Medical Journal of Indonesia

How important is early detection and prompt treatment in congenital hypothyroidism patients?

Vivian Soetikno — 2019-12-13

[None]

A randomized clinical trial of nasogastric tube insertion in intubated patient: comparison between finger method and reverse Sellick maneuver

Rahendra — 2019-12-13

BACKGROUND Finger method is a new simple technique of nasogastric tube (NGT) insertion for intubated patients which only requires the practitioner’s own fingers. This study was aimed to compare the feasibility of finger method and the standard reverse Sellick maneuver in NGT insertion for intubated patients.

METHODS This was a single-blinded, randomized clinical trial that included 210 patients aged 18–65 years old who were intubated under general anesthesia and needed NGT insertion. Initially, subjects were randomly allocated by the third party into two groups: subjects who had NGT insertion with finger method and those with reverse Sellick maneuver. Success rate of NGT insertion at the first attempt, duration of the procedure, and complication rate of blood spots were all recorded. Chi-square test and Mann–Whitney analysis were used to analyze the data.

RESULTS Success rate of NGT insertion at the first attempt in finger method group was higher in comparison with reverse Sellick maneuver group (81.6% versus 60%, respectively, p = 0.002). Likewise, the median of NGT insertion duration was longer in finger group compared to reverse Sellick maneuver group (13 sec versus 12 sec, respectively, p < 0.001) but it was not clinically significant. Moreover, the complication rate of blood spots found during the procedure was lower in subjects with finger method than with reverse Sellick maneuver (10.7% versus 28%, respectively, p = 0.003).

CONCLUSIONS Using finger method was more feasible than reverse Sellick maneuvers in NGT insertion.

Radial extracorporeal shockwave therapy on calcaneal spurs: a randomized controlled trial

Desy Kurniawati Tandiyo — 2019-12-13

BACKGROUND The effectiveness of extracorporeal shockwave therapy (ESWT) in handling pain and calcaneal spurs is still controversial, whereas research on the effectiveness of ESWT in the reactive ossification process of calcaneal spurs, involving osteoprotegerin (OPG) and the receptor activator of nuclear factor-kappa B (RANK), does not exist. This study was aimed to assess the effect of ESWT on pain, the length of the spur, plasma OPG and RANK level on the calcaneal spur.

METHODS This study was a randomized controlled trial in patients with calcaneal spurs. ESWT was administered at the pain point by applying 2,000 shocks, at an intensity of 2 bars, given six times with a 7–10-day interval. The visual analog scale (VAS) data, plasma OPG and RANK level were analyzed using Mann–Whitney U test, whereas spur size was analyzed using chi-square test.

RESULTS One month after therapy at rest (p < 0.001) and when walking after getting up (p = 0.020), the VAS was lower than that in the control group. The plasma OPG level was lower than control group shortly after therapy (p < 0.001). The plasma RANK level was higher than control group shortly after therapy (p < 0.001). ESWT did not affect the reduction of spur measurement (p = 0.382).

CONCLUSIONS ESWT reduced pain, decreased plasma OPG level, and increased plasma RANK level. Although ESWT did not have any effect on spur reduction, it affected plasma OPG and RANK level that play a role in the activity of osteoblasts and osteoclasts.

Safety profile of Td vaccination in Indonesian pregnant women: a post-marketing surveillance study

Hindra Irawan Satari — 2019-12-13

BACKGROUND The Indonesian Expanded Program of Immunization has implemented tetanus and diphtheria (Td) vaccination to replace the tetanus toxoid vaccine in pregnant women since the year 2016. Td vaccine is administered to protect against diphtheria and tetanus to the mother and her baby as well. This prospective study was conducted to assess the adverse reactions after Td immunization; besides, a retrospective study was conducted to observe the presence of severe local reaction (Arthus reaction), premature birth, and low birth weight history in the medical records of pregnant women who had received Td immunization in the past year.

METHODS A prospective observational study was conducted in 200 pregnant women. Local reactions and systemic events occurring within 28 days after immunization were recorded in the diary card and were confirmed by the health worker in the follow-up visit. A retrospective study was also conducted to evaluate 750 medical records of pregnant women who had received Td immunization. The study was conducted from
September 2017 to January 2018. The study has been registered at ClinicalTrials.gov ID: NCT03383653.

RESULTS In 185 pregnant women who completed the study, the most common local reaction was pain, occurring in 33.5% of subjects within 24 hours after vaccination. Fever, other systemic reactions, and serious adverse events were not reported during the observation. In the retrospective study, 647 medical records were validated. No Arthus reaction was observed. The prevalence of premature birth was 1.24%, and that of low birth weight was 2.63%, which were below the normal rates.

