PENDAHULUAN
Foto toraks merupakan pemeriksaan yang umum dilakukan dalam mendiagnosis penyakit. Rontgen toraks dapat membuat gambaran dari hati, paru-paru, saluran pernafasan, pembuluh darah, dan tulang-tulang pada tulang belakang dan dada. Rontgen merupakan tes kesehatan non-invasif yang dapat membantu para dokter dalam menegakkan diagnosis dan memberikan terapi. Pencitraan dengan sinar-x melibatkan tereksposnya bagian tubuh, dengan dosis kecil radiasi pengion untuk menghasilkan gambar bagian dalam tubuh. Rontgen adalah bentuk tertua dan paling sering digunakan pencitraan medis.
Pada gambar 1, gambaran paru nampak lusen karena mengandung banyak udara pada alveolinya. Ukuran jantung tampak normal. Namun, dibandingkan dengan udara di luar tubuh, udara dalam paru memiliki warna lusen yang lebih rendah. Jika warna lusen paru-paru sama dengan udara luar tubuh maka ada kemungkinan pneumotoraks (toraks memiliki udara), misal saat luka tusuk yg mengakibatkan paru-paru mengempis, maka di luar paru-paru terdapat udara.
Ukuran jantung dewasa tidak boleh melebihi
setengah diameter intertorakal (CTR: Cardio Thoracic Ratio). Sedangkan ukuran jantung batita adalah lebih besar dari setengah diameter intertorakal (sekitar 0,6 atau 0,7). Jika melebihi ukuran tersebut, maka dicurigai bahwa jantung anak tersebut membesar. Pemotretan toraks dapat dilakukan dengan tiga cara, yaitu posteroanterior (PA) yaitu sinar dari belakang ke depan, anteroposterior (AP) yaitu sinar dari depan ke belakang, dan dari samping (lateral).
Menurut penelitian, dengan sumber sinar Rontgen berjarak 100 cm dan diambil gambar AP dalam posisi berbaring, ukuran jantung (CTR) normal ialah 0,56. Dalam melihat hasil foto toraks harus
diperhatikan adanya kelainan-kelainan seperti garis- garis putih, kabut, atau gambaran bulat seperti koin (coin lesion) pada paru-paru. Di Indonesia, penyakit paru seperti tuberkulosis masih banyak.

Zulkifli Amin1, Riahdo J. Saragih2
1Respirology and Critical Care Division, Internal Medicine Department FKUI/RSCM 2Internal Medicine Department FKUI/RSCM

ABSTRACT
Background: Ventilator-associated pneumonia (VAP) is considered as the most common nosocomial infection in the intensive care unit (ICU) with high mortality rates. Hypoalbuminemia has been recognized as poor prognostic indicator in critically ill patients but its role in patients with VAP is not fully known. The aim of this study was to evaluate the role of initial serum albumin in predicting the mortality of patient with VAP. Method: We designed a retrospective study to analyze data from hospitalized patients with VAP between 2003 - 2012 in Cipto Mangunkusumo Hospital, a tertiary hospital in Indonesia. Patients were grouped based on their initial serum albumin levels into: Group-1 (less than 2.7 g/dL), Group-2 (2.7 to 3.5 g/dL), and Group-3 (above 3.5 g/dL). We analyzed the hazard of in-hospital-mortality with cox proportional hazard model.
Results: Out of 194 patients evaluated in this study, 95 patients (49%) were included in Group-1, 83 patients (42.8%) in Group-2, and 16 patients (8.2%) in Group-3. Overall mortality rate was 58.2%. The hazards of in-hospital- mortality in Group-1 and Group-2 were 2.48 (95% CI 1.07 to 5.74; p = 0.033) and 1.42 (95% CI 0.60 to 3.34; p = 0.43), respectively, compared to Group-3.
Conclusion: Hypoalbuminemia increases the risk of mortality and initial serum albumin level should be considered as a predictor of mortality in every patient with VAP.
Key words: Serum albumin, predictor, mortality, VAP

Jerry Nasarudin1, Anna Uyainah ZN2, Teguh H Karjadi3, C Martin Rumende2
1Departemen Ilmu Penyakit Dalam, FKUI-RSCM
2Divisi Respirologi dan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, FKUI-RSCM 3Divisi Alergi Imunologi, Departemen Ilmu Penyakit Dalam, FKUI-RSCM

ABSTRAK
Latar belakang: Pasien HIV berisiko 20-37 kali lipat terinfeksi TB dan TB merupakan penyebab kematian tertinggi pada HIV. Resistensi OAT menjadi masalah utama pengobatan TB pada pasien HIV yang menyebabkan peningkatan mortalitas dan biaya. Rifampisin merupakan OAT utama sehingga perlu diketahui prevalensi resistensi rifampisin dan faktor-faktor yang mempengaruhinya pada pasien TB-HIV.
Tujuan: Mengetahui prevalensi resistensi rifampisin pada pasien TB-HIV dan faktor-faktor yang mempengaruhi.
Metode: Studi potong lintang terhadap 196 pasien TB-HIV yang menjalani pemeriksaan Xpert MTB-RIF di poli pelayanan terpadu HIV RSUPN-CM selama tahun 2012-2015. Analisa bivariat untuk mengetahui hubungan faktor- faktor terkait dengan kejadian resistensi rifampisin. Analisa multivariat menggunakan uji regresi logistik. Hasil: Didapatkan prevalensi resistensi rifampisin sebesar 13,8%. Usia, jenis kelamin, riwayat penggunaan ARV, dan TB ekstraparu tidak berhubungan dengan kejadian resistensi rifampisin pada pasien TB-HIV. Jumlah CD4 <100 memiliki hubungan dengan kejadian resistensi rifampisin (OR 2,57; 95% IK 0,99-6,69), namun secara statistik tidak bermakna. Riwayat pengobatan TB memiliki hubungan signifikan dengan kejadian resistensi rifampisin (OR 3,98; 95% IK 1,68-9,44)..
Simpulan: Prevalensi resistensi rifampisin TB-HIV di RSUPN-CM sebesar 13,8%. Riwayat TB memiliki hubungan signifikan dengan kejadian resistensi rifampisin pada pasien TB-HIV.
Kata kunci: Prevalensi, resistensi, rifampisin, TB-HIV

