Amelia Lorensia1, Zullies Ikawati2, Tri Murti Andayani2, Daniel Maranatha3
1Department of Clinical pharmacy-Community, Faculty of Pharmacy, University of Surabaya, Jl. Raya Kalirungkut, 60293 Indonesia
2Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy Universitas Gadjah Mada, Sekip Utara Yogyakarta, 55281 Indonesia
3Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Airlangga, General Hospital Dr. Soetomo, Surabaya

ABSTRACT

Background: Intravenous aminophylline is one of the most frequent exacerbations of asthma therapy in Indonesia. Even abroad, the use of aminophylline / theophylline is often used because of higher and better effectiveness than the first line, ie salbutamol nebulasi.
Objective: To determine the effectiveness of salbutamol mebulasi and aminophylline intravenously on exacerbation of asthma in improving lung function with peak expiratory flow (PEF) value with peak flow meter.
Method: This study used quasi experimental method, with research variable is PEF value. The study was conducted from January 2014 to June 2016. The study subjects were adult patients with asthma exacerbations in hospital in Surabaya, with consecutive sampling method. Test the dependent sample t-test (scale scale) to see the population in one group and test the independent sample t-test (scale scale) to see the differences between groups.
Results: This study activated 27 subjects in group A (intravenous aminophylline) and 30 people in group B (salbutamol nebulasi). The comparison of PEF improvements between the two groups used an independent sample t-test, which had previously been tested for normality with Shapiro Wilk with a p value of 0.001 (group A) and 0.001 (group B) which was not published by parametric tests. And after administration of asthma therapy, there is no number equal to both, both intravenous aminophylline and nebulized salbutamol.
Conclusion: The effectiveness of intravenous aminophylline is no different from salbutamol nebula in the improvement of PEF values.
Keywords: exacerbation of asthma, intravenous aminophylline, salbutamol nebulation, peak expiratory flow

Fahreza Akbar Siregar1, Gurmeet Singh2
1Program Studi Pendidikan Dokter, Fakultas Kedokteran Universitas Indonesia, Jakarta
2Divisi Pulmonologi dan Kedokteran Respirasi, Departemen Ilmu Penyakit Dalam, Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo, Jakarta

ABSTRACT

Background: Community-acquired pneumonia (CAP) is one of the top leading causes of mobidity and mortality worldwide. CAP also becomes the sixth most prevalent cause of overall mortality in adults. Corticosteroids are known to be the most potent anti-inflammatory drugs and have physiologic rationale for their use in patients with infection. Its efficacy in the treatment of CAP is still debatable. Objective: This study aims to evaluate the efficacy and clinical outcomes of systemic and inhaled steroid therapy for patients with community-acquired pneumonia.
Methods: We used four databases for literature searching process, Pubmed, EBSCO, ProQuest, and Science Direct, which selected articles are those therapeutic studies with relevant clinical question and met the inclusion-exclusion criterias. Critical appraisal was performed by assessed its validity, importance, and applicability based on Oxford Center of Evidenced-Based Medicine 2011. Results: Three retrieved articles feature cohort studies. Two studies conducted systemic steroid therapy research which other conducted inhaled steroid. Two of three articles show steroid therapy was associated with lower mortality and shorter clinical stability.
Conclusion: We suggested that steroid therapy, both systemic and inhaled steroids help hasten clinical recovery, prevent pneumonia-related complication, lower mortality, and reduction in the duration of mechanical ventilation and length of hospital stay.

Keywords: community-acquired pneumonia, steroid, inhalation, therapeutics, clinical outcomes

Puji Astuti Tri K1, Anak Agung Arie1, Cleopas Martin Rumende2, Zulkifli Amin2
1)Internal Medicine Department, Cipto Mangunkusumo National General Hospital-Faculty of Medicine, Universitas Indonesia
2)Division of Respirology and Critical Care, Internal Medicine Department, Cipto Mangunkusumo National General Hospital-Faculty of Medicine, Universitas Indonesia

ABSTRACT
Systemic sclerosis (SSc) is a chronic tissue disorder characterized by immune dysfunction, microvascular injury, and fibrosis. Many organs involved in patients with SSc; especially, pulmonary involvement occurs in up to 90% of patients with SSc. Interstitial lung disease (ILD) is a major complication in SSc and causing high mortality rate. The SSc-ILD therapy is basically consistent with the progress of scleroderma pathophysiology. We reported a case of 59-years-old female patient with a blackened ulcer on her left hand ring finger with disappearing of her distal finger segment, and also a chronic white phlegm cough followed by dyspnea in exertion. Clinical examination and evaluation showed that she had a scleroderm, accompanied with ILD. Her complaint did not improve, so she got an immunosuppresant and supportive therapy to control her worsening disease.
Keywords: systemic sclerosis, interstitial lung disease

Lidya Lustoyo Putrajaya1, Ari Sisworo2
1General Practitioner at East Belitung District Regional Public Hospital, East Belitung, Indonesia; 2Internist at East Belitung District Regional Public Hospital, East Belitung, Indonesia

