Background: Incidence of chronic obstructive pulmonary disease (COPD) acute exacerbation of increases in pilgrims during hajj period. Early diagnosis and grading of COPD before hajj is important to start treatment and reduce risk of acute exacerbation. Body Mass, Obstruction, Dyspnea, Exercise (BODE) Index is a multidimensional grading system to predict risk of COPD acute exacerbation.
Objective: To find association between BODE Index and incidence of COPD acute exacerbation in hajj pilgrims.
Methods: This is a retrospective cohort study among hajj pilgrims from Jakarta in 2012 who were known to have COPD. BODE index was calculated from medical records which had been obtained from health screening 24 hours before flight. Exacerbation was determined immediately after arrival home through history taking and examination of subject, interview with the physician in-charge of each flight group, and analysis of personal hajj book. Association between two variables and relative r isk were calculated using Chi-Square test or Fisher Exact test. Results: Sixty COPD subjects with complete BODE index data were identified and recruited. Thirty five subjects (58.3%) suffered from acute exacerbation of COPD, 5 (14.2%) of which were hospitalized. In BODE index range from 0-6, 48 subjects (80%) had 0-2, 6 subjects (10%) had 3-4, and 6 subjects (10%) had 5-6. The result of Chi-Square and Fisher Exact test between low risk group (BODE index 0-3) and high risk group (BODE index >3) is p=0.01 and relative risk 1.9 (CI95% 1.4-2.5).
Conclusion: There is an association between BODE Index and acute exacerbation of COPD among hajj pilgrims from Jakarta in 2012. The range of BODE index was 0-6. Hajj pilgrims with BODE index of >3 had significantly higher risk of acute exacerbation of COPD compared to pilgrims with BODE index of 0-3.
Keywords: BODE, hajj, pilgrims, acute exacerbation of COPD.

Background: Chronic obstructive pulmonary disease (COPD) becomes a significant health problem during pilgrimage for Moslems. Data from Indonesian Ministry of Health showed that acute exacerbation of COPD (AECOPD) ranked second in the causes of death of pilgrims in 2008, with mortality proportion of 12.3%. To date, no known publication has reported the proportion and risk factors associated with AECOPD in pilgrims from Indonesia. Objective: To obtain data on the characteristics of pilgrims with COPD and the proportion and risk factors for AECOPD in the pilgrims embarking from Jakarta during hajj year of 2011-2012.
Methods: This is a cohort prospective study using univariate statistical analysis which was conducted in Jakarta Embarkation during pilgrims seasons during hajj year of October-December 2011 and September-November 2012. Results: Ninety-seven COPD patients were identified and subsequently recruited to this study. General characteristics of the subjects were as follows: male (95%), under 60 years of age (54%), low educational status (72%), non-residents in DKI Jakarta (20%), current smokers (54%) and having no co-morbidity (60%). Most of the subjects (98%) were not known to have COPD prior to pilgrim’s health examination; 79% of them had moderate COPD. The proportion of AECOPD during hajj year 2011-2012 was 48%. General characteristics of the subjects with AECOPD were as follows: elderly (53%), non-current smokers ( 53%), having co-morbidity (55%), having suffered from acute respiratory tract infection (98%) and of moderate COPD severity (83%).
Conclusion: This study found high proportion of AECOPD in the pilgrims embarking from Jakarta during hajj year 2011-2012. Acute respiratory tract infections were commonly found in the pilgrims with AECOPD.
Key words: Acute exacerbation, chronic obstructive pulmonary disease, Hajj, pilgrims.

Background: Hospital-acquired pneumonia (HAP) is a common infection occurring in hospitalized patients. CURB-65 (Confusion, Uremic, Respiratory, Blood Pressure, Age over 65) scoring system was developed to assess severity and risk in community-acquired pneumonia (CAP) but its use has not been validated in HAP patients in Indonesia. Objective: To validate the performance of CURB-65 scoring system to predict mortality in Indonesian patients with HAP.
Methods: This is a validation study with retrospective cohort design. Data were taken from medical records in Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from January 2006 to December 2012. Among 204 recruited HAP patients, 171 patients with complete data were included. Hosmer-Lemeshow test was conducted to test the accuracy and area under Receiver Operating Curve (ROC) was calculated to discriminate the performance of CURB-65 scoring system. The specificity and sensitivity value of CURB-65 to predict mortality in HAP patients were analyzed. Statistical analysis was performed using SPSS 16.0.
Results: The overall mortality proportion is 42.7%. Hosmer-Lemeshow test shows good accuracy (p=1.00). The area under the ROC is 0.376, showing bad discriminating performance of CURB-65 scoring system. Using the cut-off value of score 2, the sensitivity of CURB-65 is 71.2% and its specificity is 42.9% to predict mortality in HAP. Conclusion: CURB-65 has low specificity and sensitivity value to predict mortality in HAP patients.
Key words: CURB-65, hospital-acquired pneumonia