Alexander Randy Angianto1, Krishna Adi Wibisana1, Widayat Djoko Santoso2
Departemen Ilmu Penyakit Dalam FKUI/RSCM
Divisi Penyakit Tropik dan Infeksi, Departemen Ilmu Penyakit Dalam FKUI/RSCM

ABSTRACT
Pleural effusion is a condition when there is an accumulation of fluid in pleural space. The condition may manifest in breathing impairment by limiting lung expansion space. Pleural effusion is suffered by more than 1.5 million people
per year in America. A study held in Persahabatan Hospital between 2010-2011 found 119 cases of pleural effusion,
42,8% was malignant pleural effusion. Pleural malignancy is the most common indication for thoracocentesis, thus must be considered in massive pleural effusion (MPE). Therapy for MPE is palliative with the goal being relief of dyspnea. Treatment options for MPE are detemined by several factors: symptoms and performance status of the patient, the primary tumor type and its response to systemic therapy, and degree of lung re-expansion following pleural fluid removal. In this case, we will present a case of malignant pleural effusion as an illustration in searching of evidence in comparing between pleurodesis and indwelling pleural catheter in management of malignant pleural effusion.

Keywords: Pleural catheter, pleurodesis, malignant pleural effusion.

Nurul Aliyah S.1, Emmy H. Pranggono2, Basti Andriyoko3
1Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran, Bandung
2Divisi Respirologi dan Respirasi Kritis Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran, Bandung 3Departemen Patologi Klinik, Fakultas Kedokteran Universitas Padjadjaran, Bandung

ABSTRACT
Background: The incidence of Tuberculosis (TB) infection has increased throughout the years with a high mortality rate. The clinical manifestation of TB is a result of interaction between bacterial virulence, host immunity, and environmental factor. Nutritional component, such as vitamin D, plays a significant role in the host immune system. Vitamin D magnifies anti tuberculosis response toward macrophage. There was no data regarding vitamin D level in accordance to new cases of TB.
Objective: to describe the sputum smear conversion and vitamin D level in accordance to new cases of TB.
Methods: This study was performed in multicenter health facilities. Patient that has been confirmed with new case of TB and met the inclusion and exclusion criteria was enrolled to this study. The follow-up was done within 2 months. The data on socio demography, anthropometry, baseline vitamin D level, and conversion parameter were collected. Vitamin D level was differentiated into 3 categories: normal, insufficient, and deficient. In the 7 months period (October 2014-April 2015), 109 subjects were enrolled: 88 completed the follow-up, 20 dropped out, and 1 died. Results: In the study of 88 subjects, there were 55 people (62.5%) with sputum conversion and 33 people (37.5%) with non sputum conversion. The results of vitamin D levels were normal in 15 people (17%), insufficient in 29 people (33%), and deficient in 44 people (50%). Sputum conversion occurred in 9 people (16.4%) in the normal vitamin D group, 16 people (29.1%) in insufficient group, and 30 people (54.5%) in the deficient group. It means that conversion didn’t occur in 6 people (18.2%) in normal group, 13 people (39.4%) in insufficient group, and 14 people (42.4%) in deficient group.
Conclusion: People with vitamin D deficiency had both the highest number of subjects who experienced sputum conversion, and didn’t experience sputum conversion. This results indicated that there are other factors that play a role in TB infection, such as VDR polymorphism. This interaction will manifest especially in patients with low level of vitamin D. Further investigation should be done in order to evaluate the correlation between VDR polymorphism with TB infection.
Keywords : Sputum conversion, therapy, tuberculosis, vitamin D

Gurmeet Singh1, Ceva Wicaksono Pitoyo1, Dita Aditianingsih2, Cleopas Martin Rumende1
1 Departemen Ilmu Penyakit Dalam, Divisi Respirologi dan Penyakit Kritis, Universitas Indonesia, Rumah Sakit Ciptomangunkusumo, Jakarta
2 Departemen Anestesi dan Perawatan Kritis, Universitas Indonesia, Rumah Sakit Ciptomangunkusumo, Jakarta

ABSTRACT
Background: The incidence of Invasive Fungal Disease (IFD) is increasing worldwide in the past 2 to 3 decades. Critically ill patients in Intensive Care Units (ICU) are more vulnerable to fungal infection. Early detection and treatment are important to decrease morbidity and mortality in critically ill patients.
Objective: To profile critically ill patient associated with early invasive fungal disease.
Method: Prospective cohort study was conducted on critically ill patients at Cipto Mangunkusumo Hospital within March 2015 - September 2015 period. Total number of subject (74) in this study was drawn based on one of the risk factor (HIV). Specimens were collected on day 5 to 7 of hospitalization.
Results: A total of 206 patients were enrolled in this study. Among 74 subjects with IFD, majority were males (52.7%), mean age was 58 years (range 18-79), mean Leon’s Scores was 3 (score range 2-5), majority group was non-surgical/ non- trauma patient (72.9%), and mean fungal isolation was positive on the 5th day. The highest number of isolated fungal specimen found in this study was Candida sp (92.2%). Urine culture yields the highest fungal isolates (70.1%). Mortality rate in this study was 50%.
Conclusion: Incidence of early invasive fungal disease mostly found in critically ill patients with high mortality rate.

Key words: Critically ill, invasive fungal disease.

