Aim: to compare the in-hospital major cardiovascular events between thrombolysis therapy and primary percutaneous coronary intervention (PCI) in patients with ST-elevation acute myocardial infarction (STEMI). Methods: the study design is retrospective cohort. Medical record of patients with STEMI onset <12 hour receiving thrombolysis treatment or primary PCI in Dr. Sardjito Hospital Yogyakarta between January 2008 and March 2010 are evaluated. The primary outcome is major cardiovascular events which comprise cardiovascular death, reinfarction and stroke during hospitalisation. The secondary outcomes are post infarction angina pectoris, heart failure, cardiogenic shock and bleeding. Results: among 78 patients with thrombolysis and 53 patients with primary PCI, in-hospital major cardiovascular events do not differ significantly (10.3% versus 9.4%; RR 1.09, 95%CI 0.33-3.55; p=0.87). Post infarction angina pectoris is 7% versus 3.8% (RR 2.51, 95%CI 0.50-12.60; p=0.24). The incidence of heart failure is significantly higher in thrombolysis (17.9% versus 5.7%; RR 3.64, 95%CI 0.99-13.38; p=0.04), primary PCI reduces 68.1% relative risk to develop acute heart failure in STEMI. The incidence of cardiogenic shock is not different. Major and minor bleeding do not differ significantly either. Conclusion: the in-hospital major cardiovascular events between STEMI receiving thrombolysis therapy and primary PCI is not significantly different. Heart failure is significantly higher in thrombolysis therapy and the primary PCI reduces the risk. Key words: major cardiovascular events, STEMI, primary PCI, thrombolysis

A 67-year-old gentleman underwent fistulectomy for low trans-sphincteric anal fistula along with curettage for an associated abscess extending proximally for half a centimeter into the intersphincteric plane. The roof of the cavity became clearly visible after satisfactory culmination of the surgical procedure. Histopathological examination of the fistulous tract and the curetted granulation tissue revealed presence of multiple trophozoites of Entamoeba histolytica exhibiting erythrophagocytosis in the background of mixed inflammatory infiltrate. This case report provides the outlook that yields the novel insight into the possible role of Entamoeba histolytica in the pathogenesis and persistence of the fistulous tract. Key words: anal fistula, Entamoeba histoliytica, fistula.

Sickle cell anemia is an inherited abnormality of the globin chain with very high prevalence in the Indian subcontinent. A significant proportion of these patients present late in life and are at a risk of complications like acute chest syndrome and painful episodes till a definitive diagnosis is reached and appropriate treatment is started . We report a novel triad of abdominal imaging findings which is not reported in literature until now and which may suggest a diagnosis of sickle cell anemia in retrospect. Patients with this triad of abdominal findings should be suspected to have an underlying hemoglobinopathy and should be referred for further hematological workup. Although in our case the patient was diagnosed to have sickle cell anemia depending on the abnormal morphology of red cells and hemoglobin electrophoresis, it should be remembered that this triad of findings may be seen in other hemoglobinopathies which induce a state of chronic anemia. Key words: sickle cell anemia, adrenal myelolipoma, gall stones, calcified spleen.

Irritable bowel syndrome (IBS) is one of the most commonly encountered functional gastrointestinal disorders in the elderly. IBS is characterized by abdominal pain and altered bowel habits in the absence of specific organic pathology. The diagnosis of IBS usually depends primarily on established clinical criteria. Currently, Rome III criteria are the criteria of choice for defining IBS. However, aging itself is categorized as one of the alarm symptoms in the diagnosis of IBS that may warrant further investigation. Therefore, exclusion of organic diseases, using several investigations, is of paramount important in the older patients. In general, the treatment of IBS in the elderly is not different from the younger populations. However, greater caution needs to be considered before treating with drugs because of the altered risk-benefit profile in the elderly. Several studies have shown a strong relationship of IBS with psychiatric conditions. Thus, psychological treatments should also be considered in the management of IBS in the elderly. Key words: irritabel bowel syndrome, elderly, management.