CONCLUSIONS Td vaccination in pregnant women was safe and well-tolerated.

Five-year experience of continuous ambulatory peritoneal dialysis in children: a single center experience in a developing country

Cahyani Gita Ambarsari — 2019-12-13

BACKGROUND The pediatric peritoneal dialysis (PD) program in Cipto Mangunkusumo Hospital, Indonesia was started in 2014. However, there has been no published data on the patients’ outcome. This study was aimed to report the characteristics and outcomes of a continuous ambulatory peritoneal dialysis (CAPD) program for children.

METHODS This retrospective study was conducted in Cipto Mangunkusumo Hospital as a national referral hospital. Data were collected from medical records of patients aged ≤18 years with end-stage renal disease who underwent CAPD in 2014–2019. The baseline characteristics, PD-related infection rate, as well as patient and technique survivals were analyzed.

RESULTS Out of 60 patients who underwent CAPD, 36 (60%) were boys on the age range of 4 months–18 years. The mean follow-up duration was 12 (95% confidence interval [CI] = 9.4–15.3) months. The number of PD related infections increased along with the growing number of patients on CAPD. The peritonitis rate was 0.42 episodes per year at risk, and the most common etiology was alpha-hemolytic Streptococcus (5/24, [20.8%]). The 1- and 3-year technique survival rates were 60.3% (95% CI = 44.5–72.9) and 43.9% (95% CI = 23.2–62.9). The 1- and 3-year patient survival rates were 69.6% (95% CI = 52.5–81.5) and 58% (95% CI = 31.2–77.5).

CONCLUSIONS In this unit, CAPD could be performed in children as young as 4 months of age. The peritonitis rate was relatively low which was likely caused by skin-derived microorganisms. Both technique survival and patient survival were also relatively low.

Effectivity of microscopic test as a simple diagnostic method to detect fat malabsorption in children

Ariani Dewi Widodo — 2019-12-13

BACKGROUND Lipid malabsorption causes many health problems, for example stunting, a major worldwide issue. There has not been any assessment on the effectivity of lipid microscopic test in diagnosing lipid malabsorption. This research was aimed to study the effectivity of lipid microscopic test in detecting lipid malabsorption in children.

METHODS This was a cross-sectional diagnostic study that evaluated the effectivity of lipid microscopic test using Sudan III against steatocrit test as the gold standard in diagnosing lipid malabsorption. The study was done in 68 children aged 6–60 months in Cipto Mangunkusumo Hospital, Jakarta. Results of lipid microscopic test were compared with that of steatocrit test among children with lipid malabsorption and normal children. The primary endpoints of this study are the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS A total of 68 children consisting of 41 boys and 27 girls were included, with a median age of 14.3 months. The most frequently found stool consistency was mushy (50%). The most common result of microscopic test, found in 42% of subjects, was positive 1. Sensitivity, specificity, PPV, and NPV of lipid microscopic test were 49.15%, 66.67%, 90.63%, and 16.67%, respectively.

CONCLUSIONS Lipid microscopic test has a moderate sensitivity in diagnosing fat malabsorption and needs to be complemented with other methods such as steatocrit.

Patient assessment of constipation quality of life questionnaire: validity and reliability for Indonesian population

Murdani Abdullah — 2019-12-13

BACKGROUND Constipation is a condition commonly encountered by physicians, causing a significant reduction in patients’ quality of life. Therefore, successful management of constipation should also include increase the quality of life. The Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire is a questionnaire developed to address this issue. However, this questionnaire had not been translated into the Indonesian language. This study was aimed to adapt PAC-QOL into Indonesian culture and perform the psychometric evaluation.

METHODS Translation and cultural adaptation were performed based on the linguistic validation guidelines by Acquadro et al in 2012. To perform the psychometric evaluation, a total of 64 subjects in Petamburan district in Jakarta, Indonesia, were recruited from February to March 2018. Test-retest reliability was assessed by completing the PACQOL twice with one-week interval. Subjects also completed the Short Form 36 (SF-36) Health Survey Questionnaire to assess concurrent validity. Internal consistency was analyzed with Cronbach’s alpha value (>0.7) and the intraclass correlation coefficient.

RESULTS The mean (standard deviation) overall average score was 1.52 (0.66), while the Cronbach’s alpha value for the overall average score was 0.910. Concurrently, the intraclass correlation coefficient for the overall score was 0.87. Simultaneously, several experts judged content validity to be adequate. All the questions had significant correlations with their respective domains. Moreover, each domain of PAC-QOL also had a significant correlation with several SF-36 domains.

