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Major Adverse Cardiac Events (MACE) are the main causes to increase mortality in ST-Elevation Myocardial Infarction (STEMI) patients who undergo Primary Percutaneous Coronary Intervention (PPCI). In-hospital MACE inducing factor predictors identification is expected to enhance STEMI patients’ care and outcome. This study aims to identify in-hospital MACE factor predictors in STEMI patients with PPCI treatment at RSCM. Retrospective cohort study by tracing medical records on patients with PPCI treatment at RSCM from January 2015 - March 2020. The chi-squared bivariate analysis concluded between predictor factors; age, smoking, hypertension, diabetic Mellitus, chronic kidney disease, time-to-treatment, Killip class, left ventricle ejection fraction (LVEF) and LDL cholesterol level. Logistic regression is used in multivariate and prediction model analysis on variables with p 60 years (29,6%), smoking (61,2%), hypertension (50,9%), diabetes mellitus (36,1%), chronic kidney disease (6,2%), Killip class II-IV (32,2%), LVEF > 50% (57%) dan cholesterol LDL level > 100 mg/dl (79,4%). Median time-to-treatment is 528 (379-730) minutes. Age, Killip class, and LVEF influences in-hospital MACE during PPCI with OR (95% CI) consecutively are 2,15 (1,22-3,79), 4,34 (2,49-7,56) and 2,88 (1,72-4,82). MACE prediction model in this study produces area under curve (AUC) 0,729 (95% CI 0,67-0,78). In-hospital MACE on STEMI patients after PPCI occurrence is 43.3%, influenced by age, Killip class, and LVEF. Keywords: major adverse cardiac events, primary percutaneous coronary intervention, myocardial infarction. Faktor Prediktor Major Adverse Cardiac Events Selama Perawatan pada Pasien ST-Elevasi Miokard Infark yang Menjalani Intervensi Koroner Perkutan Primer di RSUPN dr. Cipto Mangunkusumo Abstrak Major Adverse Cardiac Events (MACE) merupakan penyebab utama meningkatnya mortalitas pada pasien STElevasi Miokard Infark (STEMI) yang menjalani intervensi koroner perkutan primer (IKPP). Identifikasi faktor prediktor yang mempengaruhi terjadinya MACE selama perawatan diharapkan dapat meningkatkan perawatan dan luaran klinis dari pasien STEMI. Penelitian ini bertujuan untuk mengetahui faktor prediktor MACE selama perawatan pada pasien STEMI yang dilakukan IKPP di RSCM. Studi kohort retrospektif dengan menelusuri rekam medis pasien yang menjalani IKPP di RSCM periode Januari 2015-Maret 2020. Dilakukan analisa bivariat antara faktor prediktor usia, status merokok, hipertensi, diabetes mellitus, penyakit ginjal kronik, time-to-treatment, kelas killip, fraksi ejeksi ventrikel kiri (FEVK) dan kadar kolesterol LDL dengan kejadian MACE selama perawatan pada pasien STEMI yang menjalani IKPP, menggunakan metode Chi-square. Analisa multivariat dan analisa model prediksi dilakukan dengan metode regresi logistik terhadap variabel dengan nilai p= 60 tahun (29,6%), status merokok (61,2%), hipertensi (50,9%), diabetes mellitus (36.1%), penyakit ginjal kronik (6,2%), kelas Killip II-IV (32,2%), FEVK > 50% (57%) dan kadar kolesterol LDL > 100 mg/dl (79,4%). Median timeto-treatment didapatkan sebesar 528 (379-730) menit. Usia, kelas killip dan FEVK mempengaruhi kejadian MACE selama perawatan dengan OR (IK 95%) masing-masing 2,15 (1,22-3,79), 4,34 (2,49-7,56) dan 2,88 (1,72-4,82). Model prediksi MACE selama perawatan pada pasien STEMI yang menjalani IKPP memiliki nilai area under curve (AUC) 0,729 (IK 95% 0,67-0,78). Major Adverse Cardiac Events (MACE) selama perawatan Kata kunci: major adverse cardiac events, intervensi koroner perkutan primer, infark miokard.