Tim Editor
Korespondensi: Tim Editor
Kontak: pulmonologi89@yahoo.co.id

PENDAHULUAN
Kanker paru adalah penyebab utama kematian akibat kanker. Sekitar 32% dari semua kematian akibat kanker pada pria dan 25% pada wanita disebabkan oleh kanker paru. Sebagian besar kasus kanker paru terjadi pada individu berusia 35-75 tahun dengan insidensi puncak terjadi antara usia 55-65 tahun. Di Amerika Serikat pada tahun 2010, 157.300 orang diproyeksikan meninggal akibat kanker paru-paru. Angka tersebut melebihi total jumlah kematian akibat kanker kolon, rektum, payudara, dan prostat. Hanya sekitar 2% pasien kanker paru yang didiagnosis dengan metastasis dapat tetap hidup lima tahun setelah diagnosis. Tingkat kelangsungan hidup untuk kanker paru yang didiagnosis pada stadium awal lebih tinggi, yakni sekitar 49% dapat bertahan hidup selama lima tahun atau lebih.

DEFINISI
Kanker paru umumnya dibagi menjadi dua kategori besar, yakni kanker paru sel kecil (small cell lung cancer-SCLC) dan kanker paru non-sel kecil (non-small cell lung cancer-NSCLC). Kategori NSCLC terbagi lagi menjadi adenokarsinoma, karsinoma sel skuamosa, dan karsinoma sel besar. Sekitar 80% kasus kanker paru merupakan NSCLC.
EPIDEMIOLOGI
Jumlah kasus kanker paru di Rumah Sakit Kanker Dharmais Jakarta tahun 1998 menduduki
urutan ke-3 sesudah kanker payudara dan leher rahim. Angka kematian akibat kanker paru di seluruh dunia mencapai kurang lebih satu juta penduduk tiap tahunnya. Oleh sebab sistem pencatatan kita belum baik, prevalensi pasti kanker paru di Indonesia belum diketahui. Di negara berkembang lain, insidensi
kanker paru dilaporkan meningkat dengan cepat karena konsumsi rokok berlebihan, misalnya China yang mengkonsumsi 30% rokok dunia. Sebagian besar kanker paru mengenai pria (65%) dengan life time risk 1:13 , sedangkan pada wanita risikonya 1:20.

Beta A.Wisman1, Radhiyatam Mardhiyah1, Eric Daniel Tenda2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM

ABSTRACT
Background: Chronic Obstruction Pulmonary Disease (COPD) has a high morbidity and mortality rate in the world, include in Indonesia. COPD GOLD D as an end stage of COPD contributes to a poor quality of life besides its high number in mortality.
Method: This is a case report of COPD GOLD D patient who were hospitalized in Cipto Mangunkusumo Natinal Hospital.
Results: A 53-year-old man complained of dyspneu 1 day before admission. Patient was diagnosed as COPD and was frequently admitted in hospital. Patient had an episode of exacerbation due to pneumonia, was admitted for 14 days and got a long acting of beta-2 agonis, corticosteroid inhalation (budesonide) and cephalosporine 4th generation. During the admission patient was diagnosed as an acute exaserbation in COPD GOLD D. Patient was clinically improved and got a combination of salmeterol+fluticasone and tiotropium.
Conclussion: The goal of COPD GOLD D management is a supportive care, the present standar therapy gives a clinical improvement although it has a high number in recurency, morbidity and mortality.
Keywords: management, COPD, GOLD D.

Astrid Priscilla Amanda1, Oviliani Wijayanti2
1Asisten Penelitian Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia/Rumah Sakit Cipto Mangunkusumo
2Fakultas Kedokteran, Universitas Indonesia

ABSTRACT
Pneumothorax can be caused by lung disorders such as COPD, malignancy, and tuberculosis with cavities. However, pneumothorax which occurred in miliary tuberculosis is very rare. This case, a male, 26 years old, came with unconsciousness one hour before hospital admission. Patient complained of chest pain and dyspnea. Chest x-ray showed right pneumothorax and miliary infiltrate on the left lung, suspected as miliary lung tuberculosis. After WSD insertion, chest x-ray showed that the right lung pneumothorax was improved post WSD insertion and miliary infiltrate on the left lung suspected as miliary lung tuberculosis. For miliary tuberculosis management, patient received anti tuberculosis drugs.
Keywords: miliary, pneumothorax, tuberculosis
ABSTRAK
Pneumotoraks dapat disebabkan oleh penyakit paru seperti PPOK, keganasan, dan tuberkulosis dengan kavitas. Namun, pneumotoraks yang terjadi pada penderita tuberkulosis milier jarang terjadi. Dalam kasus ini, seorang laki-laki berusia 26 tahun, datang dengan penurunan kesadaran. Satu jam sebelum masuk rumah sakit, pasien mengeluhkan nyeri dada dan sesak. Foto polos toraks memperlihatkan gambaran pneumotoraks kanan dan infiltrat milier di lapangan paru kiri, suspek tuberkulosis paru milier. Setelah pemasangan WSD, foto polos toraks menunjukkan adanya pneumotoraks kanan post WSD dengan perbaikan serta infiltrat milier di lapangan paru kiri, suspek tuberkulosis paru milier. Untuk penanganan tuberkulosis milier, pasien mendapatkan terapi OAT.
Kata kunci: milier, pneumotoraks, tuberkulosis

Rizqi A. Nabilah, Eric D. Tenda
Fakultas Kedokteran Universitas Indonesia
Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM

Abstract
Introduction: Community-acquired pneumonia is an infectious disease with one of the highest mortality rates. Recently, there are two widely-used models that have been developed to predict the severity of the disease: CURB-65 and PSI. This case report aimed to compare PSI and CURB-65 as the better severity assessment model based on the 30-day mortality rate.
Methods: Literature searching was done using two electronic databases: Cochrane® and PubMed® on October 1st, 2015 using CURB-65, Pneumonia Severity Index (PSI), Community-acquired pneumonia, and mortality as keywords. Results: One study suggested that PSI is more accurate for predicting short-term mortality in higher risk patients (AUC 0,81), while another study suggest that CURB-65 is better (AUC 7,44) as a prediction model. Discussion: The study that suggest CURB-65 as a better prediction model used very old patients and most of them had more than one comorbidities which can affect mortality rate. Our patient is a 68-year old woman with chronic kidney disease stage III and chronic heart failure with preserved ejection fraction. We conclude that PSI is better at predicting short-term mortality in our patient.
Keywords: CURB-65, PSI, community-acquired pneumonia,30-day mortality

