Aim: to develop a reference equation for prediction of the total distance walk using Indonesian anthropometrics of sedentary healthy subjects. Subsequently, the prediction obtained was compared to those calculated by the Caucasian-based Enright prediction equation. Methods: the cross-sectional study was conducted among 123 healthy Indonesian adults with sedentary life style (58 male and 65 female subjects in an age range between 18 and 50 years). Heart rate was recorded using Polar with expectation in the sub-maximal zone (120-170 beats per minute). The subjects performed two six-minute walk tests, the first one on a 15-meter track according to the protocol developed by the investigator. The second walk was carried out on Biodex®gait trainer as gold standard. Results: an average total distance of 547±54.24 m was found, not significantly different from the gold standard of 544.72±54.11 m (p>0.05). Multiple regression analysis was performed to develop the new equation. Conclusion: the reference equation for prediction of the total distance using Indonesian anthropometrics is more applicable in Indonesia. Key words: six-minute walk test, reference equation for prediction of total distance, Indonesian anthropometrics

Aim: to determine the difference in serum matrix metalloproteinase-9 (MMP-9) levels among acute coronary syndrome patients with and without hyperglycemia. Methods: this study was a cross-sectional study on patients with acute coronary syndrome admitted to ICCU of Dr.Sardjito Hospital Yogyakarta Indonesia. Measurements of blood glucose level were performed on hospital admission, while measurement of MMP-9 level was performed upon arrival at the ICCU. Hyperglycemia was defined as a random blood glucose level of >140 mg/dL. Student’s t test was performed to analyze the difference of MMP-9 level between subjects with and without hyperglycemia. Results: of 72 enrolled subjects, there were 34 subjects with hyperglycemia and 38 subjects without hyperglycemia. The mean blood glucose level was significantly different in subjects with hyperglycemia as compared to those without hyperglycemia (204.4±92.16 vs. 108.93±19.1 mg/dL, p=0.0001). The mean MMP-9 level in subjects with hyperglycemia was significantly higher than those without hyperglycemia (1574±573.61 vs. 1370±573.66 ng/ mL, p=0.025). The prevalence ratio of high MMP-9 level among subjects with hyperglycemia was 2.88 (95% CI: 1.16-7.14), p=0.004. Conclusion: serum MMP-9 level in patients suffering from acute coronary syndrome with hyperglycemia was significantly higher than those without hyperglycemia. Key words: acute coronary syndrome, matrix metalloproteinase-9, hyperglycemia.

The incidence of colorectal cancer (CRC) is rapidly increasing world-wide including in Indonesia and controversy not with standing, making it as the second most common malignancy (GLOBOCAN 2012). As with other cancers – more importantly with its adenoma-carcinoma sequence being one of the first to be elucidated by Vogelstein1 – its treatment and prognosis are determined by disease staging and molecular profile. Yet, identifying those for whom chemotherapy is indicated is still a challenge due to its histopathological heterogeneity; with special emphasis on stage II disease, for example, having a five-year survival that ranges from 87.5% for IIA to 58.4% in stage IIC. It is in such situation that predictive and prognostic markers are constantly being investigated. As one of the leading causes of cancer death in developed countries, much interest has grown in research in the development of biomarkers to improve the diagnostic process and to predict efficacy of chemotherapy.2 Only a few biomarkers are qualified as such, and the paucity of data has resulted in under- and overtreatment when relying only on the current TNM system. At present, only mutant KRAS, mutant BRAF, Microsatellite Instability (MSI) and the Oncotype DX® ColonCancer Assay are used in clinical practice. MSI and mutant KRAS are the established markers to date.3 But as the world is shifting towards personalized medicine (or “precision therapy” as is more frequently called), much work remains to be done.

One of the cornerstones of critical care medicine is support of the failing respiratory system. The 2 major components of managing respiratory failure are the acute intervention and the weaning process. Many of the studies to determine the optimal methods of ventilation and weaning have focused on non-invasive positive-pressure ventilation as an alternative to invasive ventilation, with various causes of acute respiratory failure. Non-invasive ventilation refers to the provision of ventilatory support to the lungs, without the use of an endotracheal airway. It has emerged as an important tool in the treatment of acute respiratory failure. Non-invasive positive ventilation has undergone a remarkable evolution over the past decades and is assuming an important role in the management of both acute and chronic respiratory failure. There is improvement in gas exchange, relief of respiratory muscle fatigue, and clinical outcome with reduced morbidity and mortality. Nevertheless, contraindications and failures need to be identified early, as delaying endotracheal intubation is associated with increased morbidity and mortality. Furthermore, although it is common practice to give intubation and mechanical ventilation, complications can result from the intubation process (damage to local tissue) and during the course of ventilation (pneumonia and sinusitis associated with ventilators), prolonging stay in intensive care, length of hospital stay and mortality in selected patients. Key words: non invasive ventilation, mechanical ventilation, acute respiratory failure.