Background: Various determinants of 30-day mortality risk in CABG patients have been formulated into certain scoring models such as the EuroSCORE and ACEF model. However, these models only consider preoperative parameters while excluding intraoperative, postoperative, and perioperative parameters. Currently, the prior research has increasingly emphasized the role of these excluded parameters as determinants of post-CABG mortality. Furthermore, there are differences in mortality rate of CABG procedures in Indonesia when compared with other countries. Hence, this study aimed to identify preoperative, intraoperative, and postoperative determinants of 30-day mortality after CABG surgery in Indonesian population. Methods: In this retrospective cohort study, secondary data were obtained from the medical records of 263 patients aged ≥ 18 years who underwent CABG at a single center in Indonesia during the year 2012–2015. Selected preoperative, intraoperative, postoperative, and perioperative determinants were analyzed in both bivariate and multivariate Cox regression models to identify determinants associated with 30-day mortality. Results: The 30-day mortality rate after CABG was 11.8%. Multivariate analysis identified neurological dysfunction (HR 6.16; 95% CI 2.42-15.66), renal impairment (HR 3.9; 95% CI 1.46-10.38), left ventricle dysfunction (HR 3.53;95% CI 1.55-8.03), aortic clamp duration (HR 3.7;95% CI 1.53-8.96), surgery duration (HR 3.85;95% CI 1.39-10.70), postoperative thrombocytopenia (HR 3.99;95% CI 1.72-9.23), and postoperative intra-aortic balloon pump (HR 10.98; 95% CI 4.77-25.28) as significant determinants associated with 30-day mortality after CABG Conclusions: Neurological dysfunction, renal impairment, left ventricle dysfunction, aortic clamp duration, surgery duration, postoperative thrombocytopenia, and postoperative intra-aortic balloon pump were independent determinants for 30-day mortality after CABG.

BACKGROUND: Colorectal cancer is the third-most common cancer in the world, in which 15%–25% of patients already had metastatic colorectal cancer (mCRC) at the time of diagnosis. The overall survival (OS) of mCRC is poor with the use of chemotherapy. AIM: This systematic review and meta-analysis aim to examine the outcomes of OS and progression-free survival (PFS) of adding bevacizumab to different chemotherapy regiments compared to chemotherapy regiments only in the treatment of untreated mCRC. METHODS: Literature searching was done in databases such as PubMed, EBSCO, SCOPUS, and ScienceDirect. The primary outcome measured in this systematic review and meta-analysis was OS, while the secondary outcome was PFS. Hazard ratio (HR) was used as the main summary measure with 95% confidence interval (CI). Publication bias was measured using a funnel plot. RESULTS: Literature searching resulted in 11 selected studies, 9 selected for meta-analysis. Addition of bevacizumab showed significant better results in OS (HR 0.83, CI 95% 0.74–0.93; p = 0.002; I2 = 29%) and PFS (HR 0.62, 95% CI 0.51–0.75; p < 0.0001, I2 = 78%). CONCLUSION: The addition of bevacizumab to chemotherapy resulted in better OS and PFS in untreated mCRC. Further studies are needed to confirm PFS benefit from the combination of bevacizumab and chemotherapy due to significant heterogeneity.

we aim to conduct a systematic review and meta-analysis in population of adult MDS patients to elucidate the role of these genes in AML transformation risk.The protocol for this systematic review and meta-analysis was registered in the international prospective register of systematic reviews (PROSPERO) with ID number of CRD42020218581. Systematic literature search was conducted by all authors up to October 2021 on: (1) PubMed, (2) EBSCOhost, (3) Scopus, (4) JSTOR, and (5) grey literatures. Hand-searching for relevant articles was also conducted. The following keywords with their synonyms and combinations using Boolean operators were applied to all database: "myelodysplastic syndrome", SRSF2", "SF3B1", "U2AF1", "ASXL1", "DNMT3A", "TET2", "IDH1", "IDH2", "RUNX1", "acute myeloid leukemia progression", and "leukemia free survival". Outcome was measured using hazard ratio (HR).We identified 14 articles to be used for this systematic review and meta-analysis. There was no statistically significant difference in AML transformation risk between U2AF1 mutant and U2AF1 wildtype MDS patients (HR: 1.41; 95% CI: 0.95-2.07, p=0.08, I2=0%). Pooled HR showed that patients with SRSF2 mutation had higher risk of AML transformation (HR 2.62; 95% CI: 1.54-4.45; p= .0004; I2= 55%). The pooled HR for SF3B1 was 0.48 (95% CI: 0.22-1.06, p=0.07, I2=55%). Mutations of TET2, ASXL1, and EZH2 were not associated with AML transformation. Meanwhile, DNMT3A mutations were associated with AML transformation with pooled HR of 2.73 (95% CI: 1.43-5.21; p= 0.08; I2: 67%). The pooled HR for IDH genes was smaller (HR: 2.92; 95%CI: 1.21-7.06; p=0.02; I2:65%). Patients with RUNX1 mutation were associated with AML transformation (HR: 1.85; 95%CI: 1.11-3.09; p=0.02; I2:38%).Based from our analyses, MDS patients with mutations of SRSF2, DNMT3A, IDH, and RUNX1 have higher hazard ratio for AML transformation.