Abstract

Premature ventricular contractions (PVCs) are early depolarizations begin in the ventricle instead of the usual place, the sinus node. Frequent and complex PVCs could occur in apparently healthy individuals, they also showed it could be associated with a benign prognosis. PVCs may occur at rest or during exertion, or as a result of excessive caffeine intake, smoking, drinking alcohol, the use of illicit drugs (e.g., cocaine, amphetamines), or the use of over-the-counter medications (e.g., diet pills, antihistamines) that contain ingredients that mimic the effects of sympathetic nervous system stimulation. In individuals with and without heart disease, hypokalemia and hypomagnesaemia often contribute to the development of PVCs. The symptoms that can occur are palpitations, lightheadedness, passing out, chest pain, and shortness of breath. If the patient without heart disease feels any discomfort, he/ she could be given minor tranquilizer such as benzodiazepine.
Keywords: Premature Ventricular Contractions, Sympathetic nervous system, Tranquilizer, Benzodiazepine

Raymond Pranata1, Emir Yonas2, Veresa Chintya3
1Assistant Physician, Siloam General Hospital - Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
2Faculty of Medicine, YARSI University, Jakarta, Indonesia
3General Practitioner, Sanjiwani General Hospital, Gianyar, Bali, Indonesia

ABSTRACT

Introduction: Frequent premature ventricular complexes (PVCs) have theability to cause or contribute to cardiomyopathy and heart failure symptoms in long-term.
Case Illustration: A 46 years old male presented with recurrent palpitations, the latest since 6 hours before admission. PMH of hypertension, diabetes and heart disease were denied. BP: 120/80 mmHg, HR: 138 bpm, RR 22x/minute. ECG: LV focus multifocal PVC bigeminy. Lab: within normal limits. CXR: cardiomegaly. Echocardiography: MR and LVH. The patient was administered diltiazem IV in the ED. Bisoprolol was given during discharge.
Discussion: PVC-induced cardiomyopathy’s mechanisms are not entirely clear; a more likely explanation is abnormal ventricular activation resulting in mechanical dyssynchrony, >10.000 PVCs/day has high risk and this patient’s PVC burden should be calculated. It is a diagnosis of exclusion andmade after exploring possible causes and excluding them.Pharmacotherapy to suppress PVCs includes β-Blockers, CCB, and other antiarrhythmic drugs. Results of the use of β-Blockers and CCB are modest with reported efficacy rates in the 20% range.In patients with PVC-induced cardiomyopathy, successful elimination of PVCs with ablation frequently restores ventricular function acutely and has aprocedural success rate of PVC elimination of 84%. Unfortunately, this patient is not a suitable candidate for catheter ablation. Hence, β-Blockers was chosen for long-term therapy.
Conclusion: Frequent PVCs with high burden has potential to cause adverse cardiovascular events and should be treated to prevent its deleterious consequences. Suppression of PVCs using either antiarrhythmic pharmacological agents or emerging catheter ablation techniques appears to reverse the LV dysfunction.
Keywords: PVC, Cardiomyopathy, burden

 Latar belakang: Di Indonesia, sebanyak 18,4 % pasien yang menjalani operasi non-kardiak di RSUPN Cipto Mangunkusumo Indonesia mengalami Komplikasi Paru Pasca Operasi(Post-operative Pulmonary Complication/PPC).Beberapa penelitian menunjukkan durasi operasi memiliki hubungan dengan PPC.Penelitian ini bertujuan untuk mengetahui peranan durasi operasi sebagai prediktor kejadian komplikasi gagal napas dan pneumonia dalam 30 hari pasca operasi.

Metode: Penelitian menggunakan desain kohort retrospektifpada November 2016-Juli 2017dengan data rekam medis pasien yang menjalani operasi di RSUPN Cipto Mangunkusumo tahun 2012-2016.Sampel penelitian diambil dengan metode consecutive samplingyang memenuhi kriteria inklusi dan eklusi, dilihat luarannya selama 30 hari pasca operasi.

Hasil: Dari 102 pasien diketahui 58,8 % perempuan, 35,5 % 41-50 tahun, 25,5 %berpendidikan SMA, 34,3 % tidak bekerja, 77,5 % tidak mengalami penurunan berat badan, 80,4 % tidak merokok, tidak ada yang memiliki riwayat PPOK, 61,8 % anestesi umum, 64,7 % operasi elektif dan 51,96 % lokasi operasi di abdomen. Didapatkan 10,8 % mengalami gagal napas dan 6,9 % mengalami pneumonia. Dari analisis bivariat, durasi operasi tidak dapat digunakan sebagai prediktor kejadian gagal napas (p 0,106; RR 3,56; CI 95 % 0,885 -14,280) maupun pneumonia (p 0,701; RR 1,61; CI 95 % 0,342-7,601).

Kesimpulan:Durasi operasi tidak dapat digunakan sebagai prediktor tunggal dalam memprediksi kejadian komplikasi gagal napas maupun pneumonia pasca operasi.

