO. Inclusion criteria of this literature searching was meta analysis, systematic review, and randomized control trial articles, adult requiring mechanical ventilation, compare semi recumbent and supine position. The exclusion criteria was language used other than English or Indonesian
Result: Two meta analysis included in this study. semi recumbent postioning has a significant reduction in clinically suspected VAP and a trend toward a reduction of all cause mortality. Even though, results of this review need to be interpreted cautiously due to the risk of bias.
Conclusion: There is no associated nursing cost in applying semi recumbent position and potential benefit of reducing clinically suspected VAP, so Semi recumbent position (>30o) should be applied if no contraindications are present
Keywords: ventilator associated pneumonia, semi recumbent, supine, mechanically ventilated

Dazril Wiradinata ¹,  Prayudi Santoso^1,2, Arto Yuwono Soeroto^1,2

¹ Fakultas Kedokteran, Universitas Padjadjaran, Bandung, Indonesia.

² Departemen Ilmu Penyakit Dalam-Divisi Pulmonologi dan Respirasi Kritis, Rumah Sakit Umum Pusat dr. Hasan Sadikin - Fakultas Kedokteran Universitas Padjadjaran, Bandung, Indonesia.

Abstract

     Pleural effusions can develop as a direct consequence of uremia (uremic pleuritis) which occurred in 40% of the end stage renal disease patients on chronic hemodialysis in one study. The diagnosis of uremic pleuritis is challenging as there is no pathognomonic diagnostic test.

     In this case, a 68 year old woman who is known to have end-stage chronic renal failure on chronic hemodialysis with shortness of breath was admitted. Previously, the patient had undergone pleurocentesis twice in 2 week intervals. Further examination found a unilateral pleural effusion. Therapeutic pleurocentesis was done uneventfully and modified light’s criteria was exudated. Adenosine deaminase 15.5 U/L, negative bacterial and mycobacterial. Pleural fluid cytology revealed nonspecific chronic inflammation, no lymphocytic effusion and no malignant cells was noted.

     Uremic pleuritis is diagnosed by excluding other causes that persists or recurs despite aggressive haemodialysis. A close relationship between the degree of uremia and the occurrence of pleural effusions has not been found. Effusion is exudative with predominant lymphocytes and cytology reveals nonspecific chronic inflammation. Most patients respond to continuation of hemodialysis, but corticosteroids may have benefit for refractory uremic pleuritis. Some patients may develop pleural fibrosis with a trapped lung and about 20% of cases the pleuritis persists, recurs or occasionally progresses to restrictive ventilatory dysfunction that needs decortication.

      We need to consider this diagnosis in patients with end-stage renal disease despite routine hemodialysis because of the high incidence of uremic pleuritis. There are no pathognomonic signs, so all causes of pleural effusion must be excluded first.

Keyword: uremic pleuritis, end stage renal disease, pleural effusion

ABSTRACT

Background: Parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia. It can occur in 57% of pneumonia cases in adults. Current guidelines recommend that if chest tube drainage is ineffective, then surgical procedures should be first line management. Morbidity and mortality rate of surgical intervention are on concern. Less invasive therapies still need to be considerable clinical utility. Intrapleural Fibrinolytic agents have been used safely and effectively for complicated parapneumonic effusion but its role in parapneumonic effusion is still unknown.
Method: Literature search was performed on the PubMed, Cochrane Library, Proquest, Scopus, and EBSCO Host. Inclusion criteria of this literature searching was meta analysis, systematic review, and randomized control trial articles, articles in English or Indonesian, adult with parapneumonic effusions, and compare of fibrinolytic agents with placebo. The exclusion criteria was animal and in vitro research. Critical appraisal was assessed using FAITH tool.
Result: Three meta analysis included in this study. All of the studies concluded that there is no evidence intrapleural fibrinolytic therapy better than placebo to prevent mortality in adult with parapneumonic effusions. Even though, it is associated with reduction in surgical intervention and overall treatment failure.
Conclusion: Fibrinolytic therapy is potentially benefi cial in the management of parapneumonic effusions in the adult population. Although there is insuffi cient evidence to support the routine use of this therapy for all parapneumonic effusions. Fibrinolytic therapy may be considered in patients with loculated pleural effusions, because it may prevent the need for surgical intervention.
Keywords: Parapneumonic effusion, Intrapleural fibrinolytic, mortality