Torakoskopi medis pertama kali diperkenalkan pada 1866 oleh S. Gordon dan diikuti oleh Hans Jacobeus, seorang dokter spesialis penyakit dalam, pada 1910. Antara 1915-1955, torakoskopi digunakan secara eksklusif untuk terapi pneumotoraks pada tuberkulosis. Pada awal tahun 1960-an, torakoskopi digunakan terutama oleh dokter ahli bidang pulmonologi di Eropa, dengan basis yang jauh lebih besaruntukdiagnosisbanyakpenyakitpleuropulmoner. Torakoskopi kemudian dikembangkan oleh dokter- dokter bedah toraks pada awal dekade ini dan dinamakan kembali menjadi torakoskopi “bedah”, lebih dikenal sebagai Video-Assisted Thoracoscopy Surgery (VATS), yang membutuhkan anestesi umum dengan intubasi endobronkial selektif, perlengkapan sekali pakai, dan setidaknya tiga jalur masuk.1
Torakoskopi medis adalah prosedur invasif minimal yang memungkinkan akses ke rongga pleura dengan menggunakan kombinasi instrumen visual dan tindakan. Prosedur dilakukan dengan anestesi lokal di bawah sedasi ringan. Prosedur ini memungkinkan prosedur diagnostik dasar (cairan pleura yang tidak terdiagnosis atau penebalan pleura) dan terapeutik (pleurodesis) untuk dilakukan secara aman. Torakoskopi medis juga membantu visualisasi langsung permukaan pleura sehingga memungkinkan biopsi pleura, evakuasi cairan pleura, dan pleurodesis. Sebagian dokter menggunakan teknik ini untuk menilai pneumotoraks, biopsi paru perifer pada penyakit paru interstisial, pembentukan jendela perikardial pada efusi perikardial maligna, dan simpatektomi pada pasien-pasien dengan hiperhidrosis. Torakoskopi medis dapat dilakukan dengan scope kaku atau scope semi-kaku dengan ujung fleksibel.3

Background: Tuberculosis (TB) remains a major global public health problem, responsible for more than 1 million deaths each year. The association between TB and malnutrition is well recognized. Malnutrition is common in pulmonary TB patients, especially those who are hospitalized, and may adversely affect treatment outcomes. However, data from Indonesia are sparse, despite high burden of TB.
Objective: To evaluate nutritional status among hospitalized pulmonary TB patients in Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
Methods: This is a descriptive study using secondary data of 345 hospitalized pulmonary TB patients in Cipto Mangunkusumo Hospital between January 2011 and September 2013. We assessed nutritional statuses at the time of hospital admission using body mass index (BMI), Malnutrition Screening Tool (MST) and serum albumin level. Results: At the time of admission, 66.4% of subjects had BMI <18.5 kg/m2, 50.7% of subjects had serum albumin level <3.0 g/dL and 83.8% of subjects had MST score >2.
Conclusion: More than half of hospitalized pulmonary TB patients were malnourished at the time of admission. These findings can be used to support the argument for initiation of nutritional status assessment to identify hospitalized pulmonary TB patients in Indonesia who are in risk of malnutrition.
Key words: Pulmonary tuberculosis, malnutrition, body mass index, albumin, Malnutrition Screening Tool

Hingga saat ini tuberkulosis (TB) masih merupakan masalah kesehatan yang mengemuka di dunia. Sebanyak 30% dari populasi dunia terinfeksi TB dengan sekitar 2 juta orang meninggal setiap tahunnya. Dalam beberapa tahun terakhir, jumlah kasus TB mulai menurun berkat peningkatan kesadaran masyarakat dan upaya-upaya pengendalian TB di bidang kesehatan masyarakat. Namun, dewasa ini TB menjadi perhatian kembali seiring peningkatan epidemi HIV di seluruh dunia. Di sisi lain, reaktivasi infeksi TB laten yang banyak terjadi pada kelompok sosioekonomi rendah merupakan sumber penularan infeksi TB yang baru. Dari sana terlihat bahwa sistem imun dan status sosioekonomi berperan penting dalam penularan TB. 1,2
Saat ini, TB resistan obat merupakan masalah kesehatan yang banyak dijumpai, terutama di daerah endemik TB. Resistansi terhadap obat antituberkulosis (OAT) terdiri dari 2 jenis, yaitu multi- drug resistant (MDR) dan extensive drug resistant (XDR). TB resistan obat disebut MDR jika mikobakteri resistan terhadap rifampisin dan isoniazid (dua obat TB lini pertama) atau XDR ketika mikobakteri yang resistan terhadap kedua obat tadi tidak merespons juga dengan fluorokuinolon dan minimal satu OAT lini kedua yang disuntikkan (misal amikasin, kanamisin, kapreomisin). World Health Organization (WHO) telah menetapkan MDR-TB dan XDR-TB sebagai salah satu tantangan utama dalam eradikasi TB.2,3