Kata kunci:durasi operasi, gagal napas,komplikasi paru pasca operasi,pneumonia

ABSTRACT

Background: Community acquired pneumonia is a major health problem with high mortality rate, especially in Indonesia. The CURB-65 score is a widely used scoring system, but has some drawbacks so a new scoring system is needed to assess the severity of community pneumonia. This study aims to assess the expanded-CURB-65 scoring system as a predictor of 30-days mortality of community pneumonia.

Aim : To evaluate calibration and discrimination performance of the expanded-CURB-65 score in predicting 30 days mortality of community acquired pneumonia patients at the National Center General Hospital dr.Cipto Mangunkusumo.

Metho : This study was a prospective cohort study with the study subjects of community pneumonia patients who came to the Emergency Room (ER), pulmonary polyclinics or hospitalized in RSCM. The assessed outcome was patient mortality within 30 days. Discrimination performance  of the expanded-CURB-65 score assessed using the area under the curve (AUC). Calibration performance was evaluated with calibration plot and Hosmer-Lemeshow test.

Results : 267 patients participated in the study with a mortality rate of 31.5%. Calibration plot of expanded-CURB-65 score showed r= 0,9697 and Hosmer-Lemeshow test showed p = 0,210. Discrimination was shown by ROC curve with AUC 0,701 (CI95% 0,633-0,768). Conclusion: Mortality increases with increasing risk class of expanded-CURB-65. Expanded-CURB-65 showed a good calibration and discrimination performance in predicting 30-day mortality higher in community acquired pneumonia patients in Cipto Mangunkusumo Hospital.

Keywords : Community acquired pneumonia patient, 30 days mortality, expanded-CURB-65 score

ABSTRACT

Background: Many cases of malignancy, either inside the thoracic cavity or fromother body organs, accompanied by massive pleural effusion. The treatment for those cases isdone by drainage and continued with pleurodesis after pleural fluid production <150 ml/day. This method takes long drainage duration and care, and the cost is enourmous. To solve that problem we proposea way of management of malignant pleural effusion more efficiently.

Methods: From July 2008 to July 2009 there were 60 patients with pleural effusion due to malignancy. In the case group we performed pleurodesis early (pleural fluid production> 1000/day), while in the control group pleurodesis performed if pleural fluid production <150 ml/day. Pleurodesis is succes if acchieve pleural fluid production <100 ml/day before third days after procedure. Both groups used pleurodesis with chest tube (no.28-32).

Results: There were 60 patients which is elligible for this research. Allocation to groups were 30 patients performed early palliative therapy with talk and 30 patients performed conventional therapy (conventional pleurodesis).  From the demographic depiction, tumor type, disease characteristic and length of stay both pleurodesis group result were no significant difference (p> 0,05). The duration of drainage and length of care was much shorter in group early pleurodesis (p <0.01).

Conclusion:Early pleurodesis methods can shorten the drainage time and length of care without affecting the effectiveness of pleurodesis results

Keywords: massive pleural effusion, malignancy, pleurodesis, talc

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: 16CHA₂DS₂-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

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

Adhella Menur Naysilla
Dokter Umum RSUD Brigjen H. Hasan Basry, Kandangan,
Hulu Sungai Selatan, Kalimantan Selatan, Indonesia

ABSTRACT
The development of congenital heart disease management (PJB) causes patients to live an adult life now known as Congenital Heart Disease (GUCH) and Adult Congenital Heart Disease (ACHD). Patients with acute ureanotic ACHD with natural survival (no intervention measures in childhood) can suffer from complications of pulmonary hypertension and Eisenmenger syndrome. Complications can increase patient morbidity and
mortality and worsen the quality of life. The patient may need corrective surgery and even a heart transplant. Some conditions that can not be administered by surgery cause the patient to take medication and in high lifetime medical surveillance. This case report discusses a 26-year-old male Banjar tribe coming with cough and breath with oxygen saturation of four extremities of 80%. Patients have a history of congenital heart disease with no intervention measures in childhood. Patients were diagnosed with sekundum ASD with severe pulmonary hypertension and Eisenmenger syndrome, secondary polycythemia PJB, and pulmonary TB in advanced stage 1 treatment. Diagnosis is obtained from anamnesis, physical examination, and investigation. ECG, radiology, laboratory, spirometry, and echocardiography Doppler. Patients care in ICU and treated with oxygenation, pulmonary vasodilators, diuretics, and iron supplementation and folic acid. Advanced pulmonary TB treatment. The patient underwent flebotomy 3 times. After treating 18 days, the patient showed a clinical improvement and was referred to the Ulin Hospital Banjarmasin for further examination and management.
Keywords : ACHD asianotik, ASD sekundum, pulmonary hypertension, Eisenmenger syndrome

Davin Takaryanto,1,2, Ade Erna1,2, Hendarsyah Suryadinata1,3
1 Faculty of Medicine, UniversitasPadjadjaran, Bandung, Indonesia
2Department of Internal Medicine, Sumedang Regional Public Hospital, Sumedang, Indonesia
3 Respiratory Critical Disease Division, Department of Internal Medicine, HasanSadikin General Hospital, Bandung, Indonesia