Kartika Juwita1, Gurmeet Singh2, Adhrie Sugiarto3, Hamzah Shatri4
1Department of Internal Medicine, Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia
2Respirology and Critical Care Medicine Division, Dept.of Internal Medicine, Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia
3Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia
4Psychosomatic Division, Department of Internal Medicine, Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia
ABSTRACT

Background: Pneumonia is a common respiratory tract infection which is considered as one of the top causes of death. Patients with severe pneumonia often require intubation in order to achieve adequate ventilation. Extubation failure, however, is associated with increased complications and mortality. We aim to determine the predictors associated with extubation failure in patients with severe pneumonia.
Methods: A retrospective cohort study was conducted, which included patients with severe pneumonia intubated in the intensive care unit of Ciptomangunkusumo General Hospital over the period of 2015-2019. Patient characteristics, laboratory values and outcomes were retrieved from medical records. Relationships between variables and extubation outcomes were assessed in bivariate analysis and multivariate cox regression model.
Results: A total of 192 subjects with severe pneumonia was included in this study. Incidence of extubation failure among patients with severe pneumonia was 70.3%, with a mortality rate of 85.2%. Bivariate analyses found that age of >60 years, smoking history, moderate-to-severe Charlson Comorbidity Index, renal replacement therapy, not having neuromuscular disease, procalcitonin >2 ng/mL, and APACHE II score of ≥25 were associated with extubation failure. In multivariate analysis, moderate-to-severe Charlson Comorbidity Index (HR 2.254, 95% CI 1.353-3.755, p=0.002) and procalcitonin > 2 ng/mL (HR 1.859, 95% CI 1.037-3.333) were found to be independent predictors of extubation failure in patients with severe pneumonia.
Conclusion: Moderate-to-severe Charlson Comorbidity index and procalcitonin level of >2 ng/mL were independent predictors of extubation failure in patients with severe pneumonia.
Keywords: severe pneumonia, extubation failure, Charlson Comorbidity Index, procalcitonin

Muhammad Ifham Hanif¹,   Taufik Ridwan Hadi Kusuma², Saiful Hidayat², Naufal Aminur Rahman²

1. Fakultas Kedokteran, Universitas Padjadjaran, Bandung
2. Fakultas Kedokteran, Universitas Sebelas Maret, Surakarta

Correspondence: muhammadifhamhanif@gmail.com

ABSTRACT

Introduction: As the WHO has declared that Coronavirus Disease 2019 (COVID-19) is a global emergency, clinical predictors of severity must be identified to optimize the treatment. Hypertension is the most prevalent comorbidity. It has been commonly reported that it increases the mortality rate, although some research has shown conflicting results. This study aims to measure some literature on the correlation between hypertension and mortality rate in COVID-19.

Methods: This study is a meta-analysis. The research was conducted using secondary data by searching and selecting clinical studies. The article searching was through a systematic and comprehensive database from PubMed, ScienceDirect, Google Scholar, ProQuest, and Springer Link. Articles were collected using the PRISMA diagram, critically appraised using the PRISMA checklist and PICO analysis, then the data were analyzed using Review Manager 5.4.1 application with Random Effect Model (REM). The analysis results are the effect size, heterogeneity, and the study model.

Results: Based on the meta-analysis from the five included studies, the hypertension group had a 2.76-fold higher risk of mortality (RR 2.76, 95% CI 2.58-2.96) caused by COVID-19 compared to the group without hypertension. I2 statistics showed heterogeneities among the included studies, and hence the random effect model is used. Funnel plots were plotted for the included studies in the meta-analysis, which suggested a publication bias in the studies of our meta-analysis.

Conclusion: COVID-19 patients with hypertension are associated with a higher risk of COVID-19 mortality rate.

Keywords: Hypertension, COVID-19, Mortality rate.

Perkembangan di bidang respirologi khususnya di bidang tuberkulosis paru mengalami perubahan yang cukup banyak, terutama dalam pengobatan TBC RO. Program TBC RO yang sering disebut sebagai TB Multi Drug Resistant  dimulai pada tahun 2019. Seiring dengan perkembangannya, jumlah kasus TBC RO yang ditemukan semakin meningkat dan tantangan yang dihadapi juga semakin komplek. Pengobatan dimulai dengan regimen standar pada semua pasien dengan menggunakan dasar regimen injeksi Kanamisin/Kapreomisin sesuai dengan rekomendasi WHO. Seiring dengan perkembangan pengobatan MDR, mulai diperkenalkan tahun 2015 obat Bedaquilin oleh WHO sebagai obat baru untuk terapi MDR. Perkembangan selanjutnya, pada tahun 2017,  terapi MDR TB dapat diperpendek yang kita sebut sebagai terapi jangka pendek di bawah 1 tahun , tetapi masih memakai regimen suntik. Penelitian terus dilakukan dan diperkenalkan Delamanid sebagai obat untuk regimen jangka panjang pada tahun 2018. Setahun kemudian mulai diperkenalkan regimen all oral longer regimen. Regimen all oral shorter regimen mulai digunakan pada tahun 2020, jadi praktis sejak tahun 2020  semua pasien TB MDR menggunakan regimen tanpa suntikan, kecuali pada kasus-kasus tertentu saja yang menggunakan regimen suntik. Indonesia termasuk negara yang sangat cepat mengadopsi pengobatan TB MDR yang dicanangkan oleh WHO.