A 50-year old man was consulted due to right leg swelling concomitant with redness and pain since two months between admission. The patient experienced fever and dull pain in right inguinal region before the leg became swollen. Antibiotic and antipyretic had been given but gave unsatisfaction response. No history of bedridden, hospitalization, or malignancy. He worked as a palm oil farmer in Geragas Village, langkat District, North Sumatera, Indonesia, an endemic region of Bancroftian filariasis. Physical examination revealed normal vital signs, there was non pitting oedema and redness in right gastrocnemius region (Figure 1). Laboratory results of routine blood count and haemostasis were within normal limit, except leucocytosis (12000/m3) and eosinophilia (15%). Peripheral blood sample was drawn between 10 pm and 2 am and showed positive microfilariae with gently curved body, a tail that is tapered to a point, and the nuclear column is loosely packed, appropriate for Wuchereria bancrofti (Figure 2).

We discuss and illustrate various endovascular treatment options for intracranial aneurysms, to reflect common technique used in endovascular treatment of brain aneurysm. We select five cases of various aneurysm types to show assortments of endovascular treatment (EVT) are performed. Selective catheterization of the intracranial aneurysms and endovascular treatments are technically feasible, offering a viable alternative to the surgical approach. We discuss the radiographic features, clinical presentation, and strategies of endovascular treatment of intracranial aneurysms. Key words: endovascular treatment, intracranial aneurysm, intracranial stent, balloon assisted.

To manage cases of avian influenza A/H5N1 virus infection and in anticipation of a pandemic triggered by this virus, Indonesia purchased and distributed oseltamivir to the government health facilities. Oseltamivir is an antiviral drug that was developed for the treatment of influenza infections. Disease surveillance and research suggests that seasonal influenza (A/H1N1, A/H3N2 or B) results in considerable morbidity and mortality in Indonesia, where over 15% of influenza-like illness and severe acute respiratory illness patients test positive for the influenza virus. Indonesia currently limits oseltamivir for the management of avian influenza A/ H5N1cases and in anticipation of a pandemic triggered by the A/H5N1 virus. We present the evidence for the use of oseltamivir in the treatment of seasonal influenza infections so that doctors have the option to prescribe the drug. We propose that the benefits of this approach will largely outweigh the risk of antiviral resistance. We recommend that oseltamivir be available for administration to patients with seasonal influenza infections especially for those hospitalized and for groups with high risk of complications and adverse outcomes. Overall, this will reduce morbidity and mortality of seasonal influenza.Key words: antiviral, policy, Indonesia, influenza, treatment.

There are many causes of urticaria, which may vary from infections to malignancy. Among the infections, infestations by cysticercosis (larval stage of the tapeworm called Taenia solium) is an important cause. The present report is of forty four years old female who presented with urticaria and swelling on face. The swelling was later diagnosed as cysticercosis by noninvasive ultrasonography. The urticaria subsided after the treatment of cysticercosis. We report this case for rarity of its presentation. Key words: cysticercosis, chronic urticaria, Taenia solium, ultrasonography

Primary breast tuberculosis is a rare entity. We are reporting a case of primary breast tuberculosis, which presented as breast abscess. On histopathology, it was diagnosed as breast tuberculosis. Aspiration cytology was not done due breast abscess. Patient was put on anti-tubercular drugs. In follow up, after 3 months patient condition was improved. Key words: breast, abscess, tuberculosis, conservative treatment.