Mega C Diatri, M. Harun Iskandar
Divisi Pulmonologi Departemen Ilmu Penyakit Dalam FK Universitas Hasanuddin Makassar

ABSTRACT
Background: Community-Acquired Pneumonia (CAP) had caused high prevalence of morbidity and mortality worlwide. Management of CAP depends on the severity of the disease. CURB-65 and PSI are the most frequently used clinical scoring system with high sensitivity and specifity in predicting mortality among inpatients with CAP. Procalcitonin (PCT) is a good biomarker for diagnosing CAP. High level of PCT indicates higher risk of complication among CAP patients, even if they were classified as low-risk by CURB-65 and PSI.
Objective: To determine the correlation between severity of CAP and PCT level.
Methods: Descriptive-analytic method was used in this cross-sectional study among CAP subjects in Dr. Wahidin Sudirohusodo Hospital, Makassar from September 2014 to January 2015. Severity of CAP was assessed with CURB-65 and PSI score. Initial PCT level was measured quantitatively with immunoluminometric method. Results: There are a total of 40 subjectsincluden in this study (mean age of 52 years). Range of CURB-65 score is 0-4, range of PSI socre 41-191, and range of PCT level 0,05-86,66. PCT showed significant correlation with both CURB-65 and PSI. PCT level (y) could be predicted using CURB-65(x): 1,33 + 5,22x. Mean PCT level had a significant difference among CURB-65 risk category, but it was not observed among PSI risk class. Age had a significant influence on mean PSI score. Comorbidty had no significant impact on CURB-65, so does the effect of the number of comorbidity on PSI score.
Conclusion: This study showed that severity assessment of CAP using CURB-65 score has been proved to be significantly correlated with PCT level. However, no significant correlation was observed with PSI score. Key words: Severity assessment of CAP, CURB-65 score, PSI score , PCT level.

Amin LZ1, Nasution SA2, Panggabean M2, Shatri H3
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Kardiologi, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Divisi Psikosomatik, Departemen Ilmu Penyakit Dalam FKUI/RSCM

ABSTRACT
Background: Mortality and major adverse cardiovascular effect (MACE) was a frequent post-PCI complication. Risk stratification by clinical scoring system could predict those complications. New Mayo Clinic Risk Score (NMCRS), which used easy to collect seven variables from medical record, had a good performance for predicting post PCI complication. No study has been done regarding mortality and MACE outcome in relation to NMCRS characteristics of post PCI patients at ICCU RSCM.
Objective: To obtain mortality and MACE incidence according to NMCRS characteristics of post PCI patients at ICCU RSCM.
Methods: A retrospective cohort study was conducted to evaluate 313 post PCI patients in ICCU RSCM between August 1st 2013 and August 31 2014. Seven variables were collected from patients’ medical records and NMCRS results for each risk category were determined.
Results: Post-PCI inhospital mortality incidence was 3,8% (CI 95% 2,6-5) and post-PCI inhospital MACE incidence was 8,3% (CI 95% 6,6-10). Older patients, patients with low left ventricular ejection fraction, elevated serum creatinine level,and patient suffering from pre-procedure cardiogenic shock, myocardial infarct, or peripheral arterial disease had a higher post-PCI mortality and MACE incidence. Results of NMCRS regarding mortality risk showed very low risk in 167 patients (53%), low risk 60 (19%), moderate risk 47 (15%), high risk 10 (3%), and very high risk 29 9%). Mortality incicence in very low risk category was 2 (1,2%), low risk 0, moderate risk 2 (4,25%), high risk 1 (10%), and very high risk 7 (24,13%). Results of NMCRS regarding MACE risk showed very low risk in 101 patients (32%), low risk 128 (41%), moderate 52 (17%), high risk 16 (5%) very high risk 16 (5%). MACE incidence in very low risk was 4 (3,96%), low risk 7 (5,46%), moderate risk 4 (7,69%), high risk 5 (31,25%), and very high risk 6 (37,5%).
Conclusion: Inhospital mortality incidence after PCI was 3,8% (CI 95% 2,6-5) and inhospital MACE incidence after PCI was 8,3% (CI 95% 6,6-10). The increase of NMCRS score was also followed with the increase of mortality and MACE incidence after PCI.
Keywords :, characteristic, mortality, major adverse cardiovascular effect, new mayo clinic risk score, post-PCI.

Siti TF Lubis1, EN Keliat1, Alwinsyah Abidin1
1Divisi Pulmonologi dan Alergi Imunologi, Departemen Ilmu Penyakit Dalam, FK USU/RSUP H. Adam Malik, Medan

ABSTRACT
Background: The assessment of severity in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at early admission is important to determine the risk of in-hospital mortality, the need of hospitalization or requirement of intensive care unit and further management. Two scoring systems, DECAF (Dyspnea, Eosinopenia, Consolidation, Acidaemia, Atrial Fibrillation) and BAP-65 (elevated BUN, Altered mental status, Pulse 109 beats/min, age >65 years were developed as prognostic tools.
Objective: To compare the sensitivity and specificity of DECAF scoring and BAP-65 scoring in predicting 30-days mortality in AECOPD patients.
Methods: A cohort study was conducted on patients in Emergency Unit and in-patients with AECOPD in H. Adam Malik Hospital, Medan, from February to June 2013. Both DECAF scores and BAP-65 scores were assessed. The sensitivity and specificity of both scorings were compared to determine the more accurate predictor. Results: A total of 40 subjects were recruited with mean age of 61,07 ± 12,42 years old. Nine subjects died during the study. Chi-square test showed that both scoring systems were significantly related to 30-days mortality, with p=0,003 for DECAF scoring and p=0,002 for BAP-65 scoring. The sensitivity and specificity of DECAF scoring are 100% and 16%, while those of BAP-65 scoring are 100% and 39%, respectively.
Conclusion: Both DECAF scoring and BAP-65 scoring have significant correlation with 30-days mortality in AECOPD patients. Both scoring systems have high sensitivity. However, low specificity renders both systems unfitting as predictor tools.
Key words: Acute exacerbation, COPD, BAP-65 score, DECAF score, predictor.