ABSTRACT

Background: Extubating failure due to severe pneumonia increases morbidity and mortality. Systemic adaptive immunity, T lymphocyte cells CD4/CD8 in blood, has special role as a mortality predictor in severe pneumonia. Further study still needed to evaluate local adaptive immunity through bronchoalveolar lavage cellular examination in both lungs.
Objective: The aim of this study was to find out the differences between T lymphocytes CD4/CD8 in both lungs based on extubating status and mortality status.
Methods: We performed a cohort prospective study of 40 patients with severe pneumonia whom underwent endotracheal intubation and bronchoscopy hospitalized in intensive care unit between November 2020 to January 2021 in Dr. Cipto Mangunkusumo National General Hospital. Primary data was taken and analyzed using univariate and bivariate to investigate mean or median differences with unpaired t-test for normal numeric distribution data and Mann-Whitney test for abnormal distribution numeric data.
Result: The proportion of extubating failure was 80% and mortality rate was 75%. There were significantly different results of BALF CD4 T cells lymphocyte fraction in severe pneumonia group of patients based on extubating status (p=0,006) and mortality status (p=0,002). Blood CD4 T cells lymphocyte fraction and blood CD4/CD8 T cells lymphocyte ratio were found significantly higher in the successfully extubating group of patients compared to extubating failure group of patients; and also, significantly higher in survived group of patients compared to mortality group of patients with pneumonia severe.
Conclusion: Fraction of CD4 BALF in severely injured pneumonia lungs group of patients who had successful intubation processes were statistically different compared to the group of patients with unsuccessful extubating. Fraction of CD4 BALF were also found statistically different in the group of patients who were survived compared to the group of patients who were passed away.
Key Words: Local Adaptive Immunity; Subset T Lymphocyte; CD4 cells; CD8 cells; Bronchoalveolar Lavage; Extubating failure; Severe Pneumonia

ABSTRACT

Background: COVID-19 is caused by the SARS-CoV-2 virus and was declared a pandemic in early 2020. Moderate degree COVID-19 patients are generally hospitalized and receive several treatment regimens. Vitamin D3 is one of the additions to the standard therapy of COVID-19. Calcifediol is a more potent vitamin D3, able to increase serum 25OHD levels rapidly. However, it is not yet known the effectiveness of calcifediol in reducing mortality and worsening of COVID-19. Objective: Figure out the effectiveness of calcifediol and standard therapies in reducing mortality or clinical worsening of COVID-19 hospitalization patients.
M
ethods: The literature search was conducted through five databases: Pubmed, Cochrane, EBSCO, ProQuest, and Scopus. Three literatures that matched clinical questions and eligibility criteria were then critically examined using Oxford’s Center for Evidence-Based Medicine (CEBM) and Critical Appraisal Skills Program (CASP) forms.
Result: The three selected studies include one RCT and two cohort studies. All studies used calcifediol at doses of 0.266 mg/capsule and standard therapy according to hospital protocol. All three studies suggest that calcifediol and standard therapy can lower the risk of mortality compared to standard therapy use alone, two studies suggest it can reduce clinical worsening in the form of ICU admission.
Conclusion: Administration of calcifediol in addition to standard therapy of COVID-19 inpatients results in a better decrease in mortality and clinical worsening than standard therapy alone.
Keywords: Calcifediol, COVID-19, standard therapy, hospitalization

ABSTRACT

Intensive care unit-acquired weakness (ICUAW) is condition of weakness that found in critically ill patient when no reasonable reason besides the presence of critical illness. This condition often occurs in intensive care unit (ICU) patient that undergo prolong bed rest. Rehabilitation intervention has important role to prevent and manage this condition. This case report aims to depict the role of rehabilitation management in ICU patient and its benefit.
Keywords: rehabilitation, intensive care unit acquired weakness