A 51-year-old male came with thickening lesion in both legs since 2.5 years before presented. It started with small lesion and went larger. Before diagnosed, he was admitted to hospital due to unresolved headache. He complainted nausea, easily hungry, protrusion of both eyes without diplopia or diminution of vision, tremor, palpitation, and unintentional weight loss (25-30 kgs in a year). On examination, it was found that he was in thyrotoxic condition and has diffuse goiter. From skin examination he had raised hyperkeratotic, and waxy plaque like lesions over both pretibial region. Laboratory examination confirm for thyrotoxic with presumably Graves’ disease with the result on Table 1. Thyroid scintigraphy showed diffused enlargement and increased uptake. Skin biopsy from the pretibial skin showed epidermis with vacuolar degeneration, partly spongiotic and hyperpigmentated, thickening basalis membrane, miksoid dermis and spreading chronic inflammatory cell in perivascular and periadneksal. It confirmed the diagnosis of myxedema hystologically.

Myocardial infarction is one of the main cause of mortality in many countries. Therefore, an effective therapy for myocardial infarction is required. Reperfusion and other conventional therapy have been the mainstay therapy for myocardial infarction. However, many patients remain refractory to this therapy. Cellular cardiomyoplasty is considered a novel therapy, in which stem cells are used for cardiac repair. Stem cells are potential therapeutic approach that could be the ultimate solution for salvaging damaged cardiomyocyte. Based on current studies, stem cells are a promising therapeutic approach for myocardial infarction. However, some challenges need to be answered by future studies before this novel therapy can be widely applied. As we advance our understanding, all questions behind stem cell therapy would finally be revealed, and eventually provide the ultimate solution for ischaemic cardiac repair. This paper provide an overview of the latest progress in stem cell therapy for myocardial infarction. Key words: stem cells, cellular cardiomyoplasty, myocardial infarction

he Indonesian Society of Gastroenterology has compiled a national consensus guideline for the management of non-variceal upper gastrointestinal bleeding (NVUGIB). It is an endeavor to raise the quality of service for NVUGIB patients associated with peptic ulcer. The references for developing this consensus include three recent consensus guidelilnes on the management of NVUGIB and a modification of Delphi process was done to develop clinical guidelines. The three references are: The International Consensus Recommendations on the Management of Patients with Non-variceal Upper Gastrointestinal Bleeding (ICON-UGIB), 2010; Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding, 2011; and Management of Patients with Ulcer Bleeding, ACG guidelines, 2012. The consensus is compiled as a reference for Indonesian medical practitioners all across the country on the management of patients with non-variceal upper gastrointestinal bleeding associated with peptic ulcer. However, the technical implementation extremely depends on diagnostic and therapeutical facilities available in each health care center. Key words: endoscopy, bleeding, non-variceal upper gastrointestinal bleeding/NVUGIB, peptic ulcer.

It is projected that the elderly population in Indonesia will increase from approximately 19 million people in 2010 with life expectancy of 69.8 years during period of 2005-2010 to 29 million people in 2020 (11.11% of total population) with life expectancy of 73.6 years during period of 2020-2025. Higher elderly female proportion compared to male (11.43% versus 10.78%) will also be found.1 Aging process happens as people get older. Its process is influenced by genetic and environmental factors that can lead to successful aging, usual (normal) aging or pathologic aging. People with pathologic aging would have an increased risk to become frail.2,3 Nowadays, frailty syndrome is considered as one of the geriatric syndromes which increase the risk of worsening clinical outcome in mobility, functional status, hospitalization, institutionalization and mortality, as well as lower health-related quality of life.4,5 Moreover, frailty syndrome reflects a biological age that predicts mortality risk better than chronological age [RR 1.57 (95% CI 1.41-1.74) versus RR 1.08 (95% CI 1.06-1.2)].6 No wonder, frailty syndrome has attracted clinician’s attention, especially the geriatricians, all over the world with increasing research in this field.