AIM: This study aims to identify the correlation between patient generated-subjective global assessment (PG-SGA) with serum C-reactive protein (CRP) to be used to predict inflammation and prevent cachexia in head-and-neck cancer patients. METHODS: This was a cross-sectional study using 51 patients with inclusion criteria of patients diagnosed with head-and-neck cancer irrespective of stage, age ≥18 years old, had not received treatments of radiotherapy, chemotherapy, and surgery. The statistical analysis performed was Kolmogorov–Smirnov normality test, bivariate analysis by Spearman test, and linear regression analysis. RESULTS: As many as 64.7% of the patients had PG-SGA score ≥9 (average PG-SGA score 11.7 ± 6.2). The CRP median value was 6.4 (0.4–170.4) mg/L. There was a statistically significant positive but weak correlation between PG-SGA score with serum CRP (r = 0.372 and p = 0.007) and a significant linear relationship (r2 = 0.201). CONCLUSIONS: Malnutrition risk assessment using PG-SGA showed a high prevalence of malnutrition risk in head-and-neck cancer patients. PG-SGA score is correlated with serum CRP level. Further studies are needed to confirm the result of this study.

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: STAT5 is a transcriptional factor which when highly expressed in chronic myeloid leukemia (CML) cells stimulate proliferation and mediate resistance from tyrosine kinase inhibitors, resulting in major molecular response (MMR) failure. STAT5 has two isoforms, STAT5A and STAT5B. However, prolonged use of imatinib appears to only upregulate STAT5A pathway. In addition, the resistance conferred by STAT5A does not extend to other drugs such as hydroxyurea. Hence, STAT5A and STAT5B might have different functions in CML cells. AIM: The objective of the study was to determine the association of STAT5A and STAT5B expression with MMR failure in CML patients. METHODS: This was a cross-sectional study of CML patients in chronic phase with age ≥ 18 years old, receiving IM therapy ≥ 12 months, and previously given hydroxyurea. MMR status was evaluated and patients were categorized as achieved or failed to achieve MMR. Expression levels of STAT5A and STAT5B were conducted using RT-PCR methods. Associations between STAT5A expression, STAT5B expression, hydroxyurea duration, and imatinib duration with MMR achievement were calculated using logistic regression. RESULTS: A total of 118 patients were analyzed; 71.1% failed to achieve MMR. Multivariate logistic regression analysis showed statistically significant association between high STAT5A expression (odds ratio [OR]: 3.852; 95% confidence interval [CI]: 1.420–10.452; p = 0.008), STAT5A/STAT5B interaction (OR: 0.150; 95% CI: 0.038–0.593; p = 0.007), longer hydroxyurea administration (OR: 3.882; 95% CI: 1.023–14.733; p = 0.046), and shorter imatinib administration (OR: 0.333; 95% CI: 0.132–0.840; p = 0.020) with MMR achievement failure. After adjusting STAT5A expression with STAT5A/STAT5B interaction, high STAT5A expression independently increased the likelihood of MMR achievement failure only in high expression STAT5B patients (OR: 3.852; 95% CI: 1.420–10.452; p = 0.008). CONCLUSION: High STAT5A expression which is induced by high STAT5B is associated with MMR achievement failure of chronic phase CML patients who received hydroxyurea before imatinib. Longer duration of hydroxyurea and shorter duration of IM confound of STAT5A expression to MMR achievement failure.