ABSTRACT

I
ntroduction: Myasthenia Gravis (MG) is a relatively rare autoimmune disorder caused by an antibody-mediated blockage of neuromuscular transmission resulting in a skeletal muscle weakness and rapid muscle fatigue. Muscular weakness in MG can affect ocular, limb, respiratory, and bulbar muscles, which varies over time and is often activity or exercise induced. Case Illustration: A 28-year-old man with easily fatigued when performing working activities as an anesthesiology resident such as manual bagging, intubation, and cardiopulmonary resuscitation. Patient was diagnosed with MG with dominant symptoms which are hand tremors and fatigue. From physical examination, we found fair left hand grip strength, relatively similar dexterity on both hands, exercise intolerance, low cardiorespiratory and muscle endurance. Laboratory examination showed negative antibodies for MG. Radiology findings showed that he had no abnormalities. The patient did several physical exercises given by physiatrist, such as aerobic exercise, upper extremity resistance exercise, task-spesific exercise, and core muscle exercise. Discussion: Exercise capacity in MG may be restricted by proximal muscle weakness, fatigability, and impairment in respiratory muscle function. Physical exercise leads to an immune response, with a rise in T regulatory cells, decreased immunoglobulin secretion, and a shift in the Th1/Th2 balance towards a decreased Th1 cell production. Beneficial effects of physical activity are improvements in mood, reduction in fatigue, and positive effects on cognition and mobility. Conclusion: Physical exercise such as aerobic exercise and resistance training on upper extremities are proven to reduce fatigue and hand tremors, and also improve the quality of life of MG patients.
Keywords: myasthenia gravis, physical exercise

ABSTRAK

Latar Belakang: Pada COVID-19 kritis, terdapat pelepasan masif IL-6 yang dapat menyebabkan terjadinya acute respiratory distress syndrome (ARDS). Oleh karena itu, pemberian antagonis reseptor IL-6 diharapkan dapat mengurangi gejala dan kematian. Namun, belum terdapat bukti yang cukup terkait waktu pemberian antagonis reseptor IL-6 pada pasien COVID-19 yang berat dan kritis.
Tujuan: Laporan kasus berbasis bukti ini dibuat untuk mengetahui waktu pemberian antagonis reseptor IL-6 untuk menurunkan mortalitas dan memperbaiki klinis pada pasien COVID-19 kritis.
Metode: Penelusuran studi dengan desain sytematic review and meta analysis of RCT dan randomized controlled trial (RCT) melalui PubMed, Cochrane, dan Science Direct. Kemudian, studi dilakukan seleksi dan dilanjutkan telaah kritis menggunakan panduan dari Central of Evidence Based Medicine (CEBM) Oxford University.
Hasil: Didapatkan 1 studi sytematic review and meta analysis of RCT oleh Lin dkk dan 1 studi RCT oleh Lescure dkk. Hasil yang didapatkan adalah pemberian antagonis reseptor IL-6 tidak terlalu berpengaruh pada mortalitas (OR = 0,92; 95% CI, 0,66-1,28), tetapi memberikan efek yang baik terhadap perbaikan klinis. Kedua studi tersebut memberikan antagonis reseptor IL-6 pada 10 hari pertama sejak timbul gejala.
Kesimpulan: Pemberian antagonis reseptor IL-6, terutama tocilizumab, pada 10 hari pertama sejak timbul gejala membantu memperbaiki klinis pasien, tetapi tidak berhubungan dengan mortalitas.
Kata Kunci: COVID-19 kritis, antagonis reseptor IL-6, waktu pemberian, mortalitas, perbaikan klinis

ABSTRACT

Background: COVID-19 is an infectious disease caused by SARS-CoV-2 virus, which has become the main health issue worldwide. COVID-19 has a wide spectrum of clinical manifestations, ranged from asymptomatic to critical disease, which further can lead to death. In the advanced stage, COVID-19 can cause ARDS (Acute Respiratory Distress Syndrome), sepsis shock, and multiorgan failure that increase the hospitalization and mortality rate. Presently, the administration of high dose vitamin C (> 5 gram/day) is being considered as the adjuvant therapy in hospitalized COVID-19 patient. Objective: To explore the effect of high dose vitamin C in hospitalized COVID-19 patients.
M
ethods: Literature searching was done in five different databases (PubMed, Cochrane Library, SpringerLink, Semantic Scholar, and EBSCOhost) with „vitamin C‟, „high dose‟, „COVID-19‟, and „outcome‟ as the keywords.. The subsequent critical appraisal was performed in four relevant studies to assess the validity, importance, and applicability using Oxford Centre for Evidence-Based Medicine checklist. Result: Three studies showed that administration of high dose intravenous vitamin C in hospitalized COVID-19 patient could reduce COVID-19 symptoms, improve laboratory result, and prevent the aggravation of COVID-19 disease, yet its effect in reducing mortality rate was not seen yet. Meanwhile, one study didn‟t show any good effect from the administration of high dose oral vitamin C in COVID-19 patient. Conclusion: The administration of high dose intravenous vitamin C can be considered as the adjuvant therapy in hospitalized COVID-19 patients.
Keywords: high dose vitamin C, COVID-19, clinical symptom improvement, laboratory value improvement, mortality rate reduction

