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BACKGROUND: Myelodysplastic syndrome (MDS) is a heterogeneous group of hematopoietic stem cell disorders which is characterized by ineffective hematopoiesis and risk of progression into acute myeloid leukemia. The diagnosis and classification of MDS are determined from the findings of dysplasia in one or more cell lineage and the percentage of blast cell on bone marrow examination. However, it should be noted that an abnormality in one marrow cell lineage does not necessarily translate to the corresponding clinical phenotype. Here, we present a case of MDS with multilineage dysplasia (MLD) (erythrocyte, leukocyte, and thrombocyte) from bone marrow aspiration, but with anemia as the sole clinical manifestation (single cytopenia). CASE REPORT: A 78-year-old male patient came to our clinic on July 10, 2020, with chief complaint of worsening fatigue which started approximately 1 year before visit. His vital signs during the visit were stable and no other abnormalities observed other than pale conjunctivae. Complete blood count showed macrocytic anemia with no abnormalities in leukocyte count and thrombocyte count, which suggested a single cytopenia. Peripheral blood smear was negative for megaloblasts and hypersegmented neutrophils. The patient’s bone marrow examination showed MDS with MLD. This result was in contrast to complete blood count examination which only showed anemia (single cytopenia). CONCLUSION: This case showed that there could be discrepancy between clinical manifestations of the cytopenia with bone marrow dysplasia, which highlighted the importance of conducting bone marrow examination to properly classify MDS type.

Background Readmission is related to high cost, high burden, and high risk for mortality in geriatric patients. A scoring system can be developed to predict the readmission of older inpatients to perform earlier interventions and prevent readmission. Methods We followed prospectively inpatients aged 60 years and older for 30 days, with initial comprehensive geriatric assessment (CGA) on admission in a tertiary referral centre. Patients were assessed with CGA tools consisting of FRAIL scale (fatigue, resistance, ambulation, illness, loss of weight), the 15-item Geriatric Depression Scale, Mini Nutritional Assessment short-form (MNA-SF), the Barthel index for activities of daily living (ADL), Charlson Comorbidity Index (CCI), caregiver burden based on 4-item Zarit Burden Index (ZBI), and cognitive problem with Abbreviated Mental Test (AMT). Demographic data, malignancy diagnosis, and number of drugs were also recorded. We excluded data of deceased patients and patients transferred to other hospitals. We conducted stepwise multivariate regression analysis to develop the scoring system. Results Thirty-day unplanned readmission rate was 37.6 %. Among 266 patients, 64.7 % of them were malnourished, and 46.5 % of them were readmitted. About 24 % were at risk for depression or having depressed mood, and 53.1 % of them were readmitted. In multivariate analysis, nutritional status (OR 2.152, 95 %CI 1.151–4.024), depression status (OR 1.884, 95 %CI 1.071–3.314), malignancy (OR 1.863 95 %CI 1.005–3.451), and functional status (OR 1.584, 95 %CI 0.885–2.835) were included in derivation of 7 score system. The scoring system had maximum score of 7 and incorporated malnutrition (2 points), depression (2 points), malignancy (2 points), and dependent functional status (1 point). A score of 3 or higher suggested 82 % probability of readmission within 30 days following discharge. Area under the curve (AUC) was 0.694 (p = 0.001). Conclusions Malnutrition, depression, malignancy and functional problem are predictors for 30-day readmission. A practical CGA-based 7 scoring system had moderate accuracy and strong calibration in predicting 30-day unplanned readmission for older patients.

Introduction Cancer and its treatment have a broad impact on patients' Quality of Life (QoL). Previous researches showed that many factors in Comprehensive Geriatric Assessment (CGA) affect QoL. CGA could predict toxicity, overall survival rate and can help adjust the choice and intensity of treatment in each patient. However, there has been no research explicitly exploring factors related to the QoL in older patients with Non-Hodgkin's Lymphoma (NHL). This research aims to explore the how factors in CGA relate to the QoL in older patients with NHL. Materials and Method The study design was cross-sectional in NHL patients aged ≥ 60 years, research was conducted in Integrated Geriatric Polyclinic and Hemato-Oncology Polyclinic of three public hospitals in Jakarta, during March–August 2019. Results There were 62 subjects, with a median age of 66 years, 56.5% male. The result showed that most of the patients have a good QoL, based on each domain of SF-36 and EORTC QLQ-C30. In multivariate analysis, it was found that depression and frailty status were related to PCS SF-36 domain with PR 12.086 (95% CI 1.596–92.124) and PR 5.622 (95% CI 1.060–29.807), respectively. Multivariate analysis with SF-36's Mental Component Summary (MCS) showed a significant relationship with depression status with PR 24.400 (95% CI 2.961–140.539). While the results of multivariate analysis with the EORTC QLQ-C30 functional scale showed a significant relationship with the ECOG performance score with PR 171 (95% CI 8.470–3452.28). Discussions After multivariate analysis, only frailty status, depression status and ECOG performance score have a statistically significant relationship.

We investigated the gut microbiota in patients with non-alcoholic fatty liver disease (NAFLD) and its correlation with fibrosis and steatosis stratified by body mass index, as reflected in the controlled attenuation parameter and transient elastography values. A cross-sectional study was performed on 37 patients with NAFLD at Cipto Mangunkusumo National General Hospital from December 2018 to March 2019. The gut microbiota was investigated in fecal samples with 16S RNA sequencing using the MiSeq next-generation sequencing platform (Illumina). NAFLD was more common in patients with metabolic syndrome. Firmicutes, Bacteroidetes, and Proteobacteria were the predominant phyla. Bacteroides was more dominant than Prevotella, contrary to the results of previous studies on healthy populations in Indonesia. Microbiota dysbiosis was observed in most samples. The gastrointestinal microbiota diversity was significantly decreased in patients with NAFLD, high triglyceride levels, and central obesity. The Firmicutes/Bacteroidetes ratio correlated with steatosis and obesity, whereas some of the other species in lower taxonomy levels were mostly associated with steatosis and obesity without fibrosis. Proteobacteria was the only phylum strongly correlated with fibrosis in patients with an average body mass index. The gut microbiota diversity was decreased in patients with NAFLD, high triglyceride levels, and central obesity, and certain gut microbes were correlated with fibrosis and steatosis.