Aim: to describe the profile of urinary infection (UI) and to analyze its risk factors and impacts. Methods: subjects were enrolled consecutively from pediatric, urology, obstetrics & gynecology, and geriatric outpatient clinics at six teaching hospitals in various regions of Indonesia. Those with urinary tract infection and diabetes mellitus were excluded. The UI questionnaire was adapted from the 3 Incontinence Questions (3IQ). Written informed consent was obtained prior to the interview. Results: about 2765 completed questionnaires were obtained. The overall UI prevalence was 13.0%, which consisted of prevalence of stress UI (4.0%), urgency UI/wet OAB (4.1%), dry OAB (1.6%), mixed UI (1.6%), overflow UI (0.4%), enuresis (0.4%), other UI (0.7%). The prevalence of UI was significantly higher (p<0.001) in geriatric population (22.2%) compared to the adult (12.0%), and pediatric population (6.8%). There was no prevalence difference (p>0.05) between male and female subjects. Enuresis and urgency UI/wet OAB were the most common UI in pediatric population. The prevalence was 2.3% and 2.1% respectively. Urgency UI and stress UI were the two most common type in adult and geriatric population. Both have an equal prevalence of 4.6%. The multivariate analysis showed that the prevalence of UI increased with LUTS (PR 4.22, 95%CI 2.98-5.97), chronic cough (PR 2.08, 95% CI 1.32-3.28), and fecal incontinence (PR 1.85, 95% CI 1.03-3.32). We found that UI impaired family life (25.3%), sexual relationship (13.6%), and job/school performance (23.7%). Frequent toilet use and reducing fluid intake were the two most common behavior changes. Conclusion: the prevalence of UI in Indonesia is nearly similar to other Asian countries. It increases with age and is not affected by gender. LUTS, chronic cough, and fecal incontinence may have significant effects on the prevalence. UI seems to impact daily life and behavior. Key words: urinary incontinence, daily life, LUTS, prevalence, age.

Aim: to explore the possibility of metformin protective effect on frailty syndrome. Methods: this was a case control study conducted in subjects’ ≥60 years old who visited the Geriatrics and Diabetes outpatient clinic of Cipto Mangunkusumo National Referral Hospital between March and June 2013. Diagnosis of frailty was established using the FI-40 item criteria. Statistical analysis was done with chi-square method for bivariate and logistic regression method in multivariate analysis, all data was accompanied with 95% confidence interval. Results: frailty syndrome was found in 25% of subjects (n=59), with median age of 72 years old (SD 6.27) and median of FI-40 item score was 0.18 (SD 0.085). Metformin was found to have a significant relationship with frailty syndrome in the elderly diabetics, which retained significant value after multivariate analysis (adjusted OR 0.043; 95% CI 0.019-0.099; p<0.001). Conclusion: metformin was shown to have protective effect against frailty syndrome in elderly diabetics. Key words: frailty, diabetes mellitus, metformin, elderly.

Aim: to investigate the effects of Vitamin D calcitriol/1,25(OH)2D3 on NETosis in systemic lupus erythematosus (SLE) patients with hypovitamin D. Methods: neutrophlis of five SLE patients with hypovitamin D were divided into 4 groups, P0 (0 nM/control), P1 (1 nM), P2 (10 nM), and P3 (100 nM) as cultured samples. Phorbol Myristate Acetate (PMA) was used to stimulate NETs formation. The supernatant was separated and cocultured with HUVECs. Externalization of Neutrophil Elastase (NE) and Myeloperoxidase (MPO) during NETosis was measured by immunofluorescence and ELISA respectively. Early and late apoptosis of endothelial cell was measured by flowcytometry using cell death kit (Annexin V and PI antibody). Results: this study showed significant decrease in early apoptosis with 10 nM of 1,25(OH)2D3 compared to control group. Significance of NE externalization found in all treatment groups (p<0.05), while MPO absorbance in the same tendency but not statistically significant. Further analysis also found a moderate positive correlation between NE externalizations with early apoptosis. Conclusion: vitamin D 1,25(OH)2D3 could reduce endothelial damage by decreasing NETosis activity. This result may reveal the possibility of Vitamin D as supplementary therapy for SLE patients with hypovitamin D to prevent endothelial damage. Key words: NETs, NE, MPO, 1,25(OH)2D3, HUVECs.