ENDOBRONCHIAL ULTRASOUND (EBUS)
Definisi
EBUS adalah prosedur invasif yang menggunakan peralatan ultrasonografi (USG) dalam saluran napas dan paru untuk mengeksplorasi struktur dinding saluran napas, mediastinum, dan paru.
Peralatan
Peralatan tambahan yang dibutuhkan untuk flexible bronchoscopy sebagian besar merupakan alat yang dipasang dan digunakan, berupa miniature probe catheter yang pada ujungnya dipasangi transduser mekanik yang dapat berputar 360o. Probe USG terdiri atas dua jenis: 1) transduser sektoral sebesar 7,5 MHz yang tergabung dalam ujung bronkoskop yang didesain khusus fleksibel berukuran 7 mm, dan 2) balon-tip probe miniatur dari 2,8-3,2 mm, dengan transduser 12 dan 20 MHz yang dapat dimasukkan melalui flexible atau rigid bronchoscope. Agar tercapai kontak sepenuhnya dengan dinding trakeobronkial, kateter dengan balon di ujungnya dimasukkan ke dalam bronkoskop kemudian diisi dengan air sehingga memungkinkan untuk terjadinya kontak sirkular. Peralatan lain yang digunakan pada EBUS adalah endoskop ultrasonik dengan scanner kurvalinier eletronik di ujungnya yang menghadirkan gambaran sektor dinding bronkus dan struktur mediatinum. Prototipe dari sistem ini masih dalam tahap penelitian dan belum dikomersilkan.

Background: Cipto Mangunkusumo Hospital (CMH) is a national referral center in Indonesia. Most of the patients come with multiple and complicated diagnosis.
Objective: To describe clinical profiles and in-hospital prognosis in adult medical patients admitted to Emergency Room in CMH. Methods: A prospective cohort study was performed on adult medical patients in Emergency Department (ED) of CMH between October and December 2012. Acute presenting symptoms and diagnosis were made by in-charge resident of Internal Medicine Department. Outcome was assessed when the patients were discharge from the hospital (alive or dead). Patients’ confidentiality was maintained throughout the study.
Results: A total of 815 non-surgical patients attended the study (51.7% were male). Mean age was 47.3 (SD
15.2) year old, mean arterial pressure was 91.7 (22.0) mmHg, mean heart rate was 101.3 (SD 23.4) bpm, mean respiratory rate was 25.0 (SD 6.8) bpm, mean body temperature was 36.9 (SD 1.1)oC, mean peripheral O2 saturation
96.2 (SD 4.2)%, median Glasgow Coma Scale was 15 (3-15). The most frequent chief complaints were shortness of breath (25.1%), general weakness (16.2%) and loss of consciousness (12.7%). Frequent diagnosis found included pneumonia (35.6%), dyspepsia (33.2%), hypertension (28.5%), renal failure (27.7%), malignancy (24.7%), sepsis (23.1%), anemia (22.0%) and diabetes mellitus (17.3%). Median length of stay was 5 (0-63) days. Mortality was observed in 145 patients (17.8%). The causes of death were irreversible septic shock (53.8%), respiratory failure (24.8%), cardiac arrest (11.0%), cardiogenic shock (6.9%) and pulmonary embolism (3.4%).
Conclusions: Clinical profile and outcome of adult medical emergency patients in Cipto Mangunkusumo Hospital differ from those of other hospitals in Indonesia. Long length of stay and high mortality was observed. Further research in CMH care system must be done for future improvements.
Key words: Clinical profile, outcome, medical emergency patients