BACKGROUND Based on the regulation of the Indonesian Ministry of Health No. 15 of 2016 about health istithaah for the Hajj, patients with tuberculosis (TB) can be categorized into ineligible or temporarily ineligible pilgrims. This study aimed to know the characteristics of pilgrims with TB and determined their level of fitness for fulfilling the health istithaah. METHODS A cross-sectional study of pilgrims from Jakarta who were receiving TB treatment during the Hajj in 2018 was conducted with consecutive sampling. The secondary data was collected from the Hajj Integrated Computer Health System 2018, TB registered form, and six-minute walk test (the fitness level data) conducted by the District Hajj Health Team at district health centers in DKI Jakarta and Pondok Gede before the Hajj embarkation in June–July 2018. The questionnaire to the Indonesian Hajj Health Team during pilgrimage was also included as additional data. RESULTS Thirty-one pilgrims received TB treatment and completed the intensive phase of TB treatment, but 29 pilgrims had no symptoms. Among them, 2 patients had MDR-TB. Most of them were male aged ≥40 years old. Twelve pilgrims with TB have a sufficient fitness. All pilgrims were able to run the pillars of the Hajj. CONCLUSIONS Pilgrims with TB, including MDR-TB, who had completed the intensive phase with a negative sputum smear test were declared eligible for the Hajj with assistance.

Aim This study aimed to elucidate the prevalence of anemia in Indonesian elderly population aged ≥60 years old and to analyze its association with handgrip strength in the elderly. Method This was a cross-sectional study using data from Indonesian Family Life Survey-5 (IFLS-5). All participants aged ≥60 years old were included in this study. Exclusion criteria were: (1) respondents who refused to take health measurements (hemoglobin level, handgrip strength, weight, stature, and waist circumference); (2) respondents with incomplete or missing data; (3) respondents with history of stroke; and (4) respondents with history of pain, swelling, inflammation, injury, and surgery on one or both hands within the last 6 months. The dependent variable for this study was handgrip strength. The independent variables were hemoglobin level, gender, age, body mass index (BMI), waist circumference, smoking history, comorbidities, and current use of drug therapies. Statistical analyses included correlation, bivariable, and multivariable analyses. Result A total of 3192 individuals were selected for analysis. Overall, 38.8% of participants aged ≥60 years had anemia based on definition of anemia by WHO. There was a positive correlation between hemoglobin level and handgrip strength in Indonesian elderly population (r: 0.349; p value: 0.000). Multivariable analysis showed that anemia was significantly associated with weak handgrip strength (OR: 1.557; 95% CI: 1.314-1.846; p value: 0.000). This association was stronger for males and elderly aged ≥80 years old. Conclusion Based on the results, anemia was associated with weak handgrip strength in Indonesian elderly population and it is more pronounced in males and elderly aged ≥80 years old.

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.

Platelet to lymphocyte ratio (PLR) is a candidate prognostic marker for metastatic castration‐resistant prostate cancer patients receiving abiraterone acetate and evidence demonstrates that a high PLR is associated with poor survival. More studies are required to verify current findings and establish a definite cutoff point.

Background: Dysbiosis of the gut microbiota has been considered to have a role in nonalcoholic fatty liver disease (NAFLD) progression. However, there is still lack of studies regarding this phenomenon. Aim: To find the difference in the proportion of gut microbiota in NAFLD patients based on the stages of liver fibrosis. Patients and Methods: A cross-sectional study was conducted at Dr. Cipto Mangunkusumo Hospital, which is the largest tertiary referral center. Human fecal samples from NAFLD patients who came to the outpatient clinic were collected consecutively. The stool sample examination was performed using an isolation DNA kit (Tiangen) and quantitative real-time polymerase chain reaction (Fast 7500). Clinical and laboratory data were also collected. The stage of fibrosis was diagnosed based on transient elastography (FibroScan® 502 Touch; Echosens, France). Results: Of 60 NAFLD human fecal samples, 35 patients had nonsignificant fibrosis and 25 patients had significant fibrosis (46.7% male and 53.3% female; median age 56 years). Most patients had diabetes (85%), dyslipidemia (58.3%), obesity (58.3%), and central obesity (90%). The proportion of Bacteroides was higher when compared to Lactobacillus and Bifidobacteria. Of these 3 microbiota, the proportion of Bacteroides was significantly higher in the significant fibrosis group when compared to the nonsignificant fibrosis group. Conclusion: There is a change in the composition of gut microbiota in NAFLD patients. The proportion of Bacteroides is significantly higher in significant liver fibrosis, which may play a role in NAFLD progression.