Ikhwan Rinaldi,1 Resti Mulya Sari,2 Vanya Utami Tedhy,3 Kevin Winston3 1Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 2Division of Hematology and Medical Oncology, Department of Internal Medicine, Dharmais National Cancer Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 3Faculty 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 +628111001758Email ikhwan.rinaldi@ui.ac.idIntroduction: Leukostasis is a medical emergency with high mortality which often occurs in acute myeloid leukemia patients with hyperleukocytosis. One of the therapies that can be used for leukostasis in acute myeloid leukemia is leukapheresis. However, whether leukapheresis can provide better survival benefit when compared with patients not receiving leukapheresis is still unclear. Hence, we aimed to evaluate the effect of chemotherapy plus leukapheresis combination versus chemotherapy only on 28-day survival of acute myeloid leukemia patients with leukostasis.Methods: This study was a dual-center retrospective cohort using secondary data from medical records collected from November 2018 to March 2019. Inclusion criteria were adult patients aged 18 years old or above, diagnosed with acute leukemia with hyperleukocytosis status defined by WBC count greater than 100,000/uL, and with symptoms of leukostasis. One-month survival analysis was conducted using Kaplan–Meier curve method. Univariate and multivariate analyses were then conducted using Cox proportional hazards model to obtain value of hazard ratio (HR) with a 95% confidence interval (CI).Results: A total of 38 patients were obtained for analysis. The median overall survival was 25 days (95% CI: 17.001– 32.999 days) in the chemotherapy only group and 20 days (95% CI: 1.497– 38.503) in the chemotherapy with leukapheresis group. The use of leukapheresis did not affect 28-day survival (HR: 1.140; 95% CI: 0.396– 3.283; p value: 0.809) and 7-day survival (HR: 1.073; 95% CI: 0.277– 4.152; p value: 0.919). In the multivariate analysis, age ≥ 60 years, blast percentage ≥ 90%, creatinine ≥ 1.4 mg/dL, and presence of disseminated intravascular coagulation were associated with worse 28-day survival.Conclusion: AML patients with leukostasis who received both chemotherapy and leukapheresis did not have better 28-day survival and 7-day survival when compared with patients receiving chemotherapy only. Old age, high blast percentage, high creatinine, and presence of disseminated intravascular coagulation were prognostic factors for worse 28-day survival.Keywords: leukemia, hyperleukocytosis, leukostasis, leukapheresis, chemotherapy, survival

Background: sepsis is a life-threatening organ dysfunction caused by an excessive host immunological response to infection. The incidence of sepsis is increasing every year, and sepsis is the primary cause of mortality in intensive care units (ICUs). DIC is a coagulopathy syndrome that causes microvascular and macrovascular thrombosis and increases the risk of bleeding due to consumptive coagulopathy. The pathophysiology of DIC in sepsis is complex, and further research is required to investigate the involved mechanisms and risk factors. Method: this study is a prognostic analysis of a retrospective cohort. Samples were patients diagnosed with sepsis and admitted to Cipto Mangunkusumo National General Hospital from January 2016 to October 2022. Research subjects were followed until occurrence of DIC during sepsis or recovery from sepsis. The research subjects were selected from medical records using a consecutive total sampling approach. The inclusion criteria were patients aged ≥18 years old and diagnosed with sepsis according to qSOFA criteria with a score of 2. The exclusion criterion was an incomplete medical record. Bivariate and multivariate logistic regression analyses were performed to determine which independent variables contributed to the incidence of DIC and obtain the odds ratios (ORs). p < 0.05 was considered to indicate a statistically significant difference. Results: a total of 248 patients were included after considering the inclusion and exclusion criteria. Of these, 50 (20.2%) septic patients developed DIC. In the multivariate analysis, albumin ≤2.5 g/dL (OR: 2.363; 95% CI: 1.201–4.649), respiratory infection (OR: 2.414; 95% CI: 1.046–5.571), and antibiotic treatment ≥1 h (OR: 2.181; 95% CI: 1.014–4.689) were associated with DIC development. On the basis of the ROC curve, the area under the curve (AUC) was determined to be 0.705 with 95% CI = (0.631–0.778). Conclusion: in our study, the prevalence of DIC in septic patients was 20.2%. Low albumin, respiratory infection, and antibiotic treatment ≥1 h were found to be risk factors for development of DIC in septic patients.

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.