Martin Winardi1, Zulkfili Amin2, Ceva W. Pitoyo2, Andi AW Ramlan3, Esthika Dewiasty4
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Departemen Anestesiologi dan Perawatan Intensif FKUI/RSCM
4Divisi Geriatri, Departemen Ilmu Penyakit Dalam FKUI/RSCM

ABSTRACT
Background: Identifying the mortality risk of nonsurgical emergency department (ED) patients is essential as a consequence of increasing number of patients with diverse disease severity. Rapid Emergency Medicine Score (REMS) was developed to predict patient’s mortality in a short time, therefore it can help doctors to make clinical decision based on objective data. Difference in patients’ characteristic may influence the score’s performance value, therefore validation of REMS is needed before deciding to apply this system in Indonesia.
Objective: To evaluate calibration and discrimination performance of REMS in predicting mortality of nonsurgical ED patients in Cipto Mangunkusumo Hospital.
Methods: This is a prospective cohort study of nonsurgical patients who went to ED of Cipto Mangunkusumo Hospital in October-December 2012. Age, body temperature, mean arterial pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow coma scale were obtained when the patient arrived at emergency room to perform the calculation of REMS. Outcome was assessed when patients were discharged from the hospital (alive or dead). Calibration was evaluated with calibration plot and Hosmer-Lemeshow test. Discrimination was evaluated with area under the curve (AUC).
Results: A total of 815 nonsurgical patients went to ED of Cipto Mangunkusmo Hospital during the study period. As many as 741 (90.9%) patients were followed until the outcome was reached. Mortality was observed in 145 patients (19.57%). Calibration plot of REMS showed r = 0.913 and Hosmer-Lemeshow test showed p = 0.665. Discrimination was shown by ROC curve with AUC 0.77 (95% CI 0.723; 0.817).
Conclusion: Rapid Emergency Medicine Score showed a good calibration and discrimination performance in predicting mortality of nonsurgical emergency department patients in Cipto Mangunkusumo Hospital.
Key Words: Validation, rapid emergency medicine score, mortality, non surgical emergency.

Kristoforus H. Djaya1, Sally A. Nasution2, Dono Antono3
1Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, Jakarta
2Divisi Kardiologi, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, Jakarta 3Divisi Kardiologi, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, Jakarta

ABSTRACT
Background: Heart failure has become a global health issue worldwide. It has been associated with a high rate of readmissions and prolonged hospitalizations. Publications describing the profile and length of hospital stay of heart failure patients in Indonesia were still limited.
Objective: To obtain the length of hospital stay and describe the demographic as well as clinical characteristic of heart failure patients hospitalized at Cipto Mangunkusumo Hospital in 2012.
Methods: A cross sectional study was done using secondary data from patients’ medical records in Cipto Mangunkusumo Hospital admitted during 2012., Data were then calculated and presented further. Results: Based on the medical records, 331 heart failure patients were included in the study. Median age was 58 years old, 62,2% were men, 42,9% used Askes/In-Health as their social insurance payor, and as many as 23,9% had graduated from senior high school level education center. Median length of stay was 8 days for all patients, For patients admitted with NYHA functional class III - IV, the median length of stay was 9 days. When patients were admitted to hospital, median systolic blood pressure was 124 mmHg and pulse 90 beats per minute. Peripheral edema was shown in 36,9% of patients; hypertension in 57,1%; diabetes mellitus in 33,2%; ischemic heart disease in 74,9%; renal impairment in 46,2%; and acute respiratory conditions in 45,9%. The most frequent CCI score was 3. Conclusion: Median length of stay for heart failure patients in Cipto Mangunkusumo Hospital was 8 - 9 days. Most patients were men, senior high school graduate, and used Askes/In-Health as their social insurance with median age of 58 years old.
Keywords: Length of stay, heart failure.

Irawan F Kusuma1, Ika Trisnawati2, Eko Budiono2
1Departemen Ilmu Penyakit Dalam FK UGM/RS Dr. Sardjito Yogyakarta
2Divisi Pulmonologi Departemen Ilmu Penyakit Dalam FK UGM /RS Dr. Sardjito Yogyakarta

ABSTRACT
Background: ARDS is a critical disease that has a mortality rate of 40-60%. Mortality due to ARDS is influenced by some factors that can be predicted. Those factors should be taken into consideration in patient management so that the mortality rate can be reduced.
Objective: To observe factors that have high contribution to the mortality due to ARDS and to give recommendation based on those factors.
Methods: This is a cross sectional study. Research subjects are ARDS patients admitted to Intensive Care Unit Sardjito Hospital, Yogyakarta from January 2009 till December 2014. ARDS diagnosis was defined based on AECC criteria. Demographic data, laboratory results, and its follow up were obtained from medical records. Data were analyzed using SPSS 17. Bivariate and multivariate analysis with log regression were used to determine the contribution of related factors to mortality.
Results: There are a total of 101 subjects (72 patients are dead and 29 patients are alive) in study. Bivariate analysis showed that there are six factors affecting mortality: pneumonia, COPD, MODS, leucocyte count, pleural effusion, and vasopressor use. According to multivariate analysis, all factors have significant contribution to mortality, except pleural effusion. Factor with the highest odds ratio value are pneumonia (6.4) and the lowest are vasopressor use (4.9).
Conclusion: There are five factors with significant contribution to mortality of ARDS patients admitted to ICU. Those factors are pneumonia, COPD, leucocyte count, MODS, and the use of vasopresor. Therefore, it is very important to give more attention to those factors and to give optimal therapy based on those factors in managing patients with ARDS to reduce its mortality.
Key words: mortality, ARDS, ICU.