The inflammatory process of head and neck cancer leads to an increase the proinflammatory cytokines and the synthesis of c-reactive protein (CRP), which then causes metabolic alteration and anorexia in the patients. Zinc is one of nutrient that has an important role in suppressing inflammation, but it is reported that about 65% of head and neck cancer patients have zinc deficiency. The aim of this cross sectional study is to determine the correlation between zinc intake and serum zinc levels with CRP level as an effort in reducing inflammation process in head and neck cancer patients. Subjects were collected by consecutive sampling in the Oncology Polyclinic Rumah Sakit Kanker Dharmais, from 49 subjects 67,3% were men, most subjects were in the age range between 46–65 years. The highest frequency (65,3%) is nasopharyngeal cancer and 69,4% are already in stage IV. All subjects (100%) in this study have a zinc intake below the recommended dietary allowance (RDA) in Indonesia. The mean serum zinc level of the subjects was 9.83±2.62 μmol/L. Most subjects have elevated CRP levels. There was a weak negative correlation between zinc concentration and CRP levels of subjects (r =-0.292, p =0.042), but there was no correlation between zinc intake and CRP levels of subjects (r =-0.25).

Objective: This study aimed to identify the association between duration of HU administration prior to IM treatment and MMR achievement in chronic-phase CML while evaluating the role of MDA, HIF-1α and P-gp. Methods: The study was conducted at Dr. Cipto Mangunkusumo National General Hospital and Dharmais Cancer Hospital, Jakarta using retrospective cohort design to analyse the association between the duration of HU before IM and its MMR achievement and cross-sectional design to analyse the association between MDA, HIF-1α and P-gp expressions with MMR achievement. Main subjects were chronic-phase CML patients treated by HU prior to IM for ≥ 12 months and HU only. The subjects were divided into four main groups: (1) chronic-phase CML patients treated with HU ≤ 6 months + IM ≥ 12 months and (2) HU > 6 months + IM ≥ 12 months (3) HU only (≤ 6 months), (4) HU only ( >6 months). Subjects were obtained from January 2015 to May 2016. Data were gathered through history taking, physical examination, medical record evaluation, and blood sample analysis. Bivariate analysis was conducted using chi square, independent T-test, and Mann-Whitney according to the variables. Results: Administration of HU for more than 6 months prior to IM was associated with unsuccessful MMR achievement (RR 1.60; 95%CI 1.29-2.00). MDA level, HIF-1α, P-glycoprotein expression were not associated with MMR achievement but the mean MDA level (0.63±0.31 vs 0.75±0.41 p=0.461) and median P-glycoprotein expressions {16,92 (0,04 – 43,86) vs. 5,15 (0,02–39,64); p=0.311} were found to be higher in patients receiving HU for > 6 months group than in HU ≤ 6 months group consecutively. Conclusion: Administration of HU for more than 6 months prior to IM was associated with unsuccessful MMR achievement in chronic-phase CML. The study suggested that P-glycoprotein overexpression as the predictor for unsuccessful MMR achievement.

Ikhwan Rinaldi,1 Rachmat Hamonangan,2 Mohamad Syahrir Azizi,3 Rahmat Cahyanur,1 Fadila Wirawan,4 Atikah Isna Fatya,4 Ageng Budiananti,4 Kevin Winston4 1Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia; 2Department of Internal Medicine, PGI Cikini Hospital, Jakarta, Indonesia; 3Division of Cardiology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 4Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaCorrespondence: Ikhwan RinaldiDivision of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, IndonesiaTel +62 811177997Email ikhwanrinaldi@gmail.comIntroduction: Patients with deep vein thrombosis (DVT) pose high morbidity and mortality risk thus needing fast and accurate diagnosis. Wells clinical prediction scores with D-dimer testing are traditionally used to rule out patients with low probability of DVT. However, D-dimer testing has a few limitations regarding its relatively low specificity. Neutrophil-lymphocyte ratio (NLR), a marker of inflammation, was found to increase in DVT. Hence, we aimed to evaluate the role of NLR for DVT diagnosis.Methods: Data were collected from medical records of patients with suspected DVT at Cipto Mangunkusumo National General Hospital during January–December 2014. Diagnosis of DVT was conducted using lower limb ultrasonography. Diagnostic values for NLR, D-dimer, and NLR + D-dimer were determined by receiver operating characteristic (ROC) analysis to obtain area under the curve (AUC), sensitivity, specificity, negative predictive value, and positive predictive values. Sensitivity and specificity analyses of NLR and D-dimer were also conducted based on Wells score and divided into groups of low and high probability of DVT.Results: The AUC values for NLR, D-dimer, and NLR + D-dimer were 72.6%, 70.4%, and 76.1%, respectively. The optimal cut-off value determined for NLR was 5.12 with sensitivity of 67.7%, specificity of 67.9%, PPV of 68.85%, and NPV of 64.91% in differentiating subjects with and without DVT. This study also found that D-dimer had sensitivity of 69.4%, specificity of 71.4%, PPV of 72.88%, and NPV of 67.8%. Meanwhile, the NLR + D-dimer combination had sensitivity of 66.1% and specificity of 72.6%. Multivariate analysis showed that NLR (OR: 2.636; 95% CI: 1.144– 6.076; p: 0.023) and D-dimer (OR: 4.175; 95% CI: 1.810– 9.633; p: 0.001) were associated with DVT.Conclusion: NLR value has wider AUC than D-Dimer and is relatively easier to obtain and does not require specific assay, thus enabling rapid evaluation of symptomatic patients suspected of having DVT. Adding NLR to D-dimer increased AUC to detect DVT. Therefore, NLR could serve as a complementary diagnostic tool for D-dimer to exclude DVT, especially in low clinical probability patients.Keywords: deep vein thrombosis, neutrophils lymphocyte ratio, NLR, inflammation, D-dimer