Ikhwan Rinaldi,1 Melva Louisa,2 Resti Mulya Sari,3 Elly Arwanih1 1Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 2Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 3Division of Hematology and Medical Oncology, Department of Internal Medicine, Dharmais Cancer Hospital,Faculty of Medicine, Universitas Indonesia, Jakarta, IndonesiaCorrespondence: Ikhwan RinaldiCipto Mangunkusumo National General Hospital, Jakarta, IndonesiaEmail ikhwanrinaldi@gmail.comObjective: To analyze theassociation of FLT3-ITD mutation and FLT3 ligand plasma level with one-year survival of Indonesian acute myeloid leukemia (AML) patients.Methods: A prospective cohort study was conducted to determine the association between FLT-3-ITD mutation and FLT3 ligand plasma level with one-year survival of Indonesian AML patients. In the study, a total of 51 AML patients were obtained from two tertiary hospitals in Indonesia from year 2018 to 2020. Inclusion criteria were de novo AML male and female patients aged ≥ 18 years old. Exclusion criteria were prior myelodysplastic syndrome and patients that refused to participate in the study. FLT3-ITD genotype of patients was then analyzed using PCR method while FLT3 ligand plasma level was measured using ELISA method. Patients were then followed-up for 1 year or until death occurred with survival as the measured outcome. Association between independent and dependent variable were analyzed by cox regression proportional hazard.Results: Eleven patients (21.5%) in this study had FLT3-ITD mutation. The median age of AML patients was 45 (18– 71) years, and the median blast percentage was 50% (5– 87%). After one-year follow-up, 33 (64.7%) patients had died. The median survival of AML patients was 6 months. Univariate analysis showed no association between FLT3-ITD mutation status (HR: 1.051 ; 95% CI: 0.483– 2.286; P: 0.901) and FLT3 ligand plasma level (HR: 0.798; 95% CI: 0.347– 1.837; p= 0.596), and age (HR: 1.283; 95% CI: 0.575– 2.862; p= 0.542) with one-year survival of AML patients, but multivariate analysis showed association between GFR with one-year survival of AML patients in this cohort (HR: 4.053; 95% CI: 1.469– 11.183; p= 0.007).Conclusion: One-year survival of AML patients in Indonesia is not affected by FLT3-ITD mutation and FLT3 ligand plasma level. However, GFR showed association with one-year survival of AML patient in this cohort study.Keywords: acute myeloid leukemia, one-year survival, FLT3-ITD, FLT3 Ligand Plasma

Anemia is a common blood disorder in the elderly which is associated with numerous poor medical outcomes. However, there is currently no study that assesses anemia prevalence of the Indonesian elderly population aged ≥60 years old in multiple provinces and analyzes its association with handgrip muscle strength using a large sample size.We aimed to elucidate the prevalence of anemia and analyze factors associated with handgrip strength in elderly.This was a cross-sectional study using data from the 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 (Hb) 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. Subjects were classified as weak if the handgrip strength was28 kg for men and18 kg for women based on classification from the Asian Working Group for Sarcopenia (AWGS) 2019. The independent variables were Hb level, gender, age, body mass index (BMI), waist circumference, smoking history, comorbidities, and current use of drug therapies. Based on WHO standard, male and female participants with Hb less than 13 g/dL and 12 g/dL, respectively, are defined as anemic. Statistical analyses used included correlation, bivariate logistic regression, and multivariate logistic regression.A total of 3192 individuals were selected for analysis. Overall, 38.8% of participants had anemia, and the prevalence of anemia increases with age. A total of 56.30% of participants aged ≥80 years had anemia. There was a positive correlation between Hb level and handgrip strength in the Indonesian elderly population (r: 0.349; p value:0.001). Multivariate analysis showed that anemia was significantly associated with weak handgrip strength (OR: 1.557; 95% CI: 1.314-1.846; p value:0.001). Age ≥ 80 years (OR: 5.234), age 70-79 years (OR: 3.152), low BMI (OR: 1.827), and hypertension (OR: 1.340) were associated with weak handgrip strength in multivariate analysis.The prevalence of anemia in the Indonesian elderly was 38.8% and anemia was associated with weak handgrip strength. The association of anemia with weak handgrip strength is more pronounced in males and the elderly aged ≥80 years.