Background: Indonesia is the world’s fourth highest tuberculosis (TB) burden in the world. TB is the second leading cause of death for all age in the country. Mortality rate remains high among hospitalized TB patients compared to the non-TB patients. The risk of death is significantly higher in HIV-infected patients with tuberculosis (TB). TB is the leading killer of HIV-infected individuals worldwide.
Objective: To describe the characteristics and to determine mortality rate among hospitalized HIV-infected patients with TB in Cipto Mangunkusumo Hospital (CMH), Jakarta, Indonesia.
Methods: A retrospective cohort study was performed among hospitalized TB/HIV patients in CMH between January 2008 and September 2013. Data were collected at initiation of inpatients period and the main outcome was all-cause mortality during hospitalization. Analyzed factors included age, sex, history of previous anti-TB treatment, sputum smear positivity, hypoalbuminemia, BMI, pulmonary radiographic lesion and comorbidity (CCI score). Data were analyzed using Chi-square test or Fischer test.
Results: A total of 191 TB/HIV patients were evaluated in this study. There were 157 (82.6%) male and 34 (17.4%) female patients. Median age was 31 (range 20 to 71) years old and median length of stay was 11 (range 1 to 57) days. In-hospital mortality rate was 29,8%. One hundred and thirty patients had CD4 count data, and 128 (98,5%) of them had CD4<200 cell/uL. Factorsassociated with in-hospital mortality were history of previous TB treatment, (p=0,001), hypoalbuminemia (p<0,001) and cavitary lesion in chest radiographic (p<0,001).
Conclusion: In-hospital mortality rate was 29,8%. The majority of TB/HIV patients had low CD4 count (<200cell/ uL). Factors associated with in hospital mortality were history of previous TB treatment, hypoalbuminemia and cavitary lesion in chest radiographic.
Key words: Tuberculosis, HIV positive, in-hospital mortality

Background: Pneumothorax is an emergency case that needs immediate management. Assessment of lung diseases and causes of pneumothorax is important to manage interdisciplinary therapy and improve the overall quality of management. Risk factors affecting the survival rate of pneumothorax are age and HIV infection, but data is not yet avalaible in Indonesia.
Objective: To determine the characteristics of pneumothorax patients and factors affecting their survival during hospitalization in Cipto Mangunkusumo Hospital, Jakarta.
Methods: Retrospective cohort was conducted on pneumothorax patients who were admitted to Cipto Mangunkusumo Hospital within 2000-2011. Cumulative survival rate in 8 days of hospitalization and the affecting factors underwent bivariate analysis using Kaplan-Meier method and log-rank test, and multivariate analysis using cox proportional hazard regression model.
Results: Among 104 included subjects, their mean age was 39.7 years (SD ± 16.2 years) with a male to female ratio of 3:1. Most common symptom was shortness of breath (99%) and abnormality on physical examination was hypersonor (97.1%). Most plain chest X-ray data showed hyperlucent avascular (91.4%). Most common etiology of secondary pneumothorax were smoking (41.3%), pneumonia (40.3%) and tuberculosis (35.5). Most common type of pneumothorax was secondary spontaneous pneumothorax (47.1%). Most of the patients were successfully managed using water-sealed drainage (94.2%). As many as 66.3% of the subjects survived. Major cause of death was respiratory failure (45.8%). Factors that worsen the survival rate were chest trauma (HR=3.49; 95%CI 1.52-8.04) and pulmonary tuberculosis (HR=3.33; 95%CI 1.39-7.99).
Conclusions: Factors that worsen the survival rate of pneumothorax patients were pulmonary tuberculosis and chest trauma.
Key words : Pneumothorax, survival

Background: Patients aided by mechanical ventilator are associated with critical illness bearing high mortality rate. Knowledge about predictors of mortality helps in clinical decision regarding the management and prognosis. To date there has been no comprehensive study about the predictors of mortality in patients with mechanical ventilator in Indonesia. Objective: To acknowledge the predictors of mortality in patients with mechanical ventilator in Cipto Mangunkusumo Hospital, Jakarta.
Methods: This retrospective cohort includes patients aided by mechanical ventilator in the Intensive Care Unit (ICU) of Cipto Mangunkusumo Hospital during 2010-2012. Clinical data and laboratory results as well as clinical outcome (survival or death) were obtained from medical records. Bivariate analysis was conducted to variables age, malignancies, acute respiratory distress syndrome (ARDS), shock, post-operative state, history of cardiac arrest, hyperglycemia, stroke, acute kidney injury, sepsis and hypoalbuminemia. Variables which made the cut were included in multivariate analysis with logistic regression.
Results: The study involved 242 patients with mortality rate of 45.4%. Age, malignancies, ARDS, shock, post-operative state, history of cardiac arrest, stroke, acute kidney injury, sepsis and hypoalbuminemia show statistical difference in bivariate analysis. Multivariate analysis gathers these predictors of mortality: acute kidney injury (OR 1,91; CI95% 1,08-3,39; p=0,002), shock (OR 2,13; CI95% 1,18-3,85; p=0,012), stroke (OR 3,39; CI95% 1,65-6,95; p=0,01), ARDS (OR 2,19; CI95% 1,10-4,35; p=0,025) and history of cardiac arrest (OR 4,85; CI95% 1,56-15,07; p=0,006). Conclusions: Acute kidney injury, shock, stroke, ARDS and history of cardiac arrest are independent predictors of mortality in patients aided by mechanical ventilator.
Key words: Predictor of mortality, mechanical ventilator