Background. Acquired hemophilia A (AHA) is a potentially life-threatening autoimmune hemostatic disorder where autoantibodies that disrupt the functions of factor VIII (FVIII) are present in the circulation. The early diagnosis of AHA is difficult since the symptoms of AHA differ from those of congenital hemophilia A. Furthermore, the management of AHA is also more complex due to the presence of autoantibodies against FVIII (FVIII inhibitors). Here, we present three case reports and conduct a literature review of AHA with the aim to increase awareness and knowledge regarding the diagnosis and treatment of AHA. Case Presentations. We present three patients diagnosed with AHA in these case reports. The first patient was a young female, while the second and third patients were middle-aged and elderly males, respectively. All patients presented with a chief complaint of bruises without hemarthrosis and a history of bleeding. Laboratory examinations of the patients revealed isolated prolonged aPTT, normal PT, and the presence of autoantibodies against factor VIII, which are characteristics of AHA. Patients were then treated with corticosteroids to reduce the titer level of autoantibodies and received factor VIII transfusion to stop bleeding. Conclusion. AHA can be suspected in patients presenting with symptoms of bruises without hemarthrosis and without the history of bleeding. Isolated aPTT elevation with normal PT should raise high suspicion of AHA. The presence of FVIII inhibitors can help to confirm the diagnosis of AHA. Treatment consists of factor VIII transfusion and corticosteroid therapy. Bypassing agents are recommended as an alternative to FVIII transfusion.

Patients with undernutrition at admission have higher risks to worsen their nutritional status, which is linked to an increase in morbidity and mortality. This study investigated the prevalence of undernutrition at admission and its associated factors. A cross-sectional study was conducted on patients aged 18 to 59 years old in Internal Medicine ward at Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia, between July and September 2019. Factors that might be associated with undernutrition at admission, such as age, sex, marital status, Charlson Comorbidity Index (CCI) and type of comorbidity, depression, and neutrophil–lymphocyte ratio (NLR), were assessed. Bivariate and multivariate analyses were used to determine the associated factors. Sixty hospitalized patients with median age of 42 years and 76.7% with married status joined the study. The most common reason for hospitalization was acute gastrointestinal disease with gallstones as the most common comorbidity. Undernutrition exists in 26.7% of subjects. High CCI score was observed among 11.7% subjects and half of subjects had NLR category ≥5. Bivariate analysis revealed that unmarried status, age ≥40 years, and malignancy were associated with undernutrition at admission. Logistic regression analysis showed malignancy as an independent predictor of undernutrition during the initial hospital admission (odds ratio [OR] = 11.8; 95% confidence interval [CI]: [1.1, 125.7]). The prevalence of undernutrition at admission was 26.7%. Factors associated with an increased prevalence of undernutrition at admission were age

Background The association between prior exposure to immune checkpoint inhibitor (ICI) and outcomes of cancer patients with coronavirus disease 2019 (COVID-19) infection has yet to be systematically evaluated. As the current evidence remains equivocal, this meta-analysis aims to investigate the effects of ICI treatment on COVID-19 prognosis, including mortality, severity, and hospitalization.Methods Eligible studies published up to 14 September 2020 were included and assessed for risk of bias using the Quality in Prognosis Studies tool. A random-effects meta-analysis was conducted to estimate the pooled effect size along with 95% confidence intervals (CIs). The quality of body evidence was evaluated using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.Results Six studies involving a total of 1647 COVID-19-infected cancer patients were included in the systematic review. We discovered that prior ICI exposure was not associated with COVID-19 mortality (odds ratio [OR] 0.93 [95% CI: 0.37-2.36]; I2=30%), severity (OR 1.15 [95% CI: 0.40-3.28]; I2=0%), and hospitalization (OR 1.35 [95% CI: 0.64-2.87]; I2=51%). However, we discovered that prior exposure to chemoimmunotherapy predicted COVID-19 severity (OR 8.19 [95% CI: 2.67-25.08]; I2=0%), albeit with small sample size. GRADE assessments resulted in moderate-quality evidence for mortality, while the other outcomes yielded very low-to-low-quality evidenceConclusion Our findings indicated that ICI treatment should not be adjourned nor terminated during the current pandemic. Rather, COVID-19 vigilance should be increased, especially in patients receiving chemoimmunotherapy. Further studies with larger ICI cohorts are required to confirm our findingsTrial registration number: This project has been prospectively registered at PROSPERO (registration ID: CRD42020202142) on 4 August 2020.

Background The association between immune checkpoint inhibitor (ICI) and outcomes of cancer patients with coronavirus disease 2019 (COVID-19) infection has yet to be systematically evaluated. This meta-analysis aims to investigate the effects of ICI treatment on COVID-19 prognosis, including mortality, severity, and any other prognosis-related outcomes. Methods Eligible studies published up to 27 February 2021 were included and assessed for risk of bias using the Quality in Prognosis Studies tool. A random-effects meta-analysis was conducted to estimate the pooled effect size along with its 95% confidence intervals. The quality of body evidence was evaluated using the modified Grading of Recommendations Assessment, Development, and Evaluation framework. Results Eleven studies involving a total of 2826 COVID-19-infected cancer patients were included in the systematic review. We discovered a moderate-to-high quality of evidence that ICI was not associated with a higher mortality risk, while the other outcomes yielded a very low-to-low-evidence quality. Although our findings indicated that ICI did not result in a higher risk of severity and hospitalization, further evidence is required to confirm our findings. In addition, we discovered that prior exposure to chemoimmunotherapy may be linked with a higher risk of COVID-19 severity (OR 8.19 [95% CI: 2.67–25.08]; I2 = 0%), albeit with small sample size. Conclusion Our findings indicated that ICI treatment should not be adjourned nor terminated during the current pandemic. Rather, COVID-19 vigilance should be increased in such patients. Further studies with larger cohorts and higher quality of evidence are required to substantiate our findings. Trial registration number This project has been prospectively registered at PROSPERO (registration ID: CRD42020202142) on 4 August 2020. Supplementary Information The online version contains supplementary material available at 10.1007/s00262-021-02990-9.