Abstract
Introduction:The prevalence of obesity continues to increase every year across the world. Obesity has been a risk factor for developing some chronic and non-communicable diseases. Obesity hypoventilation syndrome (OHS) is one of non-communicable disease that emerges with obesity as its primary risk factor. We presented a case with severe obesity, chronic hypoventilation and multiorgan impairmentscaused by OHS, a disease that is often misdiagnosed and mistreated hence leads to higher mortality rate.
Case Report: A woman, 54 years old, was brought to hospital emergency ward with decrease of consciousness (hypersomnolent) and breathlessness. The patient had an excessive sleeping amount of time with morning or nocturnal headache, snoring, and sleeping apnea. She had been diagnosed as asthma and pulmonary hypertension and had been given therapy. She was severely obese with BMI of 44.07 kg/m2. The patient suffered multiorgan failures of respiratory failure, hepatic impairment, cardiac failure, and renal disease. She underwent positive pressure ventilatory assistance after being delayed until after fourth day of hospitalization. She suffered from cardiac arrest due to septic shock and respiratory failure. Cardiopulmonary resuscitation was carried out, but eventually the patient died.
Discussions:OHS is an alveolar hypoventilation or hypercapnia that occurs daily in obese patient without underlying disease that could lead to hypo ventilatory state. Majority of patients with OHS also experience obstructive sleep apnea hypopnea syndrome (OSAHS). Patients who complain respiratory problems are often misdiagnosed as asthma or chronic obstructive pulmonary disease even though theyshowsome obvious OHS clinical features. Chronic hypercapnia could lead to dyspnea worsened by physical activity, sleep problem, excessive daily sleeping time, delirium, myoclonus, and seizures. Along with clinical findings, further confirmatory examinations are needed to support OHS diagnosis. OHS could lead to some complications such as pulmonary hypertension and right heart failure (corpulmonale). Bariatric surgery and positive pressure ventilation with mechanical ventilator are primary therapies for OHS.
Conclusions: Diagnosis of OHS should be considered when finding obese patients who complain respiratory problems. Missed diagnosis and inadequate therapy in OHS patients could lead to high morbidity and mortality rate. Advance diagnostic tools are needed to accurately diagnose, follow up and treat OHS patients intensively.
Keywords: hypoventilation, hypercapnia, obesity, Pickwickian syndrome

Harmoko1
1Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia

ABSTRACT

Background:Most clinicians are focusing on artery’s complications that might be happen due to manipulation on artery while the PCI procedure. However, vein’s complication is also happen in rarity.
Case description: A 69-year-old female patient was undergone an elective-PCI procedure. Patient’s medical history with hypertension and hyperlipidemia; pacemaker implanted; decreased effort tolerance-shortness of breath; significant mid RCA and LAD lesion shown by CT Coronary Angiogram. The PCI procedure was done through access of the right common femoral artery. A 6-FrenchCordisExoseal for vascular closure device was utilized.
After discharging, the patient complained of a painful swelling of her right leg. Physical examination showed diffuse swelling of the entire right leg and bruising around the puncture site. A vascular Doppler study was performed. It demonstrated thrombus in the right proximal superficial femoral vein.

Muhammad Ranushar, Harun Iskandar, Nur Ahmad Tabri, Makbul Aman,Syakib Bakri
Departement of Internal Medicine Medical Faculty
Hasanuddin University Makassar

Abstract
Background: Asthma is an important chronic airway disease and is still a serious and mass public health problem in many countries. Asthma control has been difficult to achieve using conventional therapies such as short-acting beta 2 agonist (SABAs), oral beta 2 agonists, oral corticosteroids and theophylline, leading to asthma difficult to control. Treatment of asthma based on GINA uses asthma control medications (controller) in the form of inhalation of beta 2 agonist combination with inhaled steroid/Inhaled Corticosteroid (ICS) and can be a combination of both. Classification of degree control based on GINA is considered more practical, easier to adapt, and more clinically valuable.
Objective: To know the relationship of type therapy with degree of control and lung function of asthma patient.
Methods: This study was a cross sectional study. The samples used were patients with asthma diagnosis both outpatient and inpatient according to GINA criteria. The subjects of the study were data collection in the form of therapy method. Spirometry measurements determine FEV1% and asthma control degree according to GINA criteria. The study was conducted in February-May 2016 at Pulmonology Polyclinic RS Wahidin Sudirohusodo Makassar and Hasanuddin University hospital in Makassar
Results: The age of the subjects varied between 19 and 69 years old, the FEV1% score ranged from 18% to 98%, male subjects were 23 (33,8%) and 45 (66,2%). There was no significant association of therapeutic method with lung function (p> 0,05). There is a significant relationship between therapy method and degree of control asthma (p <0,001).
Conclusions: In patients with asthma who received combination therapy such as combination budesonide and formoterol or salmeterol and fluticasone significantly more achieved a better degree of control than in patients who only received agonist beta 2 inhalation or corticosetoid inhalation only.
Keywords: Asthma, therapeutic method, lung function, degree of control, Forced Expiration Volume 1, Inhalation of beta 2 agonists, inhaled corticosteroids, inhalation corticosteroid and beta-2 agonist combination.