Aim: to evaluate the effect of weight loss program on fat mass, visceral fat rating and metabolic syndrome markers in obese subjects with weight cycling. Methods: this was an 8-week open trial. The subjects were recruited consecutively from Balai Kota DKI Jaya. Subjects were classified into two groups according to the fluctuation of weight gain (weight cycling/WC and first encounter obesity/FEO group). Both groups were assigned to receive weight loss program consisted with following goals: a 1000 kcal energy intake reduction and 45 minutes mild-to-moderate intensity physical activity three times a week. Body composition (fat mass, visceral fat rating), and metabolic syndrome markers (waist circumference and triglyceride levels) were measured at baseline, week 4 and at the end of study. Results: seventy two subjects completed the study (34 subjects in WC group and 38 subjects in FEO group). Following weight loss program, a decrease in fat mass, visceral fat rating, and waist circumference was lower in WC group compared with FEO group but it was not statistically significant (p>0.05). Triglyceride levels were decreased in the FEO group while it was increased in WC group. However the difference was not significant (p=0.055). Conclusion: weight loss program may contribute to changes in body composition and metabolic syndrome markers in obese subjects, which the response appears to be worse in weight cyclers. Key words: weight loss program, weight cycling, fat mass, visceral fat rating, metabolic syndrome.

Aim: to obtain formulation of an effective and efficient strategy to overcome blood stream infection (BSI). Methods: operational research design with qualitative and quantitative approach. The study was divided into two stages. Stage I was an operational research with problem solving approach using qualitative and quantitative method. Stage II was performed using quantitative method, a form of an interventional study on strategy implementation, which was previously established in stage I. The effective and efficient strategy for the prevention and control of infection in neonatal unit Cipto Mangunkusumo (CM) Hospital was established using Balanced Scorecard (BSC) approach, which involved several related processes. Results: the BSC strategy was proven to be effective and efficient in substantially reducing BSI from 52.31o/oo to 1.36o/oo in neonates with birth weight (BW) 1000-1499 g (p=0.025), and from 29.96o/oo to 1.66o/oo in BW 1500-1999 g (p=0.05). Gram-negative bacteria still predominated as the main cause of BSI in CMH Neonatal Unit. So far, the sources of the microorganisms were thought to be from the environment of treatment unit (tap water filter and humidifying water in the incubator). Significant reduction was also found in neonatal mortality rate weighing 1000-1499 g at birth, length of stay, hospitalization costs, and improved customer satisfaction. Conclusion: effective and efficient infection prevention and control using BSC approach could significantly reduce the rate of BSI. This approach may be applied for adult patients in intensive care unit with a wide range of adjustment. Key words: balanced scorecard, birthweight 1000-1999 g, bloodstream infection, neonates.