ABSTRAK

Latar belakang: Penyakit virus corona (COVID-19) yang disebabkan Infeksi Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV-2) memiliki angka total kematian dunia yang tinggi. Namun, hingga saat ini belum ditemukan terapi definitif yang sesuai untuk penyakit tersebut. Ivermectin memiliki aktivitas antivirus yang diduga dapat mempengaruhi dan menghambat replikasi virus SARS CoV-2. Laporan ini bertujuan mengetahui efektivitas ivermectin dalam menurunkan risiko mortalitas pada pasien rawat inap dengan COVID-19. Metode: Pencarian literatur secara sistematis sesuai dengan pertanyaan klinis dilakukan pada lima database, yaitu PubMed, Embase, Science Direct, Scopus, dan Cochrane. Pemilihan artikel dilakukan berdasarkan kriteria inklusi dan eksklusi. Artikel yang terpilih kemudian ditelaah kritis dan dianalisis lebih lanjut berdasarkan aspek validitas, kepentingan hasil, dan kemamputeraan. Hasil: Berdasarkan hasil pencarian dan seleksi, didapatkan satu artikel Randomized Controlled Trial dan tujuh telaah sistematis dan meta-analisis. Tidak ada artikel yang mencapai kekuatan bukti satu. Kedelapan artikel menunjukan penurunan mortalitas pada kelompok pasien dengan terapi ivermectin, namun hanya tiga artikel yang memberikan nilai yang bermakna secara statistik. Pada semua artikel, manfaat dinilai tidak lebih besar dibandingkan risiko cedera. Kesimpulan: Efektivas ivermectin sebagai terapi tambahan dalam menurunkan mortalitas pada pasien COVID-19 dewasa dengan rawat inap belum terbukti sehingga pengguaannya dalam praktis klinis sehari-hari belum dapat disarankan.
Kata kunci: COVID-19, SARS CoV-2, ivermectin, mortalitas, laporan kasus berbasis bukti

ABSTRACT

High Flow Nasal Cannule is a high flow oxygen therapy using specific equipment so that it can give high flow oxygen using nasal cannule. High flow nasal cannule can achieve FiO2 100%. High flow nasal cannule reduce airway resistance so that improve ventilation and oxygenation. Application of high flow nasal cannule is high cost and a special training is needed, however its effectivity is proven in several studies. In COVID-19 cases, HFNC is effective and also can improve patient’s survival. Moreover, HFNC can provide comfort to the patient.
Keywords: oxygen, high flow nasal cannule

ABSTRACT

Background : Severe community acquired pneumonia (SCAP) is the most commomly encountered critical illness with high short-term mortality rate. Several general prediction models have been validated in predicting the outcome of critical illnesses, but still few evidences for SAPS 3 validation for SCAP. This study aims to evaluate the calibration and discrimination performance of SAPS 3 to predict the in-hospital mortality of SCAP.
M
ethods : We used retrospective cohort design design and collected the medical record of patients admitted with SCAP to emergency ward, high care and intensive care unit of Cipto Mangunkusumo Hospital from March 2019-March 2021). The 30 days in-hospital mortality was documented during the study. Collected data were analyzed using goodness-of-fit Hosmer-Lemeshow tset for the calibration performance and Receiver Operating Curve (ROC) for the discrimination performance of SAPS 3 toward the in-hospital mortality of SCAP.
Results :There were 484 subjects with SCAP with mortality rate of 49,2%. 73,8% was identified to have viral pneumonia due to severe/critical COVID-19 and 25,6% were bacterial. The calibration performance was good (p=0,519, correlation coefficient r=0,993 for the observed and expected from Hosmer-Lemeshow). Discrimination performance was excellent for total score with AUC 0,921 (95%CI 0,898-0,944). Calibration performance was also found to be very good in predicting mortality for general SAPS 3 formula (p=0,054, r=0,984) as well as for Austalasia’s (p=0,092, r=0,986). The probability of death prediction formula, however, both shows poor graphical goodness of fit for the calibration performance.
Conclusion :The calibration and discrimination performance of SAPS 3 score in predicting the in-hospital mortality of SCAP is good, but not for the general and Australasian formula in predicting mortality.
Keywords: Severe community acquired pneumonia, mortality, SAPS 3