KeikoYolanda Gunardi1, Telly Kamelia2
1Faculty of Medicine, Universitas Indonesia
2Respirology and Critical Illness Division, Internal Medicine Department
Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia

Abstract
Introduction: Tuberculosis (TB) remains as ignificant global health problem,but it is possibly curable when TB is detected and effectively treated. Drug resistant become the hardest challenge to cure this disease. The Multidrug resistance TB is of ten linked to the diversity of Mycobacterium tuberculosis genotype.This study aimed to investigate whether diversity of genetic profile M.tuberculosis influenced the drug resistance.
Methods: A literature search was conducted in several electronic databases. PubMed, Proquest, and Scopus were used to find articles which investigate the association between diversity of MTB genotype and drug resistant. After applying the inclusion and exclusion criteria,there were six eligible articles. However, after restricting more thoroughly, there were only one case control study was used for appraisal.
Results:One case control study identified the impacts of genetic profile diversity and drug resistant was found. It also compared HIV infected and non HIV patients.A total of 158 samples were used. The association between drug resistance mutation and genetic strain background was strongly established (P<0.0001). The most frequent mutations in Switzerland were poB (S531L) resistance to rifampin and katG (S315T) which was resistant to isoniazid. The study found that genetic background, especially lineage 2 (Beijing strain) of the M.TB had a high association with drug resistance.This association was stronger formulation drug resistance and in HIV positive patients. (OR19,70;95%CI,1,30to298,19;P=<0,0001).
Conclusion: Current evidence showes there was a clear evidence that the diversity of genetic give an impact to resistant of the drug. It is recommended that future studies in Indonesia is needed to demonstrate consistent effects in clinical settings since Indonesia is an endemic area for Tuberculosis
Keywords: M.Tuberculosis, genome, genotype, genetic Profile, TB-HIV, TB-Natïve, drug resistance

Ario Perbowo Putra1, Stephanie Dewi Samsuria1, Griskalia Christine 1, Zulkifli Amin2
1Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia 2Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia

Summary: Intrapleural streptokinase was performed to a 25-year-old-male with loculated pleural effusion due to tuberculosis infection. The effusion was improved significantly after fibrinolytic and antituberculosis therapy. Before insertion of intrapleural streptokinase, the pleural volume drained twice with in total volume was 1700 ml, but no significant changes were seen on the chest X-ray. After streptokinase use, the volume drained was almost 1800 ml and the chest X-ray showed significant improvement, as well as the patient condition. Intrapleural streptokinase is an effective procedure in improving drainage of loculated pleural effusion due tuberculosis.
Key words: Pleural effusion,Streptokinase, fibrinolytic

Mohammad Adi Firmansyah1, Gurmeet Singh2, Zulkifli Amin2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM
Korespondensi : madif12@gmail.com

Evaluasi perioperatif paru merupakan bagian penting pada tatalaksana pasien dengan penyakit
paru yang akan menjalani pembedahan kardiak atau non-kardiak elektif. Tujuan dari evaluasi
perioperatif secara umum adalah (1) identifikasi kondisi komorbids yang dapat meningkatkan
terjadinya komplikasi perioperatif; (2) optimalisasi kondisi umum jika memungkinkan; (3) memahami,
mengenali, dan mengobati kejadian yang dapat menyebabkan terjadinya komplikasi pasca operasi;
(4) menganjurkan pemeriksaan preoperatif yang diduga dapat mempengaruhi stratifikasi risiko dan
manajemen pasien; dan (5) menganjurkan modalitas pasca operasi yang dapat menurunkan risiko
terjadinya komplikasi.1 Fleischer (2002) melaporkan dari 485.850 pasien yang menjalani pembedahan, sebanyak 4.038 (0.7%) diantaranya mengalami kematian, dengan penyebab terbanyak akibat adanya kondisi komorbid pasien tersebut (1:95), faktor kesalahan pembedahan (1: 420), dan kesalahan anestesi (1: 2680).1 Insiden komplikasi paru pasca operasi (postoperative pulmonary complications – PPC) cukup tinggi dengan angka bervariasi dari 2 hingga 19%.2 Smetana melaporkan komplikasi paru terjadi sekitar 6.8% dari
seluruh jenis pembedahan.3 Ateletaksis, pneumonia, gagal napas, dan eksaserbasi dari penyakit paru kronis
merupakan PPC yang sering dilaporkan. Komplikasi paru dilaporkan lebih banyak terjadi dibandingkan 
komplikasi kardiak, dan menyebabkan bertambahnya masa perawatan pasien di rumah sakit

Kripti Hartini1, Zulkifli Amin2, Ceva W. Pitoyo2, Cleopas Martin Rumende2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM

ABSTRACT
Background: Acute respiratory distress syndrome (ARDS) is an emergency in respirology field that contributes to high mortality rate. To decrease the mortality rate of ARDS patients, we need to identify factors affecting it. Studies about factors affecting ARDS mortality showed varying results and until now there is still no comprehensive study about it in Indonesia especially at Cipto Mangunkusumo National hospital (RSCM).
Objective: To analyze factors affecting mortality of ARDS patients at Cipto Mangunkusumo Hospital.
Methods: This study was a retrospective cohort on ARDS patients who were hospitalized in Cipto Mangunkusumo hospital within 2008 and 2012. Data about clinical condition, laboratory, chest X-ray, and outcome of hospitalization were all collected from medical records. Bivariate analysis were performed on age, ARDS etiology, comorbidity Charlson index, PaO2/FiO2 ratio, APACHE II score, and ventilator use in the first 48 hours since ARDS diagnosed.
Multivariate with logistic regression would be done to variables that fulfilled the condition.
Results: A total of 368 patients were included in this study. Inhospital mortality was 75.3%. On bivariate analysis we found that age, ARDS’ etiologies, comorbidity Charlson index, PaO2/FiO2 ratio, APACHE II score, and ventilator use in the first 48 hours since ARDS was diagnosed were variables that had significant associations with inhospital mortality. From multivariate analysis, we found variables that had associations with mortality were sepsis (RR 1.26; 95% CI 1.20-1.32; p < 0.001), the high APACHE II score (RR 1.19; 95% CI 1.04-1.30; p = 0.019) ,and no ventilator use in the first 48 hours since ARDS was diagnosed (RR 1.37; 95% CI 1.25-1.43; p < 0.001).
Conclusions: Sepsis, high APACHE II score, and no ventilator use in the first 48 hours since ARDS was diagnosed were independent factors affecting ARDS patients mortality.
Key words: acute respiratory distress syndrome, factors affecting mortality

Moh Syahrir Azizi1Anna Uyainah2Zulkifli Amin2Moh Sedijono3Hamzah Satri41Departemen Ilmu Penyakit Dalam FKUI/RSCM2Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM3Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Kristen Krida Wacana4Divisi Psikosomatik, Departemen Ilmu Penyakit Dalam FKUI/RSCMKorespondensi

ABSTRACT
Background: The decreased pressure in aircraft cabins may cause hypoxia symptoms in patients with Chronic Obstructive Pulmonary Disease (COPD). Currently, no publication is known to have reported the profile in-flight hypoxia symptoms and pre-flight medical screening in COPD pilgrims.
Objective: To obtain profile of in-flight hypoxia and pre-flight assessment for fitness-to-fly without oxygen
supplementation based on pulmonary function test, oxygen saturation, and the ability to walk more than 50 meters among pilgrims with COPD.
Methods: This is a desciptive study which was conducted during the pilgrimage season in 2011.
Results: Thirty six COPD patients were identified and subsequently recruited to this study. Pre-flight medical
assesment concluded that 33 subjects were fit to fly without supplemental oxygen. Nevertheless, three subjects developed in-flight hypoxia symptoms i.e. two of them were fit to fly without supplemental oxygen, while another subject was recommended to have supplemental oxygen. Characteristics of subjects with in-flight hypoxia were as follows: current smokers (10.5%), not known to have COPD prior to health examination (8.8%), moderate COPD category (9.5%), above 60 years old (5,3%), and had comorbidities (4,2%).
Conclusion: Most pilgrims with COPD were fit to fly without oxygen supplementation.
Key words: Hypoxia symptoms, COPD, Pilgrims.

Malikul Chair1, zulkifli Amin, Noorwati, Andika Rachman,Pringgodigdo

1Departemen Ilmu Penyakit Dalam FKUI/RSCM2Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM3Divisi Hematologi dan Onkologi Medis, Departemen Ilmu Penyakit Dalam RS Kanker Dharmais4 Divisi Hematologi dan Onkologi Medis, Departemen Ilmu Penyakit Dalam FKUI/RSCM5Divisi Ginjal Hipertensi, Departemen Ilmu Penyakit Dalam FKUI/RSCMKorespondensi

ABSTRACT
Background: Superior vena cava syndrome (SVCS) is a collection of symptoms of superior vena cava due to
suppression by the masses in the superior mediastinum and is a medical emergency that needs to be managed immediately. Assessment profiles and survival rate is important in determining the treatment of SVCS patients.
Objective: To obtain the profile and survival rate of SVCS patients in Mangunkusomo Cipto Hospital and Dharmais Cancer Hospital.
Methods: This is a cohort restrospective design that was conducted on SVCS patients during January 2000 to
December 2011 at Cipto Mangunkusomo Hospital and Dharmais Cancer Hospital.
Results: The study population was composed of 151 study subjects. Most of them were male sex (76.2%), 18-60 years old (76.8%), and the economic status was private financing (51.7%). Type of primary tumor was lung tumor (52.3%).
The most frequent signs and symptoms found were dyspnea (84,1%), cough (68,2%) and face or neck swelling (12%). Many study subjects presented with a moderate SVCS grade (60.3%). Based on survival rate-analysis, there were several factors that showed significant differences in survival rate, the economic status (p=0.021), SVCS grade (p=0.006), pneumonia (p=0.013), and type of primary tumor (p=0.03)
Conclusions: The most SVCS patients are males, age range 18-60 years old, lung tumor, having dyspnea and
a moderate SVCS grade. Economic status, SVCS grade, pneumonia, and the type of primary tumor, play a role in survival rate of SVCS patients. Such factors should be considered in decision making for treatment of SVCS patients.
Key words: Superior vena cava syndrome, survival