Aim: to evaluate the serum levels of anti-tetanus toxin antibodies (anti-TTA) in patients with type 2 diabetes mellitus (DM) and in a control group. Methods: totally, 100 patients with type 2 DM and 100 age-and sex-matched healthy individuals were enrolled to study. The presence of type 2 DM confirmed according to the clinical and para-clinical criteria such as fasting plasma glucose above 126 mg/dl. A peripheral blood sample was collected from all subjects. The serum samples of participants tested for the levels of anti-TTA by ELISA method. The serum antitoxin concentration ≥0.1 IU/mL was considered as a protective level of antibody. Results: the seroprotective rate in healthy group was significantly higher than diabetic group (99% vs. 92%; p<0.02). The mean titer of anti-TTA in healthy group (5.32±0.26 IU/ml) was also significantly higher than diabetic patients (3.46±0.26 IU/ml; p<0.001). In diabetic men the mean titer of anti-TTA was significantly higher in comparison to diabetic women (3.94±0.34 IU/ml vs 2.59±0.36 IU/ml; p<0.01). In diabetic patients the seroprotective rate and the mean titer of anti-TTA in subjects with age >40 years was also lower in comparison to those with age <40 years (89.23% vs 97.14%; p<0.15 and 4.57±0.38 IU/ml vs 2.86±0.32 IU/ml; P<0.002, respectively). The mean titer of anti-TTA was significantly higher in patients with diabetes duration <5 years in comparison to patients with disease duration >5 years (3.91±0.35 IU/ml vs 2.85±0.38 IU/ml; p<0.04). Conclusion: these results showed lower levels of anti-TTA in patients with type 2 DM, in diabetic women, in patients aged >40 years and in diabetic patients with disease duration >5 years . Key words: immunity, tetanus, antibody, type 2 diabetes.

Aim: to assess the safety and efficacy of telbivudine therapy in adult patients with CHB in Indonesia. Methods: the study design was prospective cohort study. Multicenter study of adult CHB patients requiring oral antiviral therapy in daily practice setting. All patients received 600 mg of telbivudine daily for one year. Recruitment and decision to start telbivudine therapy was based on clinical indication as assessed by the participating physicians. The primary end-point was patient safety (adverse event or serious adverse events); while the secondary end-points were HBeAg seroconversion, changes of serum HBV DNA levels and serum ALT normalization. Patients were assessed at week-24 and week-52 of treatment. Results: a total of 176 cases were eligible for analysis, comprising 104 (59.8%) HBeAg-positive and 70 (40.2%) HBeAg-negative patients. Adverse events were reported in 7 (4.0%) patients, most of them were mild. HBeAg loss and seroconversion rate was 28.8% and 14.14% at week-52 respectively. Undetectable HBV DNA (PCR negativity) was 51.8% at week-24 and 62.7% at week-52. Median HBV DNA levels were significantly reduced from baseline to week-24 and week-52 treatment (both p<0.001; Wilcoxon’s signed-rank test). Normalization of serum ALT activity occurred in 85 (73.28%) patients at week-52. Conclusion: Telbivudine therapy is generally safe and well tolerated among adult Indonesian patients with chronic hepatitis B. Treatment efficacy in terms of HBeAg loss and seroconversion, changes of HBV DNA levels and serum ALT normalization were similar to previous reported studies. Key words: Alanine aminotransferase, chronic hepatitis B, HBV DNA, oral antiviral treatment, telbivudine therapy.

Aim: to detect the levels of CEC and expression of NFκB in the three groups of subjects with certain conditions. Methods: this study is an exploratory study using human peripheral blood samples. The study subjects comprised three groups, the group of 23 healthy people, a group of 35 people that has one or more risk factors for vascular disease and a group of 15 vascular disease patients (coronary heart disease, diabetes mellitus, stroke). CEC were isolated from peripheral blood mononuclear cells (PBMC). CEC level is identified through the measurement of CD45 and CD146 by flowcytometry method. NFκB expression is recognized by ELISA method (imgenex, USA). Results: the highest average levels of CEC were found in the sick group (28.6%). The highest average expression of NFκB (924.9495) is found in the group with risk factors. The lowest average expression of NFκB and CEC is found in the healthy group. Statistical analysis of ANOVA at the interval confidence of 95% shows a significant difference (p=0.00) levels of CEC and NFκB expression between the healthy group with the group with the risk of cardiovascular disease (CVD) and patients with known CVD. Conclusion: increase of level CEC and NFκB expression has a strong relationship with vascular disease and its risk factors. Key words: circulating endothelial cells (CEC), nuclear factor kappa beta (NFκB), peripheral blood mononuclear cell (PBMC), vascular disease.