Venous thromboembolism (VTE) is a serious complication that can occur during and after postoperative treatment, including in treatment after orthopedic surgery. The current guidelines for VTE prophylaxis in postoperative patients recommend the use of LMWHs, one of which is enoxaparin. Another recommendation for use in pharmacological VTE prophylaxis is rivaroxaban, which has better efficacy than enoxaparin but a higher bleeding risk. The aim of this systematic review is to provide an update on the profile of rivaroxaban for VTE prophylaxis after orthopedic surgery. PubMed, SCOPUS, EMBASE, and EBSCOhost were searched up until May 2022. The outcome sought was efficacy and safety, described by the incidence of VTE and incidence of bleeding, respectively. Five randomized controlled trials (RCT) were finally included. Rivaroxaban was confirmed to have better efficacy by significantly reducing the risk of VTE and all-cause mortality (RR = 0.38; 95% CI = 0.27–0.54) compared to enoxaparin. However, regarding the safety variable, no significant difference was found between the incidence of major bleeding in rivaroxaban and enoxaparin (RR = 0.97; 95% CI = 0.56–1.68). The results of the analysis show that rivaroxaban has better efficacy than enoxaparin but the same safety profile, so when used, the bleeding of patients should still be monitored.

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.

Background: Imatinib mesylate is the first tyrosine kinase inhibitor approved for chronic myeloid leukemia (CML) therapy. Imatinib is an effective drug. However, previous studies have shown that about 20-30% of patients eventually would develop resistance to imatinib. Approximately 40% of imatinib resistance is associated with BCRABL kinase domain mutation. One of the most common and serious variations account for imatinib response is T315I of ABL1 gene. Objective: The study aimed to examine the association of T315I mutation with the ABL1 gene and its relation to major molecular response (MMR) achievement in CML patients. This study also examined other mutations adjacent to T315I, i.e., F311I, F317L, and different possible variations in the ABL1 gene. Methods: This was a cross-sectional study on Indonesian CML patients in chronic phase. We analyzed 120 blood samples from patients in chronic phase who have received imatinib mesylate (IM) for ≥12 months. Results: There were no T315I, F311I, and F317L mutations found in this study. However, we found another variation, which was 36 substitutions from A to G at position 163816 of ABL1 gene (according to NG_012034.1). Conclusions: We found no T315I, F311I, and F317L mutations in this study. Our findings suggest that there might be other factors that influenced the MMR achievement in our study patients. However, there were 36 substitutions from A to G at position 163.816 (according to NG_012034.1) that needed further examination to explore the significance of this mutation in clinical practice.

Cosmas Rinaldi Adithya Lesmana,1,2 Yoppi Kencana,1 Ikhwan Rinaldi,3 Juferdy Kurniawan,1 Irsan Hasan,1 Andri Sanityoso Sulaiman,1 Rino Alvani Gani1 1Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia; 2Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia; 3Department of Internal Medicine, Haematology and Oncology Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, IndonesiaCorrespondence: Cosmas Rinaldi Adithya LesmanaDepartment of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jalan Diponegoro No. 71, Jakarta, IndonesiaEmail medicaldr2001id@yahoo.comBackground: Non-alcoholic fatty liver disease (NAFLD) is a chronic inflammatory disease with excessive fat accumulation in the liver. Transient elastography (TE) with controlled attenuation parameter (CAP) is a device and method to examine the degree of fibrosis and steatosis. However, this device is not widely available across Indonesia. Neutrophil and lymphocyte ratio (NLR) is a simple marker for inflammation, which has a potency to predict disease outcome. This study aims to know the diagnostic value of NLR as the indicator of steatosis and fibrosis severity.Methods: This was a cross-sectional study with consecutive sample collection. We used secondary data from medical records, starting from 2016 to 2018. A descriptive and data analysis, including correlation test, multivariate linear regression, t-test, receiver operating curve (ROC) and area under the curve (AUC) were done to find out the outcome of the study. Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) Version 20.0 (SPSS Inc, Chicago, Illinois). A P value < 0.05 was considered as statistically significant.Results: Out of 106 subjects, 62.3% patients were women with the mean of age 57.29 years old and 77.4% had metabolic syndrome. Most patients had moderate to severe steatosis degree (66%) with the mean of TE mean 6.14 (2.8– 18.2) kPa. There was a positive correlation between CAP and TE compared with NLR with r = 0.648 (p < 0.001) and r = 0.621 (p < 0.001), respectively. The use of RNL to assess moderate-severe steatosis has a cutoff point of 1.775 with sensitivity, specificity, PPV and NPV, respectively, at 81.5%, 80.6%, 89.1%, and 69.1%; cutoff point 2.150 to assess significant fibrosis with sensitivity, specificity, PPV and NPV of 92.3%, 87.5%, 70.6%, and 97.2%, respectively.Conclusion: NLR has a positive and significant correlation with the degree of steatosis and fibrosis with high sensitivity and specificity as evaluated by TE/CAP.Keywords: neutrophil and lymphocyte ratio, steatosis, fibrosis, non-alcoholic fatty liver disease