CONCLUSIONS The psychometric evaluation performed in this study demonstrated that the Indonesian version of the PAC-QOL was valid and reliable, suggesting that this questionnaire can be used in daily clinical practice.

Detection of Mycobacterium leprae using real-time PCR in paucibacillary leprosy patients with negative acid-fast bacilli smears

Arleen Devita — 2019-12-13

BACKGROUND Leprosy is an infectious disease that is still a health problem worldwide, including in Indonesia. The clinical symptoms are similar to other skin diseases and it is difficult to establish a diagnosis for paucibacillary (PB) leprosy. Current serological and histopathological tests have limitations, especially in patients with negative acid-fast bacilli (AFB). Serological tests often give false-negative results, while histopathological results often consist of non-specific inflammation. Probe-based real-time polymerase chain reaction (RT-PCR) assays is an alternative test that may be more sensitive and more specific to detect Mycobacterium leprae.

METHODS This study was done in June 2015 until March 2016; detected M. leprae in PB patients with negative AFB smears using TaqMan® probe-based RT-PCR assay on slit skin scrapings and skin biopsy specimens from 24 patients. The skin scrapings were obtained from skin tissue on ear lobes, skin lesions, as well as those from biopsy. Samples were tested with RT-PCR while histopathological examinations were only performed on skin from biopsy.

RESULTS The RT-PCR assay showed positive results of 21%, 25%, and 96% for specimens obtained from skin scrapings of the ear lobe, skin lesions, and skin biopsy, respectively. On the other hand, the positive rate for the histopathological test from skin biopsy was 79%. It indicated that the TaqMan® RT-PCR assay could increase the diagnostic capacity of histopathological examination by as much as 17%.

CONCLUSIONS TaqMan® PCR assay can improve the diagnostic capacity of histopathological examinations, which could be used as the new gold standard for the diagnosis of leprosy.

The functional status, rehospitalization, and hospital cost reduction in geriatric patients after the implementation of the universal health coverage program in the national referral hospital Indonesia

Czeresna Heriawan Soejono — 2019-12-13

BACKGROUND Universal health coverage program (UHCP) might implicate negatively toward geriatric care with its impact on higher cost. The evaluation had to be made, especially in functional status, rehospitalization, and cost-effectiveness.

METHODS Retrospective cohort study with historical control was done. Seventy two geriatric inpatients in the pre-UHCP group and 86 in the UHCP group were recruited from Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Subjects with geriatric syndromes admitted from July to December 2013 (pre-UHCP era) and January to June 2014 (UHCP era). Functional status changes, rehospitalization, and process indicators were observed. Cost reduction was calculated using the incremental cost-effectiveness ratio (ICER), whereby costs, functional status changes, and rehospitalization of both groups were used to identify the differences.

RESULTS Proportions of functional status increase were 35.3% and 34.8% in the pre- UHCP and UHCP groups, respectively (p = 1.00) and the decrease were 5.9% and 4.5% in the pre-UHCP and UHCP group, respectively (p = 1.00). Rehospitalization rates were 21.7% and 18.1% (p = 0.603) in the pre-UHCP and UHCP groups, respectively. Mean hospital expenses were between 17.1 million IDR (1,221 USD; 1 USD = 14,000 IDR) for the pre-UHCP group and 20.8 million IDR (1,486 USD) for the UHCP group. ICER showed that hospitalization cost was 3.7 million IDR (264 USD) higher to increase 1 activity of daily living score in the UHCP era. As for rehospitalization, the cost was 600,000 IDR (43 USD) less, with 3.6% smaller in readmission.

CONCLUSIONS There was no changes in patients’ functional status after the UHCP implementation. There was a reduction in rehospitalization with lower cost in the UHCP era.

Anthropometric measurements associated with intertrochanteric fractures in the elderly: a case-control study

Andy Ardiansyah — 2019-12-13

BACKGROUND Femoral intertrochanteric fracture is an important cause of disability in the elderly. Low muscle mass, especially those of the lower limbs, has been associated with osteoporosis and higher fall incidents. This study was aimed to assess the association between the anthropometric indices and intertrochanteric fractures.

METHODS This case-control study was performed from September 2013 to July 2015. The criteria of case group were elderly patients with intertrochanteric fractures admitted in Dr. Sardjito Hospital within 72 hours after a low energy injury without multiple fractures or pathological fracture. For control group, the subjects were matched according to age and gender without any fracture. Thigh and calf circumferences were done on healthy limbs. Body mass index (BMI) was calculated. History of steroid use was obtained. Adjusted odds ratio (OR) was calculated using logistic regression after analyzed with student's t-test or chi-square test.