Background : We investigated the gut microbiota in patients with non-alcoholic fatty liver disease (NAFLD) and its correlation with fibrosis and steatosis as reflected in the controlled attenuation parameter and transient elastography valuesMethods : A cross-sectional study was performed on 37 patients with NAFLD at Cipto Mangunkusumo National General Hospital from December 2018 to March 2019. The gut microbiota was investigated in fecal samples with 16S RNA sequencing using the next-generation sequencing platform MiSeq (Illumina).Results : NAFLD was more common in patients with metabolic syndrome. Firmicutes, Bacteroidetes, and Proteobacteria were the predominant phyla. Bacteroides was more dominant than Prevotella, contrary to the results in previous studies on normal populations in Indonesia. Microbiota dysbiosis was observed in most samples. The gastrointestinal microbiota diversity was significantly decreased in patients with NAFLD with high triglyceride levels and central obesity. The Firmicutes/Bacteroidetes ratio correlated with steatosis and obesity, whereas some other species in the lower taxonomy were mostly correlated with steatosis and obesity without fibrosis. Proteobacteria is the only phylum strongly correlated with fibrosis in patients with normal body mass index.Conclusions : The gut microbiota diversity was decreased in patients with NAFLD with high triglyceride levels and central obesity, and certain gut microbes were correlated with fibrosis and steatosis.

Introduction: Rhabdomyosarcoma (RMS) is the most common childhood soft tissue sarcoma, but it represents only a small portion of soft tissue sarcoma in adult population. There is a treatment protocol based on Intergroup Rhabdomyosarcoma Study (IRS) that provides satisfactory results in treating RMS in children, but there is only limited evidence regarding the outcome and prognosis in extrapolating the IRS protocol to treat RMS in adults. We report a case of adult pleomorphic RMS treated with multidisciplinary approach and the results we have obtained. Case presentation: A 48-year-old woman was admitted in February 2011 due to a painful mass on her left thigh. Diagnosis of pleomorphic rhabdomyosarcoma was made by histopathology and immunohistochemistry. After multimodal treatment that includes Trans-Arterial Chemotherapy Infusion, Cryosurgery, and wide excision surgery, our patient remains disease-free as of the latest annual follow up examination on June 2017. Conclusions: The pleomorphic type of Rhabdomyosarcoma is very rare in adults and is often associated with a poor prognosis. In our case, a multidisciplinary approach with multimodal treatment provides excellent result, even after a routine follow up spanning through six years.

Background: Fms-like tyrosine kinase-3, internal tandem duplication (FLT3-ITD) mutation, is a known predictor for worse outcome in patients with acute myeloblastic leukemia (AML). However, the prognostic significance of FLT3-ITD mutation in adult, non-transplant patients is still unclear therefore we conducted a systematic review and meta-analysis to explain this issue. The main outcome was overall survival (OS), while additional outcomes included event-free survival (EFS). Methods: Seven Databases (ScienceDirect, Scopus, PubMed, Cochrane, SpringerLink, ProQuest, and EBSCOhost) were searched up to August 2020. Studies investigating the prognostic value of AML in adults with FLT3-ITD mutational status were selected. Studies which patients had received transplantation, diagnosed with acute promyelocytic leukemia (APL) or secondary AML were excluded. The selected studies were divided into subgroups based on their cytogenetic profile. Summary hazard ratios (HR) and 95% confidence intervals (CI) were calculated using fixed-effects models. Heterogeneity tests were conducted and presented in I2 value. Forest plot was presented to facilitate understanding of the results. Publication bias was analyzed by Funnel Plot test. Results: A total of ten studies describing research conducted from 1999 to 2020, met the inclusion criteria for this study. Nine studies reported OS and four studies reported EFS in HR. The highest HR for OS is 6.33 (95% CI, 2.61-15.33; p < 0.001), for EFS is 3.58 (95% CI, 1.59 – 8.05); p = 0.002)., while the lowest for OS is 1.33 (95% CI, 0.88-2.01; P = 0.174) and for EFS is 1.29 (95% CI, 0.75-2.23; p = 0.34). Nine studies were included in meta-analysis with HR for OS 1.91 (95% CI, 1.59–2.30, p < 0.00001), whereas 4 studies were included in meta-analysis for EFS with HR 1.64 (95% CI, 1.25–2.14; p = 0.0003). Conclusion: FLT3-ITD mutation is associated with worse prognosis in adult, non-transplant patients with AML, both for OS and EFS.