Nur I Afriliyantina1, Anna Uyainah2, Evy Yunihastuti3, Anis Karuniawati4, Cleopas M Rumende2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Divisi Alegi dan Imunologi, Departemen Ilmu Penyakit Dalam FKUI/RSCM
4Departemen Mikrobiologi FKUI/RSCM

ABSTRACT
Background: Tuberculosis is one of the most common presenting illness and the leading cause of death among people living with HIV. The clinical features of pulmonary tuberculosis in HIV-infected patients are not typical. The accurate diagnosis of pulmonary tuberculosis in HIV-infected patient remains a clinical challenge. Xpert MTB/RIF® is a new molecular modality for rapid diagnostic of tuberculosis. However, performance-related data from HIV-infected patients are still limited.
Objective: To determine the accuracy of Xpert MTB/RIF® in diagnosing pulmonary tuberculosis in HIV-infected patients from sputum sample.
Methods: This is a cross-sectional study performed in HIV-infected patients who were suspected of having pulmonary tuberculosis during October 2012 to April 2013 in Cipto Mangunkusumo Hospital. We investigated the diagnostic accuracy of Xpert MTB/RIF® compared to liquid media culture from sputum sample
Results: A total of 66 patients were suspected of having pulmonary tuberculosis and 43 patients were confirmed by culture examinations. Most of the patients were 25 - 35 years olds (58%), male (73%), have a low BMI (53%) and low CD4+ (56%). Most of HIV-infected patients were intravenous drugs user (62%). The sensitivity and specificity of Xpert MTB/RIF® were 93.0% (95% CI, 87.0% to 99.0%) and 91.3% (95% CI, 84.5% to 98.1%). The positive and negative predictive values were 95.2% (95% CI, 90.1% to 100%) and 87.5% (95% CI, 79.5% to 95.5%). Positive and negative likelihood ratios were 10.7 and 0.08.
Conclusion: Xpert MTB/RIF® has a good performance in diagnosing pulmonary tuberculosis in HIV-infected patients.
Key words: Tuberculosis, Xpert MTB/RIF®, HIV.,

Anggraini Permatasari1, Ceva W Pitoyo2, Dita Aditianingsih3, Cleopas M Rumende 2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Departemen Anestesi dan Terapi Intensif FKUI/RSCM

ABSTRACT
Background: Critically ill patients are increasing in number with high mortality rates. Prediction model with a good performance is needed to predict their mortalities. Modified Sequential Organ Failure Assessment (MSOFA) is one of the scoring systems which can predict 28 days mortality. It has shown many good results abroad, however it still need to be validated in Indonesia. In order to improve its performance, total serum magnesium is considered too be use as an added variable.
Objective: To evaluate the performance of MSOFA and the value of added magnesium level as predictor of mortality in critically ill patient.
Methods: This is a prospective cohort study. Medical data which consist of physical examination, Glasgow Coma Scale, peripheral oxygen saturation measurement, creatinine and magnesium serum level were obtained from subjects who were admitted to Intensive Care Unit of Cipto Mangunkusumo Hospital during April to July 2013. Subjects were assessed for outcome after 28 days of admission. Calibration performance was evaluated with calibration plot and Hosmer-Lemeshow test. Discrimination value was measured with area under the curve (AUC). Performance of MSOFA and magnesium value were appraised with ROC curve.
Results: A total of 150 critically ill patients was submitted for this study with 33,3% mortality rate. Calibration plot of MSOFA showed r = 0,7 and Hosmer-Lemeshow test showed p = 0,08. Discrimination value was shown by ROC curve with AUC 0,83 (CI 95% 0,76-0,90). With a cut-off value of 1,85 mEq/L, magnesium has shown optimal sensitivity and specificity, 38% and 48% respectively. However, AUC curve do not change after magnesium variable was added. Conclusion: MSOFA has shown a good calibration and discrimination performance in Indonesian people. Magnesium blood level has no added value to MSOFA for predicting mortality in critically ill patients.
Key words: Validation, Modified Sequential Organ Failure Assessment, total serum magnesium, mortality predictior, critically ill patients.

Ridho Adriansyah1, Gurmeet Singh2, Zulkifli Amin2, Anna Uyainah2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Pulmonologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM

PENDAHULUAN
Tuberkulosis (TB) merupakan penyakit menular melalui droplet udara yang disebabkan Mycobacterium Tuberculosis. Meskipun tingkat penularan TB relatif rendah dibandingkan dengan penyakit menular lainnya dan pengobatan yang efektif telah ditemukan sejak lima dekade lalu, TB masih menjadi masalah kesehatan global yang sulit diatasi. Tidak kurang dari sepertiga populasi dunia terinfeksi TB. Setiap tahun ditemukan sembilan juta kasus baru dan hampir dua juta penderita dilaporkan meninggal dunia. Insidens penularan infeksi HIV ikut berkontribusi terhadap meningkatnya epidemiologi TB secara global, khususnya di Afrika dan Asia. Peningkatan prevalensi tersebut juga diikuti peningkatan resistensi terhadap obat antituberkulosis (OAT). Ada tiga jenis resistensi yang dikenal dengan nama multidrug-resistant (MDR), extensively drug- resistant (XDR), dan total drug-resistant (TDR). Banyaknya jumlah kasus resistensi mencerminkan kegagalan program-program kesehatan yang sudah dijalankan selama ini.1
Indonesia sebagai salah satu negara berkembang di Asia Tenggara pun tidak luput dari masalah- masalah di atas. Indonesia menduduki peringkat ke-4 negara dengan kasus TB terbanyak setelah India, Cina, Afrika Selatan, dan Nigeria. Prevalensi TB di Indonesia cenderung stabil dari tahun ke tahun dengan angka prevalensi yang masih cukup tinggi, yaitu 261 per 100.000 penduduk. Persentase MDR TB saat ini sekitar 1,9 % dari semua kasus TB.2
Sejak tahun 1994, kasus MDR telah banyak dilaporkan oleh 114 negara. Dengan pelaporan dan pelaksanaan program tata laksana MDR TB yang intensif, diharapkan angka insidens MDR TB dapat ditekan. Kesulitan utama dalam tata laksana TB resisten obat baik MDR atau XDR adalah kualitas pemeriksaan sputum. Kualitas pemeriksaan yang baik merupakan salah satu indikasi program tata laksana nasional MDR TB berjalan dengan baik. Hal tersebut dijalankan dengan baik oleh negara-negara yang rutin mengirimkan hasil pemantauan nasionalnya