Sindrom vena kava superior (SVKS) merupakan kumpulan gejala akibat obstruksi aliran darah yang melewati vena kava superior. Obstruksi terjadi karena desakan massa intra torakal yang umumnya berupa massa mediastinum, massa paru, limfoma, atau penyebab non-maligna. Pada laporan kasus kali ini, obstruksi vena kava superior berlangsung perlahan dan disebabkan struma intra torakal yang terletak di mediastinum anterior superior. Kumpulan gejala klinis pada pasien menunjukan SVKS namun pemeriksaan lanjutan diperlukan untuk menegakkan diagnosis pasti massa penyebab. Ct scan torak, thyroid scan dilakukan untuk membantu mengarahkan pelaksanaan biopsi. Keputusan untuk melakukan biopsi terhadap massa mediastinum perlu mempertimbangkan beberapa hal, yaitu (1) ada tidaknya gejala, (2) lokasi dan luasnya lesi, (3) ada tidaknya beberapa penanda tumor, dan (4) gallium uptake oleh massa. Modalitas terapi definitif akan ditentukan berdasarkan jenis massa penyebab.

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

Definisi
Flexible bronchoscopy merupakan suatu prosedur invasif untuk memvisualisasikan nasal, faring, laring, korda vokalis, dan percabangan trakea- bronkial untuk keperluan diagnosis serta pengobatan pada kelainan paru. Prosedur ini dapat dilakukan di ruang bronkoskopi, ruang endoskopi, kamar operasi, instalasi gawat darurat, ruang radiologi, dan di unit perawatan intensif
Peralatan
Peralatan yang diperlukan untuk melakukan prosedur adalah bronkoskop, lampu, sikat sitologi, forsep biopsi, needle aspiration catheter, suction, oksigen, fluoroskopi (C-arm), pulse oxymetry, sphygmomanometer dan peralatan resusitasi yang meliputi endotracheal tube serta monitor video.

Tindakan prosedur di bidang pulmonologi intervensi seperti bronkoskopi fleksibel dan rigid serta pleuroskopi, menyebabkan nyeri dan ansietas. Pada pelaksanaan tindakan prosedur tersebut, klinisi umumnya dapat menggunakan anestesi lokal berupa infiltrasi lidocaine pada dinding thoraks dan pleura parietal (untuk pleuroskopi) serta inhalasi lidocaine dan lidocaine topikal (pada bronkoskopi). Selain itu, dapat digunakan sedasi dan analgesia prosedural (PSA), yang dapat mengurangi rasa tidak nyaman, ketakutan, dan timbulnya memori yang tidak menyenangkan akibat tindakan prosedur dan dapat memfasilitasi kelancaran tindakan prosedur tersebut

Background: Metabolic syndrome is a combination of central obesity, elevated blood pressure, impaired glucose metabolism, and dyslipidemia. Its prevalence is increasing worldwide. Several previous studies showed various differences of lung functions in patients with and without metabolic syndrome .
Objective: To determine whether patients with metabolic syndrome had lower FEV1 percent predicted and FVC percent predicted than normal population.
Methods: The study design was cross-sectional study. Patients were grouped into subjects with and without metabolic syndrome who met the inclusion and exclusion criteria.
Results: There were 96 subjects of the study with a mean age of 42.74 ± 9.14. Metabolic syndrome group consisted of 48 subjects and there were 48 healthy subjects in control group. FVC percent predicted values in subjects with and without metabolic syndrome were 99.27 ± 20.35 vs. 116.22 ± 20.67 (p < 0.001), and FEV1 values were 116.05 ± 23.77 vs 130.06 ± 20.78 (p = 0.03). In patients with metabolic syndrome, 16.7% had FEV1 < 80% predicted that indicated decline in lung function (obstruction type), and 22.67% had FVC < 80 % predicted indicating a decline in lung function (restriction type).
Conclusion: Patient with metabolic syndrome had lower FEV1 and FVC values than normal population.
Keywords: Metabolic syndrome, pulmonary functions

Penyakit Paru Obstruktif Kronis (PPOK) merupakan salah satu penyakit yang memilki beban kesehatan tertinggi.World Health Organization (WHO) dalam Global Status of Non-communicable Diseases tahun 2010 mengkategorikan PPOK ke dalam empat besar penyakit tidak menular yang memiliki angka kematian yang tinggi setelah penyakit kardiovaskular, keganasan dan diabetes. GOLD Report 2014 menjelaskan bahwa biaya untuk kesehatan yang diakibatkan PPOK adalah 56% dari total biaya yang harus dibayar untuk penyakit respirasi. Biaya yang paling tinggi adalah diakibatkan kejadian eksaserbasi dari penyakit ini.1 Kematian menjadi beban sosial yang paling buruk yang diakibatkan oleh PPOK, namun diperlukan parameter yang bersifat konsisten untuk mengukur beban sosial. Parameter yang dapat digunakan adalah Disability-Adjusted Life Year (DALY), yaitu hasil dari penjumlahan antara Years of Life Lost (YLL) dan Years Lived with Disability (YLD). Berdasarkan hasil perhitungan tersebut, diperkirakan pada tahun 2030, PPOK akan menempati peringkat ketujuh, dimana sebelumnya pada tahun 1990 penyakit ini menempati urutan keduabelas