Background The prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing. In Indonesia Hasan, I et al. (2002) reported the prevalence of 30.6%. This study evaluated the first time the profile of gut microbiota and correlation with severity of NAFLD in Indonesia. Methods We included 37 subjects age 18–60 years. The characteristic data of the patients and the food recalls were recorded. Abdominal ultrasound, liver transient elastography with controlled attenuation parameter (CAP) were performed. Next generation 16S rRNA metagenomic sequencing was conducted using stool samples. The Spearman correlation test was used to examine the correlation between specific microbial taxa with the severity of NAFLD based on fibrosis and steatosis degree. Results The subjects included 62.2% (n=23) females and 37.8% males (n=14), mean age 50 ± 7.93 years old. They were divided based on fibrosis and steatosis degree into non-significant and significant fibrosis using cut off 7 KPa, mild and moderate-severe steatosis based on cut off 270 dB/m. From all subjects, we got 73% vs 27% non-significant and significant fibrosis, 51.4% vs 48.6% mild and moderate-severe steatosis. At the phylum level, the proportion of Bacteriodetes did not change in fibrosis or steatosis group. The proportion of Proteobacteria and Firmicutes was different in fibrosis and steatosis groups. Actinobacteria unknown bifidobacteriales bifidobacteriaceae bifidobacterium Bifidobacterium adolescentis correlate positively with non significant fibrosis (r = 0.532; p=0.004). Firmicutes clostridia clostridiales lachnospiraceae unknown fusicatenibacter saccharivorans and Firmicutes clostridia clostridales ruminococcaceae unknown [clostridium] leptum correlate negatively with significant fibrosis (r = -0.695; p=0.026 vs r = -0.732; p=0.016). In the group of steatosis, we got Bacteroidetes bacteroidia bacteroidales rikenellaceae alistipes alistipes onderdonkii and Firmicutes clostridia clostridales oscillospiracea oscillospiraceao scilibacter ruminantum correlate negatively with moderate-severe steatosis (r = -0.478; p=0.045 vs r = -0.518; p=0.028); Bacteroidetes bacteroidia bacteroidales rikenellaceae alistipes alistipes putredinis correlate positively with mild steatosis (r = 0.503; p=0.028). Conclusions The abundance of microbiota in NAFLD are not significantly different based on the group of fibrosis and steatosis, especially in phylum level. But at the lower level, some specific microbiota may correlate with the degree of fibrosis and steatosis.

Rheumatoid arthritis (RA) is an autoimmune disease which has recently been recognized to manifest as not only intraarticular but also extraarticular symptoms. Cardiovascular events, presented either subclinically or clinically, were discovered more in AR patients. Atherogenic inflammatory mediator in AR including interleukin-6 (IL-6) was thought to be one of nontraditional cardiovascular risk factor contributing to increase the endothelial dysfunction biomarker such as E-Selectin. This study was purposed to determine the correlation between inflammatory mediator and endothelial dysfunction event, especially between IL-6 and E-Selectin, in RA patient without traditional cardiovascular risk factor. A cross-sectional study was performed to 40 RA patients of Rheumatology Clinic of Cipto Mangunkusumo National General Hospital, Indonesia from September to November 2017. Measurement of the level of IL-6 and E-Selectin were performed using enzyme-linked immunosorbent assay (ELISA). Bivariate correlation analysis was performed to determine the correlation between those two biomarkers. The mean age of this study subjects was 44.9 (13.1) years and median of disease duration was 36 months. This study showed weak correlation between IL-6 and E-Selectin level, but not statistically significant.232, p=0.149). There is weak correlation between IL-6 and sE-Selectin in rheumatoid arthritis patient without traditional risk factor cardiovascular Keywords: traditional risk factor cardiovascular, E-Selectin, interleukin-6, pro inflammatory mediator, rheumatoid arthritis

Background:The mortality of Rheumatoid Arthritis (RA) is quite high, which is largely due to cardiovascular complications caused by endothelial dysfunction. One of the important inflammatory mediators that contribute to RA joints arthritis of TNF-α, also proven to play a role in endothelial dysfunction and play a role in increasing intracellular lipolysis, thus increasing circulating FFA levels.Objectives:To determine the correlation between TNF-α levels with VCAM-1 levels, correlation of TNF-α levels with FFA levels, and correlation of FFA levels with VCAM-1 levels.Methods:Cross sectional and retrospective design studies of adult RA patients treated at Cipto Mangunkusumo Hospital (RSCM), without metabolic disturbances, acute infection, cardiovascular disorders, or other autoimmune diseases. The cross-sectional data was collected from October to November 2017, while retrospective samples were collected since August 2016. TNF-α, VCAM-1, and FFA levels were assessed by serum blood test by ELISA method. Correlation analysis is done by Pearson analysis when the data distribution is normal and with Spearman analysis when the data distribution is not normal.Results:A total of 35 subjects were enrolled in the study. Most (97.1%) were women with an average age of 45.29 years, median disease duration of 48 months, and most had moderate disease activity (65.7%). No significant correlation was found between TNF-α levels and VCAM-1 levels (p = 0.677; r = +0.073). as well betwen TNF-α levels and FFA levels (p = 0.227; r = -0.21). The correlation between FFA and VCAM-1 levels showed significant correlation with negative correlation and weak correlation (p = 0.036; r = -0.355).Conclusions:(1) There was no correlation between TNF-α levels and VCAM-1 levels in RA patients; (2) There was no correlation between TNF-α levels and FFA levels in RA patients; (3) There was a negative correlation between FFA levels and VCAM-1 levels in RA patients.

Because the majority of colubrid species are considered harmless to human beings, colubrid snakebites are rarely reported. However, the venom of Rhabdophis, which is part of the Colubridae family, is procoagulant and leads to severe coagulopathy. Here, we present a case of disseminated intravascular coagulation with enhanced fibrinolysis following a Rhabdophis bite. Although coagulopathy can be treated effectively with the specific Rhabdophis antivenom, this antivenom is not widely available in Indonesia. We also found transient hypertension secondary to the colubrid venom, an unusual finding.