Borries Foresto1, Eric D Tenda2, Cleopas M Rumende3
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM 3Divisi Alegi dan Imunologi, Departemen Ilmu Penyakit Dalam FKUI/RSCM
ABSTRACT
Upper airway obstruction is an emergency condition that needs to be addressed immediately in order to prevent the consequent irreversible complication. The etiology of obstruction may vary depending on the patient’s age and clinical manifestation. Diagnosis and therapy must simultaneously be attempted in order to optimize patient’s clinical outcome. One of the most effective treatment modality is airway stenting. In this case, a 56-years old male came to Ciptomangunkusumo Hospital, Jakarta with chief complaint of worsening dyspnea after receiving chemotheraphy for non-small cell carcinoma. Physical examination showed tachypnea, inspiratory stridor, and wheezing. Bronchoscopy revealed stricture with intermitten obstruction. Fiberoptic bronchoscopy found stenosis at a distance of 5 cm from vocal cords with severe obstruction (75%)

Hendra Koncoro1, Ida B Suta2
1Departemen Ilmu Penyakit Dalam FK Udayana/RSUP Sanglah Denpasar
2Divisi Pulmonologi dan Ilmu Kedokteran Respirasi, Departemen Ilmu Penyakit Dalam FK Udayana/RSUP Sanglah Denpasar

Penyakit infeksi paru hingga saat ini masih merupakan penyakit yang paling sering dijumpai pada manusia dan penyebab kematian terbanyak setelah penyakit jantung koroner.1 Sekitar 75% penggunaan antibiotik ditujukan untuk infeksi paru yang disebabkan oleh bakteri. Akan tetapi, sebagian besar kasus infeksi ternyata disebabkan oleh virus. Penggunaan antibiotik yang tidak tepat ini merupakan penyebab utama munculnya resistensi antibiotik. Semakin maraknya kasus pemakaian antibiotik yang tidak tepat merupakan masalah yang belum teratasi hingga kini.2
Diferensiasi penyebab infeksi paru menjadi sangat penting guna membatasi penggunaan antibiotik yang tidak bertanggung jawab. Beberapa tes laboratorium dapat mengetahui adanya infeksi seperti hitung leukosit, laju endap darah, C-reactive protein (CRP), tumor necrosis factor, dan interleukin 1 (IL-1) dan IL-6. Namun, berbagai tes tersebut bersifat tidak spesifik sehingga etiologi infeksi paru sulit sekali ditentukan dalam waktu cepat. Diagnosis pasti harus menunggu hasil kultur darah selama beberapa hari. Oleh sebab itu, dibutuhkan suatu penanda spesifik yang mampu mendeteksi infeksi bakteri dengan cepat.3,4
Prokalsitonin (PCT) merupakan suatu biomarker yang lebih spesifik terhadap infeksi bakteri dan dapat dideteksi lebih awal dibandingkan gejala atau tanda infeksi lain, seperti demam, perubahan hitung leukosit, atau kultur darah. Biomarker ini terdiri dari 116 asam amino yang meningkat produksinya pada infeksi bakteri dan beberapa jenis keganasan.5,6 Tulisan ini memberikan gambaran mengenai produksi dan biologi PCT, faktor mempengaruhi kadar PCT, hubungan PCT dengn derajat keparahan infeksi, perbandingan PCT dengan biomarker lain, serta aplikasi PCT dalam kasus pulmonologi.

ABSTRACT
Background: The number of visits and mortality rates of emergency patients at Emergency Department (ED) have been increasing from time to time. Those patients have a wide spectrum of conditions. Appropriate identification of patients with high mortality risk is crucial. The Hypotension, Oxygen Saturation, Low Temperature, ECG Changes, and Loss of Independence (HOTEL) score is an easy and important tool to be applied in the ED. However, the score has not been validated in Indonesia.
Objective: To evaluate the performance of HOTEL score in predicting the 24-hour mortality of nonsurgical patients in ED of Cipto Mangunkusumo hospital.
Methods: The design is a prospective cohort study. The research subjects were the nonsurgical patients who were admitted to ED of Cipto Mangunkusumo hospital between October-November 2012. We collected systolic blood pressure, peripheral oxygen saturation, body temperature, ECG changes, and loss of independence data. Those data were evaluated based on the HOTEL scoring system. The outcome were evaluated in 24-hour after admission (alive or dead). The calibration was evaluated with the Hosmer-Lemeshow test. The discrimination performance was measured with area under the curve (AUC).
Results: There are 815 non-surgical patients who were admitted to the ED between October until November 2012, but only 804 (98.7%) subjects were included in this study. The 24-hour mortality rate is 3.7% (30 subjects). The calibration performance with the Hosmer-Lemeshow test showed p value of 0.753. The discrimination performance is shown with the AUC score of 0.86 (95% CI 0.781; 0,93).
Conclusion: The HOTEL score has a good calibration and discrimination performance in predicting the 24-hour mortality of the nonsurgical patients in ED of Cipto Mangunkusumo hospital.
Key words: Validation, HOTEL score, mortality, nonsurgical patients, emergency department