Background Patients with hepatocellular carcinoma (HCC) generally only come for treatment when cancer has reached an advanced stage, with very limited treatment options. There has not been an accurate predictor marker to be able to identify which group of patients may have better survival. This study wanted to analyze the role of the inflammatory status indices as predictors of one-year survival in patients with advanced HCC who did not undergo therapy. Methods This study has a retrospective cohort design using secondary data on subjects with advanced HCC who did not undergo therapy at Cipto Mangunkusumo Hospital and Dharmais Hospital. The Neutrophil-lymphocyte ratio (NLR) and Systemic immune-inflammation index (SII) were evaluated for their role as predictors of one-year survival based on the Area Under Receiving Operator Curve (AUROC). The best optimal cutoff for NLR and SII was decided based on the Youden index, followed by survival analysis based on those cutoffs. Confounding factors were analyzed with multivariate cox regression analysis. Results A total of 196 subjects were included in the data analysis. One-year survival was 6.6%, with a median survival of 56 days (95% CI: 46-67). The NLR had a discriminatory ability based on AUROC of 0.667 (95% CI: 0.536-0.798; p = 0.044), with the optimal cut-off point to differentiate survival was 3.7513. The SII has a discriminatory ability based on AUROC of 0.766 (95% CI: 0.643-0.889; p = 0.001), with the optimal cut-off point to distinguish survival was 954.4782. SII had superiority in discriminatory ability (p = 0.0415). Conclusions The discriminatory ability based on AUROC of SII was better than that of NLR in predicting one-year survival in patients with advanced HCC who did not undergo therapy.

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 Patients with systemic lupus erythematosus (SLE) often experience anxiety and depression. Recent studies have shown involvement of intestinal dysbiosis in SLE and also psychosomatic disorders. However, there are no reports on the gut microbiota profile of patient with both conditions: SLE and anxiety or depression. We aimed to study gut microbiota profiles among SLE patients with gastrointestinal symptoms and anxiety or depression by sequencing V3–V4 region of the 16S rRNA gene from the stool samples. Results Of the 41 SLE patients who participated in the study, 53.66% had anxiety and 14.63% had depression. We found a higher proportion of Bacteroidetes and lower diversity indices in patients with anxiety than in those without anxiety. We also found a higher proportion of Bacteroidetes and lower Firmicutes/Bacteroidetes ratios and diversity indices in patients with depression than in those without depression. Moreover, compared to other groups, patients with symptoms of both anxiety and depression had the highest proportion of Bacteroidetes and lowest proportion of Firmicutes, Firmicutes/Bacteroidetes ratios, and diversity indices. Further analysis showed that there was a significant correlation between the proportion of Bacteroides and the anxiety score (r = 0.349; p = 0.03) as well as with lupus activity (r = 0.36; p = 0.02). There was also significant correlation between diversity indices and lupus activity (r= -0.34; p = 0.03 for Chao1 index, r= -0.38; p = 0.01 for Shannon index, and r= -0.33; p = 0.03 for richness index). Conclusions SLE patients with both anxiety and depression showed more unfavorable gut dysbiosis parameter compared to SLE patients with only anxiety or depression and SLE patients without anxiety or depression. There was positive correlation between proportion of Bacteroides and lupus disease activity and negative correlation between diversity indices and lupus disease activity.

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.

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.

Objective: Imatinib is the first-line drug used for the treatment of chronic myeloid leukemia (CML) patients due to high molecular response and overall survival rate. However, some patients develop resistance to imatinib even after attaining a response. Mutation in ABCB1 efflux transporters is one of the known mechanisms of resistance to imatinib in chronic myeloid leukemia patients. This study was aimed to investigate the association of ABCB1 C1236T polymorphism in Indonesian chronic myeloid patients with molecular response to imatinib treatment. Methods: We analyzed 120 samples from chronic myeloid leukemia patients in the chronic phase, who had been on imatinib treatment for at least 12 months. We analyzed the C1236T variant of the ABCB1 gene using PCR, followed by direct sequencing, and associate them with the achievement of major molecular response (MMR). Results: The major molecular response was achieved in 28% of patients. The frequencies of the SNPs were CC (40%), CT (46%), and TT (14%). Our result showed that there was a lack of association between polymorphism of ABCB1 C1236T and imatinib response in Indonesian patients, with OR = 0.646 (95% CI: 0.283, 1.471; p>0.05). Conclusion: There was no association between ABCB1 C1236T variants with the major molecular response in Indonesian chronic myeloid leukemia patients receiving imatinib treatment.