RESULTS There were 82 subjects on each group. Smaller thigh and calf circumferences and also lower BMI were risk factors of intertrochanteric fractures. Thigh circumference <39 cm (aOR 5.12; 95% CI 2.30–11.43; p < 0.001) and calf circumference <29 cm (aOR 9.42; 95% CI 4.14–21.40; p < 0.001) were independently associated with intertrochanteric fracture after adjustment of BMI and steroid use.

CONCLUSIONS Calf and thigh circumferences were independently associated with femoral intertrochanteric fractures in Indonesian elderly.

Association between HLA-Cw6 allele expression and characteristics of Javanese ethnic psoriasis patients in Indonesia

Thianti Sylviningrum — 2019-12-13

BACKGROUND Psoriasis is an autoimmune disease with involvement of genetic and environmental factors. The HLA-Cw6 allele is the strongest genetic factor that correlates with earlier onset and more severe clinical manifestation of psoriasis. In Javanese ethnic, HLA-Cw6 allelic expression has not been identified, although increasing psoriasis patients were found in hospital dermatology departments. The study was aimed to determine the allelic expression of HLA-Cw6 based on the onset and severity of psoriasis in Javanese ethnic.

METHODS A cross-sectional study was conducted from March to September 2018. Sixty psoriasis patients in the Margono Soekarjo Hospital and Banyumas Regional General Hospital were recruited consecutively. Psoriasis type, diagnosis, onset, and disease severity were assessed by dermatologists. HLA-Cw6 allelic expression was identified by DNA isolation, quantitative testing, and HLA-Cw6 genotyping. Fisher’s exact and chi-square tests were used to evaluate the association of HLA-Cw6 with age, clinical type, disease severity, onset, and gender.

RESULTS The HLA-Cw6 allele positivity was identified at 297 base pairs (bp), while control showed at 618 bp bands. Among 60 subjects, 13 subjects (22%) showed HLACw6 positivity, and 47 subjects (78%) were HLA-Cw6 negative. HLA-Cw6 genotypes were similarly distributed concerning age, onset, gender, clinical type, and disease severity in psoriasis patients of Javanese ethnic (p > 0.05).

CONCLUSIONS HLA-Cw6 expression type may not have influence to the characteristics of patients with psoriasis.

Liver fibrosis of hepatitis C virus infection in routine hemodialysis patients in Indonesia

Aida Lydia — 2019-12-13

BACKGROUND The risk of hepatitis C virus (HCV) infection is increasing in patients under routine hemodialysis, but only some patients progress to liver fibrosis. This study was aimed to identify the prevalence of significant liver fibrosis in routine hemodialysis patients with hepatitis C infection as well as factors associated with liver fibrosis.

METHODS This cross-sectional study was conducted in three tertiary general hospitals (Cipto Mangunkusumo Hospital, Persahabatan Hospital, and Fatmawati Hospital) in Jakarta, Indonesia, among hemodialysis patients infected with HCV. Total sampling was used from May to September 2017 in hemodialysis unit of all hospitals. Sex, age, time at first diagnosis of HCV, duration of HCV infection, duration of hemodialysis, AST level, hepatitis B virus coinfection and diabetes mellitus were analyzed in association with significant liver fibrosis. Liver fibrosis was assessed using transient elastography and considered significant if the value was ≥7.1 kPa. Chi-square, Mann–Whitney U, and Fisher’s exact tests were used. Risk model was analyzed with logistic regression.

RESULTS Of the 133 hemodialysis patients infected with HCV, 71.4% of the subjects had significant liver fibrosis. In the risk model, male gender (odds ratio [OR] = 3.92; 95% confidence interval [CI] = 1.74–8.84; p < 0.001) and diabetes mellitus (DM) (OR = 2.85; 95% CI = 1.03–7.88; p = 0.043) were associated with significant liver fibrosis.

CONCLUSIONS The prevalence of significant liver fibrosis in routine hemodialysis patients with hepatitis C infection was high. Male and DM were associated with significant liver fibrosis.

Perception of internet addiction among psychiatric residents in an urban area in Indonesia

Enjeline Hanafi — 2019-12-13

BACKGROUND In the last two years, many suspected cases of internet addiction have been reported by the media. However, many physicians do not have comprehensive knowledge of internet addiction. Currently, there has been no study conducted among psychiatric residents. This study was aimed to determine the perception of internet addiction among psychiatric residents.

METHODS This cross-sectional study was done from April to May 2018. Subjects were recruited by a total sampling method consisting of all psychiatric residents of the Faculty of Medicine, Universitas Indonesia. Perceptions of internet addiction were measured using the illness perception questionnaire revised version for addiction. The calculation of subscales was based on the algorithms available for this instrument. The Mann–Whitney U test was used to determine the association of different years of psychiatric education and the perception of internet addiction.