Pendahuluan. Petugas kesehatan memiliki risiko pajanan infeksi yang cukup tinggi. Hepatitis B, hepatitis C, dan human immunodeficiency virus (HIV) adalah beberapa penyakit yang dapat menular melalui pajanan cairan atau jaringan tubuh. Rumah Sakit Umum Cipto Mangunkusumo (RSCM) telah mencanangkan profilaksis pasca pajanan terhadap HIV, hepatitis B, dan hepatitis C. Penelitian ini dilakukan untuk menilai pelaksanaan profilaksis pasca pajanan terhadap HIV, hepatitis B, dan hepatitis C pada petugas kesehatan di RSCM Jakarta. Metode. Studi potong lintang dilakukan pada petugas terpajan yang terdata melalui laporan di RSCM Jakarta pada tahun 2014-2016. Data demografis dikumpulkan melalui rekam medis dan dilanjutkan dengan wawancara untuk data tambahan. Data diolah secara statistik menggunakan SPSS versi 20. Hasil. Dari 196 subjek yang melaporkan pajanan, sebagian besar merupakan perempuan (69,9%), bekerja sebagai perawat (38,3%), dan dokter (49,5%), serta mayoritas terpajan secara per kutan (93,4%). Dari seluruh laporan tersebut didapatkan 183 pajanan berisiko, dengan anti-HIV reaktif pada 19 (10,4%), HBsAg positif pada 11 (6,0%), dan anti-HCV reaktif pada 12 (6,6%) sumber pajanan. Mayoritas petugas terpajan diketahui tidak memiliki HIV, hepatitis B, dan hepatitis C. Hanya 27,5% petugas terpajan memiliki kadar anti-HBs protektif. Dari 183 pajanan berisiko, sebanyak 44,3% mendapatkan rekomendasi antiretroviral (ARV), namun hanya 49,4% petugas yang minum ARV secara lengkap (28 hari). Capaian evaluasi anti-HIV pada bulan ke-3 dan ke-6 hanya dilakukan oleh 21,3% petugas. Rekomendasi profilaksis pasca pajanan hanya diberikan kepada 20,3% laporan, dengan capaian hanya 13,5% dan 13,3% untuk vaksinasi hepatitis B dan immunoglobulin (HBIG). Evaluasi ulangan HBsAg 3 dan 6 bulan secara lengkap hanya dilakukan oleh 13,5% petugas kesehatan, mayoritas petugas (64,9%) tidak melakukan evaluasi ulang HBsAg. Dari seluruh pajanan berisiko hepatitis C, mayoritas tidak melakukan evaluasi ulang terhadap anti-HCV (69,9%). Simpulan. Pelaksanaan profilaksis pasca pajanan terhadap HIV, hepatitis B, dan hepatitis C masih rendah, terutama pada evaluasi status serologis lanjutan. Oleh karena itu, penanganan profilaksis secara komprehensif penting dilakukan termasuk peningkatan pengetahuan dan kesadaran petugas kesehatan, peninjauan kembali standar operasional prosedur, dan komunikasi yang efektif. Kata Kunci: Hepatitis B, Hepatitis C, HIV, Petugas kesehatan, Profilaksis pascapajanan Profil of Implementation of Post Exposure Prophylaxis of Hepatitis B, Hepatitis C and Human Immunodeficiency Virus to Health Care Worker in Cipto Mangunkusomo Hospital 2014-2016 Introduction. Health care workers (HCW) have a high risk of infectious substance exposure. Hepatitis B, hepatitis C, or human immunodeficiency virus (HIV) are some diseases transmitted by body fluid or body tissue. Cipto Mangunkusumo Hospital Jakarta has been implementing post-exposure prophylaxis (PEP)s towards HIV, hepatitis B, and hepatitis C. This study aimed to identify the implementation of post-exposure prophylaxis of HIV, Hepatitis B, and Hepatitis C among HCW in Cipto Mangunkusumo Hospital Jakarta. Methods. A cross-sectional study was conducted to exposed workers in Cipto Mangunkusumo Hospital Jakarta between 2014-2016 who had been recorded by report. Demographic data were collected through medical record and interview was conducted to gather additional data. Statistical analysis was conducted with SPSS 20. Results. Among 196 reports, most HCW were female (69.9%), worked as nurse (38.3%), medical doctor (49.5%), and exposed percutaneously (93.4%). There were 183 risky exposures, with 19 (10.4%) reactive anti-HIV, 11 (6.0%) positive HBsAg, and 12 (6.6%) reactive anti-HCV in source of exposure. Almost all of the HCW has no HIV, hepatitis B, nor hepatitis C at the moment of exposure. Recommendation for antiretroviral (ARV) was given to 81 HCW, but only 49.4% completed the course. Anti-HIV follow up was done only by 21.3% workers. Recommendation of PEP for hepatitis B was given to 37 HCW. But, only 13.5% and 13.3% receive hepatitis B vaccination and hepatitis B immunoglobulin, respectively. Follow-up of HBsAg and anti-HBs on 3rd and 6th months were done by 41 (31.1%), 38 (28.8%), and 2 (1.5%) workers who were recommended to receive prophylaxis. In 182 workers recommended to do the follow-up of anti-HCV, 39 (21.4%), and 37 (20.3%) workers did the follow-up on 3rd and 6th month. Majority of exposed workers were not re-evaluated for HBsAg (64.9%) and anti-HCV (69.9%). Conclusions. The implementation of post-exposure prophylaxis for HIV, Hepatitis B, and Hepatitis C was still low especially in re-evaluation serologic marker. Comprehensive management is recommended including improving knowledge of health care workers, re-evaluation of operational procedure standard, and effective communication.