Over the past few decades, treatment options have become more advanced for multiple myeloma (MM), one of the most prevalent hematological cancers; however, multiple myeloma remains an incurable disease due to its poor response to therapy and high rates of resistance, which cause relapsed/refractory or multiple myeloma. Researchers have described anti-BCMA (B-cell maturation antigen) as a promising treatment regimen that targets the BCMA biomarker in the affected plasma cells. BCMA is a protein that is specifically expressed in plasma-cell neoplasms by using several mechanisms, such as CAR T cells (Chimeric Antigen Receptor T cells), antibody-drug conjugates, and bispecific T-cell engagers, thus allowing for a rapid response in the treatment of resistant or relapsed/refractory multiple myeloma patients. Anti-BCMA treatment is novel and specific in its mechanisms of action, with noninferior complete responses, higher overall survival rates, and fewer reported adverse events compared to other currently available treatment of MM. In this review, we compared anti-BCMA mechanisms with those of previously available therapies, such as those using immunomodulators and proteasome inhibitors, and discussed the advantages of using anti-BCMA as a potential first-line treatment for multiple myeloma patients.

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

ObjectiveThis study will test the performance of the anal swab PCR test when compared with the nasopharyngeal swab PCR test as a diagnostic tool for COVID-19.DesignAn observational descriptive study which included hospitalised suspected, or probable cases of hopitalised COVID-19 patients, conducted in Dr. Cipto Mangunkusumo National Hospital, Ciputra Hospital, Mitra Keluarga Depok Hospital and Mitra Keluarga Kelapa Gading Hospital, Indonesia. Epidemiological, clinical, laboratory and radiology data were obtained. Nasopharyngeal and anal swabs specimens were collected for SARS-CoV-2 RNA detection.ResultsWe analysed 136 subjects as part of this study. The clinical spectrum of COVID-19 manifesation in this study was typical of hospitalised patients, with 25% classified as mild cases, 14.7% in severe condition and 12.5% of subjects classified as having acute respiratory distress syndrome. When compared with nasopharyngeal swab as the standard specimen for reverse transcription polymerase chain reaction (RT-PCR) detection of SARS-CoV-2 antigen, the sensitivity and specificity of the anal swab was 36.7% and 93.8%, respectively. The positive and negative predictive value were 97.8% and 16.5 %, respectively. The performance of the anal swab remained similar when only the subgroup of patients with gastrointestinal symptoms (n=92, 67.6%) was analysed (sensitivity 40% and specificity 91.7%). Out of all the subjects included in analysis, 67.6% had gastrointestinal symptoms. Similarly, 73.3% of patients in the anal swab-positive group had gastrointestinal symptoms. The two most common gastrointestinal symptoms in the subjects’ population were nausea and anorexia.ConclusionAnal swab specimen has low sensitivity (36.7%) but high specificity (93.8%) for detecting SARS-CoV-2 antigen by RT-PCR. Only one additional positive result was found by anal swab among the nasopharyngeal swab-negative group. Anal swab may not be needed as an additional test at the beginning of a patient’s diagnostic investigation and nasopharyngeal swab RT-PCR remains as the standard diagnostic test for COVID-19.

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 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.

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.

Chronic myeloid leukemia (CML) is a clonal haemopoietic stem cell disorders with reciprocal translocation in chromosome 9 (ch9) and 22 (ch22) which cause the fusion of Break cluster region-Abelson murine leukemia (BCR-ABL) oncogene. This fusion will activate tyrosine kinase. Imatinib mesylate is the first tyrosine kinase inhibitor (TKI), which could change the prognosis of CML patients. However, there is a resistance to TKI’s, and based on transcriptomic study, increase expression of gen signal transducer and activator of transcription (STAT) 5A and runt-related transcription factor 3 (RUNX3) can cause resistance to TKI’s. The STAT5 protein, which in normal myeloid cells being activated by cytokine, in CML patients was activated even without cytokines. STAT5 refer to STAT5A and STAT5B, however they have might have different role in hematopoietic stem cells or in CML cells. This review summarizes the role of STAT5 in tyrosine kinase inhibitor resistance in CML patients.

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.