Pulmonary Tuberculosis (PTB) is a common manifestation in adults with TB-HIV co-infection. However, as the immunity gets worse, HIV-infected individuals more often develop extrapulmonary and disseminated TB. The Incidence of extrapulmonary TB (EPTB) has increased after the epidemic of HIV infection. It is responsible for 10-50% of all TB case among HIV negative individuals, while in HIV positive group, it occurs in 38-80%.1 Several studies found that up to 50% TB-HIV patients die during TB treatment.2,3 In Thailand, verbal autopsies, laboratorium data, and medical records of TB-HIV patients who die during TB treatment state that TB is the cause of death in 27% of those patients, whereas more than a half of them were disseminated and Multi Drug Resistant TB (Complicated EPTB).2
In many part of the world, many studies had mentioned susceptibility of HIV patients to develop extrapulmonary TB.4-6,8 Additionally, in the recent guideline to improve diagnosis and treatment of extrapulmonary TB, World Health Organization (WHO) states EPTB in HIV-infected person has become a new clinical problem especially in remote area where advance modality supporting diagnosis and treatment are unavalaible. Although pulmonary TB is the most common presentation of TB disease, it can involve any organ in the body. Extrapulmonary Tuberculosis is defined as the isolated occurrence of TB in any part of the body other than lungs such as lymph nodes, abdomen, genitourinary system, musculoskeletal and meninges. Mycobacteria may spread to any organ of the body through lymphatic or haematogenous dissemination and lie dormant for years at a particular site before causing disease. Manifestations may relate to the system involved, or simply as prolonged fever and non specific systemic symptoms. Tuberculosis is a worldwide disease and one of the major health problems of Indonesia. Extrapulmonary tuberculosis is increasing all over the world. However, only limited data is available about the situation of EPTB in developing countries including Indonesia, hence diagnosis may be elusive and is usually delayed.1,3 This study reviews the general spectrum of cases diagnosed with EPTB at a large HIV referral center (POKDISUS) and presents their key demographics, dominant infection sites and the laboratory findings.

Key words: Extrapulmonary Tuberculosis, HIV

Latar belakang: Prosedur trakeostomi dapat menurunkan hambatan udara (apabila dibandingkan dengan selang endotrakea), memiliki potensi untuk menurunkan penggunaan obat sedasi dan analgesia sehingga dapat memfasilitasi proses penyapihan dan menghindari pneumonia terkait ventilator. Batasan waktu atau saat yang optimal untuk melakukan trakeostomi pada pasien tersebut hingga kini masih dalam perdebatan. Berbagai penelitian terdahulu menunjukkan hasil keluaran yang berbeda-beda terutama terhadap insiden mortalitas dan morbiditas. Tujuan: Mengetahui insiden mortalitas pada pasien dengan trakeostomi dini dan trakeostomi lanjut di unit perawatan intensif dan hubungan antara jarak waktu trakeostomi dengan mortalitas perawatan unit intensif. Metode: Penelitian dengan desain kohort retrospektif, dilakukan terhadap 162 pasien kritis dengan ventilasi mekanik yang menerima tindakan trakeostomi selama perawatan intensif di RSUPN Dr. Cipto Mangunkusumo pada kurun waktu Januari 2008-Desember 2012. Data saat untuk melakukan trakeostomi, klinis, laboratorium,
dan radiologis dikumpulkan. Pasien diamati untuk melihat kejadian mortalitas selama perawatan intensif. Analisis hubungan antara saat trakeostomi dengan mortalitas perawatan intensif menggunakan tes X2. Analisis multivariat dengan regresi logistik digunakan untuk menghitung adjusted odds ratio (dan interval kepercayaan 95%) antara kelompok trakeostomi dini dan lanjut untuk terjadinya mortalitas perawatan intensif dengan memasukkan variabel-variabel perancu sebagai kovariat.
Hasil: Terdapat hubungan yang tidak bermakna antara trakeostomi dini dan lanjut dengan mortalitas unit perawatan intensif pada uji X2 (p=0,07) dengan RR 0,67 (IK95% 0,51-1,05). Insiden mortalitas pada trakeostomi dini dan lanjut sebesar 28,4% dan 42%.
Kesimpulan: Kelompok trakeostomi dini cenderung untuk memiliki insiden mortalitas yang lebih rendah dibandingkan dengan trakeostomi lanjut. Namun saat trakeostomi tidak berhubungan dengan mortalitas unit perawatan intensif secara statistik.
Kata kunci: Jarak waktu trakeostomi, unit perawatan intensive, mortalitas