Pendahuluan. Komplikasi kardiovaskular yang disebabkan oleh disfungsi endotel menjadi salah satu penyebab mortalitas yang cukup tinggi pada pasien Artritis Reumatoid (AR). Faktor Reumatoid (RF) merupakan autoantibodi yang sering dijumpai pada AR dan diduga dapat meningkatkan respon inflamasi dan disfungsi endotel. Sindroma metabolik dapat pula meningkatkan disfungsi endotel. Belum ada studi yang menilai korelasi RF dan disfungsi endotel pada pasien AR tanpa sindroma metabolik. Penelitian ini bertujuan untuk mengetahui korelasi antara kadar RF dengan kadar VCAM-1 pada pasien AR tanpa sindroma metabolik. Metode. Penelitian desain potong lintang terhadap pasien AR dewasa yang berobat di Poliklinik Reumatologi RSUPN Cipto Mangunkusumo tanpa sindroma metabolik. Pengumpulan data dilakukan sejak Februari hingga Maret 2018 dari data penelitian sebelumnya yang diambil periode Februari 2016 hingga September 2017. Kadar RF dan VCAM-1 dinilai melalui pemeriksaan serum darah dengan metode ELISA. Korelasi antarkedua variabel dibuat dengan analisis korelasi Spearman menggunakan SPSS versi 20.0. Hasil. Sebanyak 46 subjek diikutsertakan dalam penelitian ini. Sebagian besar (95,7%) subjek adalah perempuan dengan rerata usia 44,43 tahun, median lama sakit 36 bulan, dan sebagian besar memiliki derajat aktivitas sedang (52,2%). sebagian besar pasien memiliki RF positif (63%). Korelasi antara kadar RF dengan kadar VCAM-1 memiliki kekuatan korelasi yang lemah tetapi tidak bermakna secara statistik (r=0,264; p=0,076). Subjek dengan RF positif memiliki kadar VCAM-1 yang lebih tinggi (626,89 vs. 540,96 ng/mL). Simpulan. Belum didapatkan korelasi antara RF dengan VCAM-1 pada pasien Artritis Reumatoid tanpa sindroma metabolik. Kata Kunci: Artritis reumatoid, Faktor reumatoid, Sindroma metabolik, Vascular Cell Adhesion Molecule-1 Correlation between Rheumatoid Factor and Vascular Cell Adhesion Molecule-1 Levels in Rheumatoid Arthritis Patients without Metabolic Syndrome Introduction. Cardiovascular complications caused by endothelial dysfunction become one of the highest causes of mortality in patients with Rheumatoid Arthritis (RA). Rheumatoid Factor (RF) is an autoantibody that is commonly found in RA and is thought increasing the inflammatory response and endothelial dysfunction. Metabolic syndrome may also increase endothelial dysfunction. There have been no study assessing correlation between RF and endothelial dysfunction in RA patients without metabolic syndrome. Aim of this study was to determine the correlation between RF levels with VCAM-1 levels in RA patients without metabolic syndrome. Methods. Cross sectional design study of adult RA patients treated in Rheumatology Polyclinic of Cipto Mangunkusumo General Hospital without metabolic syndrome. Data collection was conducted from February to March 2018 from the previous research data taken from February 2016 to September 2017. The levels of RF and VCAM-1 were assessed through blood serum testing using the ELISA method. Correlation between the two variables was made using Spearman correlation analysis with SPSS 20.0 Results. A total of 46 subjects were included in the study. Most (95.7%) subjects were women with an average age of 44.43 years, median duration of 36 months, and most had moderate activity (52.2%). Most patients had a positive RF (63%). The correlation between RF levels and VCAM-1 levels had a weak correlation strength but was not statistically significant (r= 0.264; p= 0.076). Subjects with RF positive had higher levels of VCAM-1 (626.89 vs. 540.96 ng / mL). Conclusion. There is no correlation yet between RF and VCAM-1 in RA patient s without metabolic syndrome.

Aim: To assess CML patient’s characteristic including demographic, clinical and hematological characteristic of patients with CML including quantitative BCR-ABL and BCR-ABL gene sequencing. Methods: This study was an open-label, single arm, non-randomized, cross sectional study in patients with CML being treated with imatinib mesylate (IM) from 12 centers. Result: A total of 100 patients were evaluated between January 1, 2009 and December 31, 2011. The median age was 34-35 years old (mean of age is 36 years old), and more patients in the productive age was found. ------- (?) were 80 of the 100 patients who had been examined for the BCR-ABL gene mutation with the sequencing method before consuming IM. Mutation in the P-loop was seen in 2,27% (1 out of 44 patients), this finding was beyond our expectation since 47,69% (31 out of 65 patients) of our patients did not achieved CHR at three months. On the other hand, 15,9% (7 out of 44 patients) of our patients had mutation outside the P-loop. Conclusions: The characteristics of CML patients in Indonesia were not different from CML patients in Asia in general. Our finding concerning the high frequency mutation in the BCR-ABL gene outside the P-loop needs further study.

Acquired hemophilia A merupakan kondisi dimana faktor koagulasi VIII menjadi tidak aktif akibat pembentukan autoantibodi. Kondisi ini dikaitkan dengan kehamilan, keganasan, dan penyakit auitoimun dengan kelainan kulit. Pada kasus ini, seorang wanita berusia 66 tahun, datang dengan keluhan perdarahan paska tindakan yang disertai dengan lesi kulit. Pasien didiagnosis dengan acquired hemophilia A dengan ditemukannya inhibitor faktor VIII terkait dengan pemfigoid bulosa. Kata Kunci: Acquired hemophilia A, diagnosis, pemfigoid bulosa, tata laksana Diagnosis and Treatment of Acquired Hemophilia A (AHA) with Bullous Pemphigoid Acquired hemophilia A is a condition in which coagulation factor VIII become inactive due to autoantibody formation. This condition is related to pregnancy, malignancy, and autoimmune disease with skin disorder. In this case report, a 66 years woman with a post procedural bleeding with skin disorder. Later on, patient diagnosed with acquired hemophilia A with a factor VIII inhibitors related to bullous pemphigoid. Keywords : Acquired hemophilia A, bullous pemphigoid, diagnosis, treatment