Aim: to describe non-spesific and specific immune response profile in Indonesian thalassemia major with and without splenectomy. Methods: this study was held at Thalassaemia Centre, Cipto Mangunkusumo Hospital Jakarta on September 2013 – February 2014. A comparative cross sectional study was conducted in healthy, thalassemia major aged more than 12 year and seronegative HIV. They were matched in age and sex for splenectomised and non-splenectomised groups, analysing the non-spesific immune response (neutrophil count and phagocytosis) and specific immune response (count and function of cellular immunity). Infection episodes were also analized as immune response in vivo parameter. Results: splenectomised thalassemia major showed increased neutrophil count but significantly decreased non-spesific immune response (neutrophil phagocytosis). Spesific immune response of splenectomised group presented significantly higher absolute lymphocyte, lymphocyte T, CD4+ and CD8+ counts compared to non-splenectomised thalassemia major (p<0.05). Ratio CD4+/CD8+ were similar in these groups. Serum marker of activated cellular imunity function (IL-2 and TNF-α) were similar among two groups. Mild infection episodes on splenectomised and non-splenectomised group were 2.02 (ranged 0 to 12) times and 0.81 (ranged 0 to 8) times (p=0.004), respectively. Severe infection on splenectomised group were sepsis for 2 weeks and diarrhea for 1 week, whereas on non-splenectomised group was typhoid fever for 4 days. Conclusion: there were significant differences on immune response among thalassemia major patients. Splenectomised thalassemia major showed a greater degree of susceptibility to infections than non-splenectomised thalassemia major. Key words: immune response, thalassemia major, splenectomy.

Aim: to test the precision and accuracy of a Digital Microcapillary instrument in measuring blood and plasma viscosity. Methods: about 40 blood samples were drawn for precision test. The samples were obtained from patients admitted for Medical Check-Up at CiptoMangunkusumo Hospital (RSCM) in December 2011. Accuracy test was evaluated using cross-sectional design and involving 135 patients with acute ischemic stroke. The patients underwent either inpatients or outpatients care at Department of Clinical Pathology, Department of Neurology,and Emergency Unit of RSCM, Fatmawati Hospital Jakarta, Prikasih Hospital Jakarta, and Bhakti Yuda Hospital Depok. The precision test was evaluated by calculating the coefficient of variation (CV), interrater variability of Cronbach Alpha, and reliability coefficient of Bland Altman. The accuracy of the test was evaluated with a diagnostic test. The gold standard used for these tests was Brookfield LV-DV III viscometer. Results: the results of precision test were: CV = 0.04; interrater variability of blood and plasma viscosity = 0.94 and 0.82, respectively; the Bland Altman mean difference = –0.19. The results of accuracy test were: sensitivity of blood and plasma viscosity measurement were 88.9% and 100%, respectively; specificity of blood and plasma viscosity measurement were 88.9% and 84%, respectively. Conclusion: the digital microcapillary has high sensitivity and specificity; therefore the instrument can be considered to be used as screening test tool to measure blood and plasma viscosity. Key words: digital microcapillary, blood viscosity, plasma viscosity, acute ischemic stroke

Transcatheter closure of perimembranous and muscular ventricular septal defect (VSD) has been performed widely and it has more advantages compare to surgery. However, transcatheter closure of residual VSD post operation of complex congenital heart disease is still challenging because of the complexity of anatomy and concern about device stability, so the operator should meticulously choose the most appropriate technique and device. We would like to report a case of transcatheter closure of residual VSD post Rastelli operation in a patient with double outlet right ventricle (DORV), sub-aortic VSD, severe infundibulum pulmonary stenosis (PS) and single coronary artery. The patient had undergone operations for four times, but he still had intractable heart failure that did not response to medications. On the first attempt. we closed theVSD using a VSD occluder, unfortunately the device embolized into the descending aorta, but fortunately we was able to snare it out. Then we decided to close the VSD using a patent ductus arteriosus (PDA occluder). On transesophageal echocardiography (TEE) and angiography evaluation, the device position was stable. Post transcatheter VSD closure, the patient clinical condition improved significantly and he could finally be discharged after a long post-surgery hospitalization. Based on this experience we concluded that the transcatheter closure of residual VSD in complex CHD using PDA occluder could be an effective alternative treatment. Key words: residual VSD, PDA occluder, transcatheter closure, heart failure, Rastelli.