Giri Satriya1, Gurmeet Singh2, Rudi Putranto3, Hamzah Shatri4
1Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia-RSUPN Cipto Mangunkusumo
2Divisi Respirologi dan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia-RSUPN Cipto Mangunkusumo
3Divisi Psikosomatik dan Paliatif, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia-RSUPN Cipto Mangunkusumo
4Unit Epidemiologi Klinik Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia-
RSUPN Cipto Mangunkusumo

Abstract

Background: Dispnea as a subjective sensation is a sign of certain underlying disease which need to be diagnosed and treated to prevent the mortality, especially in patients with progressive disease. Previous study has shown that patients with dyspnea at admission have higher mortality.
Objective: To determine the association between dyspnea with 1 year survival in patients with progressive disease who were admitted to RSCM. Methods: A retrospective cohort study was conducted by tracing the medical records of 155 patients with progressive disease who were hospitalized at RSCM during August 2018 until December 2019. Recruited subjects were adults patients who 18 years above diagnosed with COPD, heart failure, malignancy or CVD. Identity, dispnea, and survival data were collected through medical records. Statistical analysis was conducted by using multivariate and Kaplan Meier analysis using SPSS software. Results: In this study, the survival rate of patients with progressive disease who were admitted to RSCM in August 2018-December 2019 was 34.8% with a mean survival of 163 days and a median survival of 72 days. Among the patients 49% had dyspnea. The survival rate of patients with dispnea was 11% with a mean survival of 115 days and a median survival of 29 days. Dyspnea was significantly associated with survival with p < 0,05 and adjusted HR 1.928 (95% CI: 1.225 - 3.03). In the subgroup analysis of heart failure, malignancy, and CVD, dispnea was associated with survival with p<0,05 and the HR value for every group 16,59 (95% CI: 2,20 – 124,73), 2,18 (95% CI: 1,33 – 3,58), and 2,90 (95% CI: 1,34 – 6,28). Conclusion: Dyspnea has significant association with survival.
Key words: dyspnea, progressive disease, survival.

Lidyawati Mulyo1, Prayudi Santoso2, Arto Yuwono Soeroto2
1Departement of Internal Medicine
2Divison of Pulmonology and Critical Respiration, Department of Internal Medicine
Faculty of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin Hospital
Jl. Pasteur No.38, Bandung

Abstract

Tuberculosis (TB) is one of the infectious diseases with the highest prevalence which causes high mortality worldwide. Although rarely found, TB pericarditis can be life threatening because it can cause pericardial effusion which, if left untreated, can cause death due to cardiac tamponade. A 44 years old man presented with cardiac tamponade with clinical appearance of Tb, but pericardial fluid analysis favored bacterial pericarditis. Pericardial fluid analysis showed fluid glucose was 4, fluid protein was 5.320, LDH was 3.781, yellow, cloudy, cell count: 1.716, polymorphonuclear (PMN) 85,2, mononuclear (MN) 14,8. Patient then diagnosed with severe pericardial effusion with sign of tamponade due to bacterial pericarditis with differential diagnosis was tuberculous pericarditis. On the 4th day of treatment, it was found out from the results of GenXpert that there was Mycobacterium tuberculosis in the pericardial fluid with increased Adenosine deaminase (ADA) level, and Chest X-ray showed milliary TB. The patient was then given category 1 anti-tuberculosis drug and methylprednisolone 40 mg. The diagnosis of TB pericarditis is challenging, it requires knowledge about its pathogenesis and thorough analysis in its diagnosis. Not only depending on one tool, but still clinical assessment and confirmation with definite diagnostic tools such as culture or histopathology.
Keywords: bacterial pericarditis, diagnosis, pericardial fluid, PMN, tuberculous pericarditis