Procalcitonin (PCT) is a protein composed of 116 amino acid with a molecular mass of 13 kDa.1 The definite source of serum PCT is uncertain, but it has been speculated that PCT is produced by liver cells, monocytes
cells, and macrophage cells in response to infection.2 Serum PCT levels increase rapidly during various bacterial infection, especially Gram-negative bacterial infections.3 The outer membrane component of Gram-negative bacteria (i.e. endotoxin or lipopolysaccharides) has been shown to be a strong inducer of PCT
during bacterial infection. These bacteria cause the host to produce pro-inflammatory cytokines,
which leads to increased PCT production.3,4 Elevated cytokines levels also cause the host to
increase production of leucocyte and neutrophils cells. The lipopolysaccharides component plays
a large role in the severity of Gram-negative infections. In clinical settings, PCT together with
leucocyte and neutrophil counts are commonly used as markers of infection.5
Salmonella species, a cause of typhoid fever, are also Gram-negative bacteria that contain endotoxin on their cell surface. Binding of salmonella endotoxin to CD14/Toll-like receptor (TLR)4 on macrophage cells activates
nuclear factor kappa B (NFκB) to produce pro-inflammatory cytokine and increase inflammatory cytokines, resulting in elevated PCT levels.6,8 In clinical practice, leucocyte and neutrophil counts can be used as a marker of bacterial infection.9 In addition, several studies have reported that serum PCT levels are useful
in distinguishing Gram-negative bacteremia from Gram-positive bacteremia.3,10 However,
there have been no studies comparing laboratory markers of bacterial infection in Gram-negative
and Salmonella bacteremias. Therefore, we conduct this study to investigate the differences
in leucocyte and neutrophil cell counts and PCT levels among Salmonella and Gram-negative
bacteremias.

Postpartum pulmonary edema is a rare clinical entity.1 Acute pulmonary edema, which signifies severe disease, is a leading cause of death in women with preeclampsia, and the fourth most common form of maternal morbidity. It is also frequently the reason for intensive care admission, and may occur during antenatal, intrapartum or postpartum periods.2 Pulmonary edema complicates around 0,05% of low-risk pregnancies but may develop in up to 2,9% of pregnancies complicated by preeclampsia3-4, with 70% of cases occurring after birth.2-3 A clinician needs to be aware of the physiologic changes in the maternal cardiovascular system that accompany pregnancy predispose to the development of pulmonary edema, such as increase in plasma blood volume, cardiac output, heart rate, and capillary permeability and a decrease in plasma colloid osmotic pressure. Resuscitation is the foremost priority, followed by formulation of a differential diagnosis to address the underlying condition.4 Here we report a postpartum patient who presented with acute pulmonary edema with severe respiratory compromise.

Pneumonia komunitas (PK) adalah penyakit infeksi yang umum namun bersifat serius. Pneumonia komunitas termasuk dalam 10 penyebab kematian tertinggi di dunia.1 Terapi antimikrobial telah diketahui merupakan titik berat tata laksana PK dimana tingkat fatalitas sebelum era terapi antimikrobial adalah 80% dan setelahnya turun menjadi 20%.2 Namun demikian, sekarang ini terapi antimikrobial saja terkadang tidak cukup adekuat untuk menurunkan mortalitas pada pneumonia berat.2 Pada patogenesis PK, sitokin inflamasiseperti IL-6, IL-8, dan IL-10 berlaku sebagai protein fase akut dimana jumlah berlebih dari IL-6 dan IL-10 telah diasosiasikan dengan tingginya mortalitas pada PK.3 Kortikosteroid atau glukokortikoid adalah obat anti-inflamasi yang paling efektif dan paling banyak digunakan.1 Berbagai penelitian telah dilakukan untuk menginvestigasi manfaat penggunaan steroid sebagai terapi adjuvan pada pneumonia dengan hasil yang beragam. Sebagian studi menunjukkan bahwa pemberian kortikosteroid dosis sedang melalui intravena dapat menumpulkan respon sistemik sitokin pro-inflamatorik pada sepsis berat dan inflamasi paru pada pneumonia berat dan cidera paru akut.1 Namun demikian, studi lain mengatakan bahwa tidak ada data yang mendukung manfaat penggunaan steroid sistemik dalam perawatan rutin pneumonia.4 Ditambah lagi, meskipun penggunaan kortikosteroid tampak menguntungkan, perlu diingat bahwa penggunaan steroid diketahui memiliki berbagai efek samping.5Sampai saat ini, keuntungan penggunaan steroid untuk pengobatan pneumonia berat dianggap masih kontroversial, sehingga dibutuhkan kajian berbasis bukti untuk membahas hal tersebut lebih lanjut.