Anna Uyainah, Zulkifli Amin, Feisal 1Departemen Ilmu Penyakit Dalam FKUI/RSCM 2Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCMKorespondensi : a.uyainah@gmail.com

PENDAHULUAN

Uji fungsi faal paru pada dasarnya dilakukan untuk mengetahui apakah kerja pernapasan
seseorang mampu mengatasi kedua resistensi yang mempengaruhi kerja pernapasan, yaitu resistensi
elastik dan resistensi nonelastik, sehingga dapat menghasilkan fungsi ventilasi yang optimal.
Ventilasi dipengaruhi oleh saluran napas, paru dan dinding dada. Dua bagian terakhir mengatur
besarnya volume dan aliran udara pada saat istirahat dan ketika beraktivitas, seperti: kegiatan fisik,
bersuara, batuk, tertawa, perubahan posisi tubuh, dan lain-lain. Pada penyakit kardiopulmoner, volume paru dapat berubah sebagai hasil dari mekanisme dinamis saluran napas dan pola bernapas disertai perubahan statis pada paru dan dinding dada. Resistensi elastik dihasilkan oleh sifat elastis
paru (tegangan permukaan cairan yang membatasi alveolus dan serabut elastis yang terdapat di seluruh
paru) dan rongga toraks (kemampuan meregang otot, tendon, dan jaringan ikat). Resistensi nonelastik dihasilkan oleh tahanan gesekan terhadap aliran udara dalam saluran napas, dalam jumlah kecil yang juga disebabkan karena viskositas jaringan paru. Parameter yang digunakan untuk menilai kemampuan kerja pernapasan dalam mengatasi kedua resistensi tersebut adalah volume paru, baik volume statis maupun dinamis. Volume statis menggambarkan kemampuan kerja pernapasan dalam mengatasi resistensi elastik, sedangkan volume dinamik mengukur kecepatan aliran udara dalam saluran pernapasan dibandingkan dengan fungsi waktu yang digunakan untuk menilai kemampuan kerja pernapasan mengatasi resistensi nonelastik.

Heri Gunawan, Rahmad Isnanta, Zainal Syafri, Refli Hasan
Divisi Kardiologi, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran
Universitas Sumatera Utara/RSUP H Adam Malik

Abstract
Iskemia tungkai akut (Acute Limb Ischemia) adalah terjadinya penurunan mendadak perfusi tungkai yang biasa melibatkan trombus dan emboli. Pada pemeriksaan fisik bisa dijumpai hilangnya denyut nadi bagian distal oklusi, kulit dingin dan pucat, penurunan respons sensorik dan kekuatan otot.Seorang wanita umur 61 tahun datang ke ruang IGD dengan nekrosis setinggi betis kaki kanan dan ujung kaki kiri yang dialami 10 hari ini. Riwayat penyakit terdahulu: DM tipe 2, post stroke, dan post TBC paru. Pemeriksaan penunjang menunjukkan peningkatan fungsi ginjal (ureum 152 mg/dL, kreatinin 2,08 mg/dL),peningkatan D-dimer (1100), hipoalbuminemia (2,4 g/dL), penurunan kadar AT III (49,9), status hiperglikemia (KGDN: 125 mg/dL dan KGD2jPP: 249 mg/dL), dan USG dopler kesan suatu deep vein trombosis femoralis kiri kanan dan poplitea kanan. Pemeriksaan arteriografi menunjukkan hasil stenosis 90% arteri poplitea sinistra sebelum percabangan, dan tampak kolateral mengisi arteri tibialis anterior sinistra namun tidak tampak mengisi arteri metatarsal sinistra; dan oklusi total arteri femoralis superfisial dekstra.Pasien didiagnosis sebagai ALI(Acute Limb Ischemia) o/t cruris dextra et digiti I-III pedis sinistra. Pasien diterapi dengan pemberian heparin, insulin, aspilet, albumin, transfusi FFP dan PRC sertaamputasi setinggi lutut kanan.Kondisi pasien membaik dan dapat dipulangkan untuk berobat jalan.
keywords : Acute Limb Ischemi, pedis sinistr, thrombus graf, Paresthesia, Pain, Pallor, Pulselessness, Poikilothermia

Adhella Menur Naysilla
Dokter Umum RSUD Brigjen H. Hasan Basry, Kandangan,
Hulu Sungai Selatan, Kalimantan Selatan, Indonesia