Gurmeet Singh,1 Randhy Fazralimanda,2 Alvina Widhani,3 Juferdy Kurniawan4
1. Dept. of Internal Medicine, Division of Respirology and Critical Illness, Faculty of Medicine Universitas Indonesia,
Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
2. Dept. of Internal Medicine, Faculty of Medicine Universitas Indonesia,
Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
3. Dept. of Internal Medicine, Division of Allergy and Immunology, Faculty of Medicine Universitas Indonesia,
Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
4. Dept. of Internal Medicine, Division of Hepatobilliary and Pancreatic Medicine, Faculty of Medicine Universitas Indonesia,
Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Abstract

Background: Severe pneumonia is a major health problem in Indonesia and also in the world. The immune system is known to play important role in the pathogenesis of pneumonia, but few studies have assessed the relationship between blood CD4 and CD8 count and mortality from severe pneumonia in negative HIV population.
Methods: This study was a prospective cohort study conducted at Cipto Mangunkusumo General Hospital from June to August 2020. The outputs were 30-days survival rate and optimal cut-off value for blood CD4 and CD8 count to predict 30-days mortality and mortality risk. Data analysis used Kaplan-Meier survival, ROC curves and multivariate Cox regression.
Results: Of the 126 subjects, there was one subject who was lost to follow up. The 30-days mortality rate was 26.4%. The optimal cut-off value for blood CD4 count was 406 cells/μL (AUC 0,651, P=0,01, 95%CI 0,541-0,760, sensitivity 64%, specificity 61%), blood CD8 count was 263 cells/μL (AUC 0,639, P=0,018, 95% CI 0,534-0,744, sensitivity 62%, specificity 58%). CD4 blood count < 406 cells/μL had a crude HR of 2,696 (P=0,008, 95%CI 1.298-5.603), blood CD8 count < 263 cells/μL had a crude HR of 2,133 (P=0,042, 95%CI 1,035-4,392) and adjusted HR of 2,721 (P=0,005, 95%CI 1,343-5,512). If sepsis and pulmonary tuberculosis were added to the blood CD4 and CD8 count, the AUC value was 0,752 (P=0,000, 95%CI 0,662-0,842).
Conclusion: Blood CD4 and CD8 count had poor accuracy in predicting 30-days mortality in patients with severe pneumonia. Groups with lower blood CD4 and CD8 count had a higher risk of 30-days mortality.
Keywords: severe pneumonia, CD4 count, CD8 count, 30 days mortality

Vania Felicia1, Iceu Dimas Kulsum2, Susantina Prodjosoewojo3
1Faculty of Medicine, Universitas Padjadjaran, Bandung
2Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung
3Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung

Abstract

Background: The burden of tuberculosis (TB) and Human Immunodeficiency Virus (HIV) co-infection is still alarming with high number of cases and mortality especially in West Java. This is affected by delayed treatment in these patients due to difficulty in diagnosis of TB in HIV patients. Clinical presentations were commonly atypical.
Objective: This study aims to identify sociodemographic characteristics, clinical manifestations, and additional findings of outpatients with TB and HIV at Dr. Hasan Sadikin General Hospital Bandung in 2019.
Methods: A retrospective descriptive-observational study on medical records of outpatients in Directly Observed Treatment Short-course (DOTS) and HIV units of Dr. Hasan Sadikin General Hospital Bandung was conducted at 1 January-31 December 2019. Results: There were 22 outpatients with the diagnosis of TB with first category of treatment and HIV, mean age of 34,91 ± 7,68 years, 9,87 ± 19,07 months since HIV diagnosis, BMI of 17,9 ± 2,95. Majority were male (86,4%), married (55%), working (70,6%), in high school (88,2%). Chronic cough (18,6%) was commonly found. There were equal number of patients with positive and negative AFB sputum smear. Most were pulmonary TB (53.3%), Rifampicin sensitive (25%), CD4 cell count of <200 cells/mm3 (77,3%) and stage IV of HIV (72,7%). Most patients had available chest x-ray results (85%), with pulmonary TB (60%) and unilateral infiltrate (40%).
Conclusion: Most of the patients were male in productive age with low BMI, stage IV HIV with low CD4 cell count. Most patients were found with common cough, diagnosed as pulmonary TB, with chest x-ray results showed pulmonary TB with unilateral infiltrate. There were equal number of positive and negative results on AFB sputum smear and most were rifampicin sensitive.
Keywords: tuberculosis, HIV, characteristics

Zen Ahmad1, Alwi Shahab1, Mohamad Zacky Amirullah1, Erial Bahar1
1Departemen Ilmu Kesehatan Penyakit Dalam, Fakultas Kedokteran, Universitas Sriwijaya, Palembang