ABSTRAK
Latar Belakang: Banyaknya jemaah haji Indonesia memiliki kebiasaan merokok. Kebiasaan merokok tersebut bisa menyebabkan gangguan faal paru. Gangguan faal paru tersebut bisa bersifat obstruktif, restriktif, dan campuran. Banyak studi sebelumnya menunjukkan hubungan kuat antara kebiasaan merokok dengan penyakit saluran napas.
Tujuan: Mendapatkan karakteristik dan gambaran faal paru serta hubungan antara perilaku merokok dengan gambaran faal paru dari jemaah haji perokok di kelompok embarkasi Jakarta-Pondok Gede tahun 2012. Metode: Desain studi ini adalah potong-lintang pada jemaah haji yang menjalani pemeriksaan kesehatan haji di Puskesmas Kecamatan dan Embarkasi Jakarta-Pondok Gede. Penilaian perilaku merokok berdasarkan Indeks Brinkman dan penilaian gambaran faal paru berdasarkan pemeriksaan spirometri. Analisis bivariant menggunakan metode Kolmogorov Smirnov.
Hasil: Pada studi ini, didapatkan 209 subjek jemaah haji perokok. Karakteristik jemaah haji perokok umumnya laki-laki (99,5%), usia <60 tahun (78,0%), kategori IMT overweight (63,2%), tidak disertai komorbid (68,9%), pendidikan kategori tinggi (75,1%), dan Indeks Brinkman kategori sedang (53,1%). Gambaran faal paru ditemukan kategori restriktif 51,2%, obstruktif 8,6%, campuran 8,1% dan normal 32,1%.
Kesimpulan: Penelitian tidak menunjukkan adanya hubungan bermakna antara perilaku merokok dengan gambaran faal paru pada kelompok kategori Indeks Brinkman sedang-berat dibandingkan kelompok Indeks Brinkman ringan.
Kata kunci: Perilaku merokok, gambaran faal paru, jemaah haji perokok.

Dewasa ini penggunaan ventilasi noninvasif semakin berkembang dan membuat penderita merasa lebih nyaman. Perangkat ini menawarkan biaya perawatan yang lebih murah serta waktu perawatan yang lebih singkat dibandingkan dengan ventilasi invasif.1 Saat ini ventilasi noninvasif banyak digunakan pada pasien rawat inap dengan gagal napas akut maupun kronik pada perawatan di rumah.2

SISTEM RESPIRASI
Sistem pernapasan terdiri atas dua bagian, yaitu sistem pertukaran gas (paru) dan sistem ventilasi (pompa pernapasan). Masing-masing bagian dapat terganggu secara independen. Pada gagal paru, terapi oksigen umumnya cukup memadai, kecuali jika disertai dengan gangguan berat pada proses pertukaran gas. Sebaliknya, disfungsi dalam sistem ventilasi biasanya membutuhkan ventilasi mekanis

Insidens infeksi jamur, khususnya penyakit jamur invasif, di unit perawatan intensif (UPI) terus meningkat dalam beberapa tahun terakhir. Studi Extended Prevalence of Infections in the ICU (EPIC II) menemukan, jamur berperan dalam 19,4% dari seluruh kasus infeksi di UPI.1 Sistem National Nosocomial Infections Surveillance di Amerika Serikat melaporkan peningkatan kejadian infeksi jamur dari 2,0 infeksi/1000 pasien yang dipulangkan pada tahun 1980menjadi3,8infeksi/1000pasienyangdipulangkan pada tahun 1990. Serupa dengan hal tersebut, Voss dkk. mencatat peningkatan insidens kandidemia di sebuah rumah sakit di Belanda, yaitu dari 4,7 kasus/10 000 pasien/hari pada tahun 1987 menjadi 7,4 kasus /10 000 pasien/hari pada tahun 1994. Penelitian- penelitian saat ini melaporkan bahwa jamur terlibat hingga 17% dari seluruh infeksi-infeksi nosokomial, dan 9-12% dari infeksi darah nosokomial.2
Peningkatan infeksi jamur menggambarkan peningkatan jumlah pasien dengan sistem imunitas rendah yang membutuhkan perawatan intensif, antibiotik yang lebih banyak, perangkat bantuan hidup, dan prosedur invasif yang lebih sering. Kelompok pasien ini memiliki faktor risiko untuk infeksi jamur, termasuk pembedahan abdomen, nutrisi parental, dan kondisi imunosupresi.2
Morbiditas dan mortalitas yang bermakna dilaporkan pada pasien UPI dengan penyakit jamur invasif. Pemberian terapi antijamur yang tepat dan cepat adalah penentu utama prognosis pasien. Meski demikian, diagnosis penyakit jamur invasif sangat sulit dilakukan pada populasi ini karena tidak adanya metode diagnostik noninvasif yang akurat.
Selain itu, tidak terdapat rekomendasi jelas berbasis bukti mengenai waktu dan metode deeskalasi terapi antijamur. Akibatnya, terapi antijamur empiris sering kali digunakan untuk periode yang lama di UPI.
Terapi antijamur berkepanjangan berkontribusi dalam pembengkakan biaya perawatan di rumah sakit dan dapat mendorong terjadinya resistansi antijamur.1 Walaupun Aspergillus dan Candida masih menjadi patogen paling umum, spektrum mikosis invasif berubah dengan munculnya jamur patogen oportunistik lainnya, seperti Fusarium, Zygomicetes, dan Scedosporium. Infeksi patogen baru tersebut berpotensi mengancam jiwa jika terjadi bersamaan dengan mold (aspergillosis).3