Aim: to analyze the correlation between Receptor activator of nuclear factor-κβ ligand (RANKL), Osteoprotegrin (OPG) serum level with cartilage oligomeric matrix protein (COMP) serum level as a marker of cartilage degradation in rheumatoid arthritis patients. Methods: a cross-sectional study was conducted on the subjects who came to the outpatient clinic of rheumatology in Cipto Mangunkusumo Hospital. Patients were diagnosed based on the American College of Rheumatology (ACR) 1987 revised criteria. All numerical data, both primary data and data transformation were not normally distributed, so we did bivariate analysis with Spearman correlation test. Results: we collected the data of 60 RA patients with majority of the subject had active disease activity (78.3%). Methotrexate was the most widely disease modifying anti-rheumatoid drug (DMARD) used, either as a single drug (51.7%) or in combination with another DMARD (25.1%). Bivariate analysis was revealed that RANKL, OPG, and OPG/RANKL serum level have no significantly correlation with COMP serum level (p=0.52; p=0.25; p=0.2, respectively). Conclusion: RANKL and OPG serum level, had no correlation with cartilage degradation in rheumatoid arthritis patients. Key words: RANKL, OPG, COMP, rheumatoid arthritis.

Aim: to determine the role of serum lactate and diabetic ketoacidosis (DKA) severity as predictors for five-days mortality in DKA patients. Methods: a prospective cohort study was conducted in DKA patients admitted to emergency department (ED) at Cipto Mangunkusumo Hospital, Jakarta, Indonesia, during 2007-2008 periods. Predictors for 5 days mortality in DKA patients in this study including serum lactate and DKA severity (plasma glucose, arterial blood pH, serum bicarbonate, osmolality, anion gap, and alteration in sensorium) at admission. Cox’s Proportional Hazard Regression Analysis was used to determine independent predictors for 5-days mortality among study population. Results: sixty patients with diabetic ketoacidosis were enrolled in the study; in which 24 (40%) patients were died within 5 days after admission. In the multivariate analysis, the lactate level ≥4 mmol/L (HR, 3.09; 95% CI, 1.36-7.05) and altered in sensorium stuporous/comatose (HR, 3.38; 95% CI, 1.45-7.87) were identified as independent predictors for 5-days mortality in DKA adult patients. Conclusion: lactate level ≥4 mmol/L and altered in sensorium stuporous/comatose can be used to predict 5-days mortality in adult patients with DKA. Key words: diabetic ketoacidosis, sepsis, lactate level, alteration in sensorium mortality.

Aim: to investigate hemostatic parameter changes, such as platelet aggregation, blood and plasma viscosity, prothrombin time, APTT, CRP and fibrinogen, before and after administration of stem cell therapy. Methods: a total of 24 patients were enrolled. Peripheral blood stem cells (PBSCs) were harvested and injected into the infarct-related artery after 5 consecutive days of G-CSF administration. Recombinant human erythropoietin was administered at the time of intracoronary PBSCs injection. Results: we were able to evaluate 11 from 24 of patients regarding hemostatic status pre–post stem cell injection. There were no significant difference between baseline vs 3 months in spontaneous aggregation (p=0.350), PT (p=0.793), aPTT (p=0.255) and TT (p=0.254). There were also no significant difference between baseline vs 3 months in plasma viscosity (p=0.442) and blood viscosity (p=0.843). Nevertheless the patient who had their blood and plasma viscosity above or below normal laboratory range return to normal level after the treatment. Both PT and APTT also show normalization value. Both Fibrinogen and CRP level show significant decrease between baseline and 3 months after treatment (p=0.009) and (p=0.04) respectively. Conclusion: combined G-CSF and EPO based-intracoronary infusion of PBSCs may open new perspective in the treatment of hypercoagulable state post AMI. Key words: coagulation, platelet aggregation, myocardial infarction, hypercoagulation

Aim: to determine the current prevalence of hepatitis B infection among parturient women in Jakarta, Indonesia. Methods: a cross-sectional study was conducted in women giving birth between May and July 2009, recruited by consecutive sampling technique in 2 hospitals and 13 public health centers in Jakarta. Mothers with history of chronic liver disease were excluded. Data were collected by questionnaires including obstetric history, hepatitis B immunization history, and the presence of jaundice; maternal venous blood samples were taken before parturition for HBsAg determination that was performed by ELISA. Results: of 1,009 parturient women screened for hepatitis B infection, 22 were found positive, giving an overall hepatitis B prevalence of 2.2%, previous 5.2% in 1985. None of the subjects had any symptoms of HBV infection. The highest HBsAg prevalence was found in the East Jakarta study site, with predominance in mothers aged <20 years and those with multi-parities. Conclusion: present prevalence of HBsAg among Indonesian parturient women in Jakarta was 2.2% and markedly reduced compared with prevalence in 1985. Key words: hepatitis B, parturient women, immunization, prevalence.