Abstract
Perkembangan tata laksana penyakit jantung bawaan (PJB) menyebabkan pasien dapat menjalani kehidupanremaja hingga dewasa yang kini dikenal dengan Grown Up Congenital Heart Disease (GUCH) dan Adult Congenital Heart Disease (ACHD). Pasien ACHD asianotik dengan survivalitas alami (tanpa tindakan intervensi pada masa anak) dapat menderita komplikasi berupa hipertensi pulmonal dan sindroma Eisenmenger. Komplikasi dapat meningkatkan morbiditas dan mortalitas pasien serta memperburuk kualitas hidup. Pasien dapat sajamembutuhkan tindakan pembedahan korektif bahkan transplantasi jantung. Beberapa kondisi yang tidak dapat diperbaiki dengan pembedahan menyebabkan pasien harus mengonsumsi obat dan dalam pengawasan medis ketat seumur hidup.Laporan kasus ini membahas seorang laki-laki suku Banjar 26 tahun datang dengan batuk darah dan sesak napas dengan saturasi oksigen keempat ekstremitas 80%. Pasien memiliki riwayat penyakit jantung bawaan tanpa tindakan intervensi pada masa anak.Pasien didiagnosis dengan ASD sekundum disertai hipertensi pulmonal berat dan sindrom Eisenmenger, polisitemia sekunder PJB, dan TB paru dalam pengobatan kategori 1 fase lanjut. Diagnosis didapatkan dari anamnesis, pemeriksaan fisik, serta pemeriksaan penunjang berupa EKG, radiologi, laboratorium, spirometri, dan ekokardiografi Doppler.Pasien dirawat di ICU dan diterapi dengan oksigenasi, vasodilator pulmonal, diuretik, serta suplementasi besi dan asam folat. Pengobatan TB paru dilanjutkan. Pasien menjalani flebotomi sebanyak 3 kali. Setelah dirawat 18 hari, pasien menunjukkan perbaikan klinis dan dirujuk ke RSUD Ulin Banjarmasin untuk pemeriksaan dan tata laksana lebih lanjut.
Kata kunci: ACHD asianotik, ASD sekundum, hipertensi pulmonal, sindroma Eisenmenger

Sipta Pebrianti1, Ridzqie Dibyantari1, R.A.Linda Andriani2, Diah Syafriani2, Zen Ahmad2
1Departemen Ilmu Penyakit Dalam FKUNSRI/RSMH Palembang
2Divisi Pulmonologi Departemen Ilmu Penyakit Dalam FKUNSRI/RSMH Palembang

Abstract
Tuberkulosis payudara atau mastitis tuberkulosis merupakan tuberkulosis ekstra paru yang menyerang payudara dan seringkali didiagnosis awal sebagai kanker payudara. Kasus ini sangat jarang dijumpai pada pasien dengan jenis kelamin laki-laki. Infeksi Mycobacterium tuberculosis (M.Tb) ini, secara patologi anatomi (PA) terlihat dari adanya keterlibatan secara ekstensif lobulus mammae dengan granuloma epiteloid dan disertai berbagai derajat kaseasi, yang terdiri dari Langhan’s giant cells, seldatia, sel-sel epiteloid, infiltrasis elmono nuklear dengan fibrosis di sekelilingnya, dan disertai pembentukan mikroabses. Berikut disampaikan kasus, seorang laki-laki berumur 23 tahun datang dengan keluhan benjolan di dada kiri dan telah dilakukan biopsi. Pada pemeriksaan fisik didapatkan skar post biopsi pada payudara kiri. Pemeriksaan foto polos toraks normal dan BTA Sputum negatif, namun pada pemeriksaan histopatologi ditemukan inflamasi granulomatosa kronik spesifik sehingga didiagnosis sebagai mastitis tuberkulosis dan diberikan terapi obat anti tuberkulosis (OAT).
Kata kunci: tuberkulosis, payudara, laki-laki

Angelin Utami Cahyani1, Eko Budiono2
1Resident ofInternal Medicine Departement of UGM Medical Faculty/Dr. Sardjito Hospital Yogyakarta
2Pulmonology Division of internal Medicine Departement of UGM Medical Faculty/Dr. Sardjito Hospital Yogyakarta
1Departemen Ilmu Penyakit Dalam FKUNSRI/RSMH Palembang
2Divisi Pulmonologi Departemen Ilmu Penyakit Dalam FKUNSRI/RSMH Palembang

Abstract
The found of Epidermal Growth Factor Receptor (EGFR)mutation in patient with Non Small Cell Lung Carcinoma (NSCLC) began the personalized therapy in treatment management of NSCLC. Since discovered 10 years ago, EGFR mutation which was response to Tyrosine Kinase Inhibitor (TKI) such asgefitinib, there was also found that the condition in which that therapy was resisted. Mutation in exon 20 insertion that leads to poor signaling of EGFR inhibition is associate with oncogenic trasnformation which is resistance to TKI. This case will be disscused to know if there is any resistance to TKI that need to be treated by other strategy.
Keywords: Lung Cancer, Non Small Cell Lung Carcinoma, Adenocarcinoma, Epidermal Growth Factor Receptor, Tyrosine Kinase Inhibitor, Gefitinib, Iressa