Pulmonary papillomatosis is an extremely rare variant of recurrent respiratory papillomatosis which is hard to treat, causes prolonged morbidity, and may transform into malignant disorder in several cases. Since the symptoms and radiologic findings are not specific, pulmonary papillomatosis is often being misdiagnosed. Although considered benign, pulmonary papillomatosis carries the most significant mortality. This is a case report of a 26 year old man who complained recurrent chronic cough, slight hemoptoe, occasional pleuritic pain, and several episodes of fever. He also had laryngeal papillomatosis and undergone serial endoscopic resection since his childhood. Multiple nodular and cavitary lesions, some with air fluid level, were found in both lung fields at chest radiography and scintigraphy. Diagnosis of pulmonary papillomatosis complicated with secondary infection was made after endoscopic and histologic study. Key words: pulmonary papillomatosis, recurrent respiratory papillomatosis, nodular lesion, cavitary lesion

Chronic kidney disease (CKD) is a worldwide health problem with a high incidence not only in western countries but also in Indonesia as well. The majority of patients with CKD died due to cardiovascular disease than CKD progression itself. In addition to traditional risk factors, cardiovascular disease in CKD might also due to non-traditional risk factors. Oxidative stress, as non-traditional risk factors, is not only able to explain the high incidence of cardiovascular disease in CKD, but also become a new target in therapeutic intervention. Oxidative stress in patients with CKD appears due to increased oxidant activity and decreased antioxidant system. Hemodialysis (HD) with the use of a cellulose and semi-cellulose membrane also contribute to increase oxidant that can activate the complement pathway. It stimulates inflammation that will further expand the production of oxidants and will ultimately increase oxidative stress. Key words: chronic kidney disease, oxidant, oxidative stress.

Kaposi sarcoma defined as a multifocal lesion in mucocutaneous sites which has low-grade malignant potential. Kaposi sarcoma also commonly found in visceral organs. This malignancy is very popular among elderly men before the epidemic of HIV/AIDS in the decade of 1980-1990 Kaposi sarcoma known to be associated with immunodeficiency state as in HIV/AIDS patients. Nowdays, incidence of Kaposi sarcoma has decreased in developed countries in the era of Highly Active Antiretroviral Therapy (HAART) but still a big problem in resource-limited areas such as Sub- Saharan Africa.Eye is an unusual location for Kaposi sarcoma. There are not many study published about eye involvement of Kaposi sarcoma. Kaposi sarcoma of the conjunctiva and ocular adnexa has been reported to be strongly associated with HIV/AIDS patients.1 An old case report published Kaposi sarcoma in the eye of HIV negative patient, which stated as a unique case because of his good immunological performance.6 It is reported from the study of HIV/AIDS patients in Argentina that Kaposi sarcoma in the eye found in 0,25% patients.

The metal fume fever (MFF) is an inhalation fever syndrome in welders of galvanized steel, who join and cut metal parts using flame or electric arc and other sources of heat. Inhalation of certain freshly formed metal oxides produced from welding process can cause MFF as an acute self-limiting flulike illness. The most common cause of MFF is the inhalation of zinc oxide (ZnO). The inhalation of ZnO particles can provoke a number of clinical responses of which accompanied by changes in composition of bronchoalveolar lavage (BAL) fluid, including early increase in pro-inflammatory cytokines, inflammatory marker, and recruitment of inflammatory cells in the lungs. The MFF is characterized by fever, cough, sputing, wheezing, chest tightness, fatique, chills, fever, myalgias, cough, dyspnea, leukocytosis with a left shift, thirst, metallic taste, and salivations. The diagnosis of MFF diagnosis is based on clinical finding and occupational history. The symptoms resolved spontaneously. The treatment of MFF is entirely symptomatic, no specific treatment is indicated for MFF. The mainstay of management of MFF is prevention of sub-sequent exposure to harmful metals. Including public and physician awareness of MFF may help to reduce the occurrence of the disease. Key words: metal fume fever, zinc oxide, inflammation, prevention.