Cardiovascular disease has been well known as the most frequent cause of death in many countries all over the world.1 Acute myocardial infarction (AMI) is a sudden clinical coronary event that has high mortality and morbidity rate. The survivals of AMI will have left ventricle (LV) remodelling and decreased cardiac functions in the following years due to necrosis of cardiomyocites after AMI leading to chronic heart failure. However, revascularization therapy such as percutaneous coronary intervention (PCI) and medications cannot regenerate the necrotic cardiomyocites. Stem cell (SC) therapy as novel strategy in management of AMI has been developing so fast recently. Potential beneficial mechanism of SC therapy after AMI includes myocardial preservation, decreased infarct expansion and myocardial regeneration.2 To date, SC therapy in management of AMI seemed feasible and safe in clinical practice. Number of trials had been conducted to search for promising results and answers to many questions regarding the matter. The TOPCARE-AMI (transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction) with 59 patients showed improvement in ejection fraction and infarct size after 1 year follow-up. The REPAIR-AMI (reinfusion of enriched progenitor cells and infarct remodelling in acute myocardial infarction) trial with larger samples of 204 patients showed improvement in global LVEF at 4 months follow up from 48.3%±9.2% to 53.8%±10.2%.6 A systematic review of SC therapy in AMI with 13 RCT and 811 enrolled patients indicated LV function improvement in short term follow-up.

Osteoarthritis (OA) is the most common degenerative joint disease found in the elderly. Drug options that are recommended by the American Academy of Orthopaedic Surgeon (AAOS) are acetaminophen, NSAIDs, tramadol, capscaicin and intraarticular corticosteroids. However, there is concern for the possible side effects resulting from long term use of those medications. Researchers are searching for a safer treatment modality for OA. Leech therapy (hirudotheraphy) is one of the therapies under investigation, given its purported analgesic and antiinflammatory properties. Key words: osteoarthritis, hirudotherapy, leech therapy, NSAIDSs, elderly, alternative terapy.

Aim: to review the effectiveness of tranexamic acid therapy which has been proposed to reduce bleeding and in turn lower mortality rate. Methods: following literature searching based on our clinical question on Cochrane Library, PubMed, Clinical Key, EBSCO, Science Direct and Proquest, one systematic review that includes seven randomized controlled trials is obtained. The article meets validity and relevance criteria. Results: the systematic review found that there is no any clear evidence between intervention and control groups in term of mortality. Conclusion: the use of tranexamic acid to reduce mortality in patients with upper gastrointestinal bleeding is not recommended. Key words: tranexamic acid, mortality, upper gastrointestinal bleeding.

A fifty-five year old female patient presented with jaundice, subfebrile fever and dark yellow urine since one month before admission. She lost weight 10 kilograms during one month. One day before admission to Ciptomangunkusumo General Hospital, she complained of worsened abdominal pain at right upper quadrant urging her to come to the emergency room. An abdominal examination revealed Murphy sign, mild hepatomegaly and deeply icteric sclera. Serum bilirubin was 21.8 mg/dl, alkaline phosphatase and gamma-glutamyltransferase levels were significantly elevated (1090 IU/L and 560 IU/L consecutively) while the transaminases were moderately high (ALT 80 U/L). The C-reactive protein was 555 mg/L. An abdominal ultrasound examination revealed dilatation of right and left intrahepatic bile duct and presence of common hepatic duct stone. Subsequent magnetic resonance imaging/ magnetic cholangiopancreatography (MRI/ MRCP) revealed intrahepatic bile duct dilatation, multiple CBD stone and benign stricture at common hepatic duct causing right and left intrahepatic bile duct obstruction.We assessed the patient as acute cholangitis and obstructive jaundice suspected to be caused by biliary duct stone then we performed endoscopic retrograde cholangiopancreatography (ERCP), we revealing stenosis at distal CBD, multiple CBD stone, giant stone in CHD and dilatation of bilateral IHBD. We performed CBD stone extraction then inserted biliary stent for drainage. Then we planned to do second ERCP with SpyGlassTM for giant stone extraction. After the first ERCP, the clinical condition of the patient improved and the bilirubin decreased to 10 mg/dL. In the next two weeks we performed a second ERCP to extract the giant stone with SpyGlass TM. However, after we inserted SpyGlassTM into the biliary duct, what we found were not as we expected before. We revealed that there was a mass in biliary duct and there was no CBD stone. We did the biopsy and inserted a new plastic stent (after removed the older one) to the common biliary duct. Surprisingly, the result of histopathology also supports our findings, which was the adenocarcinoma at common bile duct.