Abstract

Background: Multidrug-resistant tuberculosis (MDR TB) is a form of tuberculosis infection caused by mycobacterium strains that are resistant to at least two of the main first-line drugs, i.e. isoniazid and rifampicin. In general, MDR TB treatment success rate in Indonesia is only 47%. One of the factors that may influence the treatment outcomes is Diabetes Mellitus (DM). Early sputum culture conversion was associated with better treatment outcomes compared to late sputum culture conversion. Late sputum culture conversion is associated with poor outcomes and increased mortality rate (50%-80%).
Objective: This study aimed to assess the effects of DM on early sputum culture conversion among MDR TB patient who received short-term regimen therapy.
Methods: This was a retrospective cohort observational analytical study conducted at Borang MDR TB of Mohammad Hoesin General Hospital Palembang from April 2019 to January 2020.
Results: A total of 91 participants were included in the study with DM prevalence of 27%. Early sputum culture conversion was found in 11 subjects with DM (44%) and in 45 non-DM subjects (68%). Analysis results showed that MDR TB patient with DM has 2,7 times of having late sputum culture conversion (RR 2,7; 95% CI, 1,061 – 7,013, p= 0.037) compared to non-DM counterpart. Conclusion: Diabetes Mellitus affects sputum culture conversion among MDR TB patients receiving short-term regimen therapy at Mohammad Hoesin General Hospital Palembang.
Keywords: multidrug-resistant tuberculosis, diabetes mellitus, sputum culture conversion.

Anita Nur Charisma1,2*, Kristin Purnama Dewi1,2, Erika Marfiani1,3
1Fakultas Kedokteran, Universitas Airlangga, Surabaya
2Departemen Pulmonologi dan Ilmu Kedokteran Respirasi, Rumah Sakit Dr. Soetomo, Surabaya
3Departemen Ilmu Penyakit Dalam, Rumah Sakit Dr. Soetomo, Surabaya

Abstract
Pneumocystis jirovecii pneumonia (PCP) is an opportunistic fungal infection in respiratory system caused by fungal organisms that cause pneumonia. The incidence of PCP is relatively low. Appropriate investigations are needed to establish diagnostics for suspected PCP infection in HIV / AIDS patients. Detection of PCP cases should be done as early as possible, so that prophylaxis and PCP treatment are not delayed and can reduce mortality.
Keywords: Investigation diagnostics, pneumocystis pneumonia, HIV/AIDS

Arfian Muzaki1, Gurmeet Singh2
1Program Studi Profesi Dokter, Fakultas Kedokteran Universitas Indonesia
2Divisi Respirologi dan Penyakit Kritis, Dept. Ilmu Penyakit Dalam,RSUPN Cipto Mangunkusumo,
Fakultas Kedokteran Universitas Indonesia

Abstract

Background: Corona virus disease 2019 (COVID-19) is a new disease caused by the SARS-CoV2 virus and announced to be a global pandemic. Symptoms can vary in different people and are divided into asymptomatic, mild, moderate, and severe. Vitamin D is said to have an effect on lowering the risk of microbial infection and death. Therefore, vitamin D is given to COVID-19 patients with the hope of reducing clinical deterioration and mortality.
Objective: To assess the effect of vitamin D on clinical deterioration and mortality in COVID-19 patients based on studies that have been conducted.
Methods: Searching randomized controlled trials and cohorts in three databases, namely PubMed, Scopus, and Cochrane. Articles will be selected and then subjected to a critical review using guidelines from the University of Oxford’s Center for Evidence-based Medicine (CEBM).
Results: A total of three studies were selected with one randomized controlled trial and two cohort studies. All studies claim that offering vitamin D therapy decreased the incidence of admission of patients to the ICU (invasive mechanical ventilation) and mortality. Study drawbacks may bias and influence the significance of the association between vitamin D administration and clinical deterioration.
Conclusion: Administration of vitamin D in hospitalized COVID-19 patients to reduce clinical worsening of patients.
Keywords: Adult, COVID-19, Vitamin D, cholecalciferol, calcifediol

Telly Kamelia
Division of Respirology and Critical Care Internal Medicine, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital - Faculty of Medicine University of Indonesia

Abstract
Nowadays, pandemic of COVID-19 impacts worldwide. Coronavirus Disease 2019 affect respiratory system dominantly. However, this virus can also affect other organ systems besides lungs, such as skin, eyes, and heart. This review article was aimed to describe the manifestation of Coronavirus Disease in another organ besides lungs.
Key words: manifestation, extra pulmonary, Coronavirus Disease 2019