Cardiovascular disease is the leading global cause of death, accounting for 17,3 million deaths per year, a number that is expected to grow to more than 23.6 million by 2030.1Of these deaths, an estimated 7,3 million were due to CAD.2Inflammation plays an integral role in the pathogenesis of atherosclerotic CAD.3-5 Therefore the interest in the EAT that is located between the myocardium and the pericardium surrounding both ventricles with variable extent and distribution patterns arouse.6-8 Because of its endocrine and paracrine activity, secreting pro-inflammatory and anti-inflammatory cytokines and chemokines, it has been suggested to influence coronary atherosclerosis development.9-13 TTE enables non-invasive assessment of EAT.14,15To date, the correlation of EAT with severity of CAD in Indonesia remains unknown. To address this issue, we examined the relationship between EAT thickness measured by TTE with coronary lesion severity in Indonesian patients with stable CAD. Methods Study Design The study was designed as an observational cross-sectional study. It was approved by Hasanuddin University ethic committee and written informed consent was obtained from all participants.

Sampai saat ini TB masih merupakan salah satu penyakit menular yang mematikan di dunia. Pada tahun 2013 diperkirakan sekitar 9 juta orang terjangkit penyakit ini dengan kematian pada 1,5 juta penderitanya. Dari jumlah tersebut, 360 ribu diantaranya mengidap HIV positif. Tuberkulosis secara perlahan menurun kasusnya dan diperkirakan sekitar 37 juta nyawa telah berhasil diselamatkan antara tahun 2000 s.d tahun 2013 seiring bertambah efektifnya proses diagnosis dan pengobatan. Kendati demikian, angka kematian yang tinggi tersebut sebenarnya kurang bisa diterima karena sejatinya hal tersebut dapat dicegah. Dibutuhkan upaya yang lebih keras untuk bisa mencapai target global pada tahun 2015 seperti tertuang dalam Millenium Development Goals (MDGs). Selain itu, upaya pemberantasan penyakit tuberkulosis saat ini diperberat dengan meningkatnya kejadian infeksi HIV serta munculnya kasus-kasus MDR TB
Pada tahun 1995, program nasional pengendalian TB mulai menerapkan strategi DOTS dan dilaksanakan di Puskesmas secara bertahap. Sejak tahun 2000 strategi DOTS dilaksanakan secara Nasional di seluruh UPK terutama Puskesmas yang di integrasikan dalam pelayanan kesehatan dasar.2 Dalam perkembangan beberapa tahun terkahir, penanggulangan TB di Indonesia saat ini sudah lebih baik, hal ini terlihat dari peringkat negara Indonesia dengan kasus TB terbanyak yang menurun menjadi peringkat 5.3 Walaupun demikian, Indonesia adalah negara high burden dan sedang memperluas strategi DOTS dengan cepat. Jika tidak bekerja sama dengan Puskesmas, maka banyak pasien yang didiagnosis oleh rumah sakit memiliki risiko tinggi dalam kegagalan pengobatan dan mungkin menimbulkan kekebalan obat.4
Multidrugs Resistant Tuberculosis merupakan masalah terbesar terhadap pencegahan dan pemberantasan TB dunia.6 Pada tahun 2003 WHO menyatakan insidens MDR TB meningkat secara bertahap rerata 2%. Prevalensi TB Indonesia tahun 2006 adalah 253/100.000 penduduk dan angka kematian 38/100.000 penduduk. Pada tuberkulosis kasus baru didapatkan TB-MDR 2% dan pada TB kasus yang sudah diobati didapatkan MDR TB 19 %.5 Untuk Indonesia, TB MDR berada di urutan ke 8 dari 27 negara dengan kasus TB MDR terbanyak.3 Hasil penelitian Sri Melati Munir, Arifin Nawas dan Dianiati K Soetoyo dari Departemen Pulmonologi dan Ilmu Kedokteran Respirasi FKUI-RS Persahabatan Jakarta mendapatkan kesimpulan bahwa resisten Obat Anti Tuberkulosis (OAT) yang terbanyak adalah resisten sekunder 77,2% dan didominasi resisten terhadap rifampisin dan isoniazid 50,5% sedangkan resistensi primer sebesar 22,8%. Baik pada resistensi primer maupun sekunder didapatkan resisten terhadap rifampisin dan isoniazid 50,5 %, resisten terhadap rifampisin, isoniazid dan streptomisin 34,6%. Tulang punggung pengobatan TB adalah rifampisin dan isoniazid. Namun demikian, paling banyak terjadi resistensi.7