RESULTS Fifty-two subjects completed the survey, and 85% of them reported feeling that they did not have adequate knowledge of internet addiction. They believed that their current knowledge was not sufficient to make diagnosis and management decisions. Junior residents had significantly lower consequence scale scores, with mean (standard deviation) scores of 4.1 (0.54) for juniors and 4.4 (0.48) for seniors (p = 0.021).

CONCLUSIONS Psychiatric residents perceived internet addiction as emotionally stressful, understandable, and cyclical, but difficult to control. Senior psychiatric residents had a better perception internet addiction consequences compared with their juniors, who have received only basic knowledge about addiction without clinical exposure, but the perceptions could still be improved.

A case of extensive symptomatic lower limb heterotopic ossification in a boy

Inez Kartika — 2019-12-13

Heterotopic ossification refers to the abnormal growth of bone in the soft tissue. This report highlighted the case of heterotopic ossification in early childhood. A 3-year-old boy was presented with poor lower limb mobility and rigid left leg. At the age of 10 days, he developed a small lump as large as a quail egg in his left groin. Within 3 months, the lump grew bigger and spread to his leg and feet. His parents claimed no trauma history. It was confirmed by computed tomography scan which revealed multiple ossifications of the soft tissue infiltrating the lower limb muscles and infiltrating the skin, the pathological features showed hard mature trabeculated bone, mature fatty tissue, and loose connective tissue. The patient was treated with a series of soft tissue resections and was still under the care of surgeon with good prognosis.

The future of radiotherapy and immunotherapy concomitantly in cancer management

Sri Mutya Sekarutami — 2019-12-13

Immunotherapy is a developing field in cancer treatment. Immunotherapy using immune checkpoint inhibitors has been successful in treating patients with metastatic disease, as well as patients who are refractory to standard treatments. Although immunotherapy has yielded considerably positive outcomes, its clinical benefits are limited to a small subset of patients. A combination of radiotherapy and immunotherapy has been shown to provide greater clinical benefits to more patients. Radiation, particularly hypofractionated radiation with stereotactic radiosurgery or stereotactic body radiotherapy, works by priming T cells, upregulating proinflammatory chemokines, and increasing the immunogenicity of tumor cells. Tumor cells develop immunosuppressive mechanisms that protect them from attack by the immune system. Immunotherapy works by disrupting the ability of tumor cells to setup these defenses. When combined with radiotherapy, it can synergistically enhance tumor cell death via cytotoxic T cells, thus causing systemic tumor regression and generating better clinical response.

Effect of delayed diagnosis and treatment of congenital hypothyroidism on intelligence and quality of life: an observational study

Aman Bhakti Pulungan — 2019-12-13

BACKGROUND Congenital hypothyroidism is one of the most prevalent, albeit preventable causes of intellectual disability. This study determined the intellectual outcome and health-related quality of life (QoL) in children and adolescents clinically diagnosed with congenital hypothyroidism and the associations among age of starting thyroid hormone treatment, current free thyroxine (FT4) level, intelligence quotient (IQ), and QoL.
METHODS Intelligence (Wechsler scales) and QoL (PedsQLTM 4.0 parent proxy-report) tests were administered to 25 patients with congenital hypothyroidism in the pediatric clinic of Cipto Mangunkusumo Hospital, Jakarta. Nineteen patients underwent thyroid ultrasonography or scintigraphy to determine the etiology of congenital hypothyroidism.
RESULTS A total of 25 patients with the median age of 9 (5.5–12.5) years were recruited. Eighteen patients had a total IQ of <70. The age of treatment initiation did not correlate with full scale IQ (FSIQ) (r = −0.261, p = 0.071) and verbal IQ (VIQ) (r = −0.232, p = 0.265). The late initiation of treatment was correlated with lower performance IQ (PIQ) (r = −0.325, p = 0.025). The higher current FT4 levels was correlated with higher scores of
FSIQ (r = 0.314, p = 0.046) and PIQ (r = 0.320, p = 0.043). The late initiation of treatment (r = 0.006, p = 0.980) and higher current FT4 levels (r = 0.246, p = 0.310) were not correlated with QoL. Hemiagenesis of thyroid gland was the most common etiology.
CONCLUSIONS The late initiation of thyroid hormone substitution in patients with congenital hypothyroidism negatively affects intellectual abilities.

Acknowledgment of Reviewers

Medical Journal of Indonesia — 2019-12-13

Front & Back Matter

Medical Journal of Indonesia — 2019-12-13