Fixed-dose combination antituberculosis therapy as a risk factor for tuberculosis recurrence: an evidence-based case report

Background: a patient with a history of tuberculosis (TB) has a risk up to 27% to develop recurrence within 2 years after being cured. Indonesia itself has more than 7,500 recurrent cases annually, regardless of reinfection or relapse. This is an important problem, as recurrent TB is associated with lower cure rates with the anti-TB therapy and higher risk of developing drug resistance. Some risk factors for this recurrence are smoking, poor treatment adherence, low economic status, and weak immune status. This study is aimed to identify whether the use of fixed-dose combination (FDC) anti-tuberculosis therapy increases the risk for tuberculosis recurrence compared with using separate drug formulation. Methods: the search was conducted on MEDLINE, ProQuest, EBSCO, ScienceDirect, and Cochrane according to clinical question. The studies were selected based on inclusion and exclusion criteria and led to five useful articles. The selected studies were critically appraised for their validity, importance, and applicability. Results: five cohort studies were found with comparable validity. Only 1 study has accurate relative risk (RR) with 3.97 (1.14 – 13.80) and number needed to harm of 18. Other four studies fulfilled the applicability criteria for our case. Conclusion: the use of FDC anti-tuberculosis therapy increases the risk for tuberculosis recurrence compared with using separate drug formulation

The Proportion of Orthostatic Hypotension and Its Relationship with HbA1c Levels in Elderly Patients with Diabetes

Aim: to obtain information on the proportion of orthostatic hypotension in elderly patients with diabetes and its relationship with HbA1c levels. Methods: this is a cross-sectional study on 350 patients with diabetes mellitus (DM) aged ≥60 years old who sought treatment at outpatient clinic of Geriatry and Diabetes Division at Cipto Mangunkusumo Hospital between January and March 2016. Orthostatic hypotension was defined as a decrease in systolic blood pressure ≥20 mmHg and/or diastolic pressure ≥10 mmHg within 3 minutes after changing position from lying to standing. HbA1c levels was measured using Nycocard from Axis Shield. Chi square test was used for bivariate analysis and logistic regression was used for multivariate analysis against confounding variables. Results: the proportion of orthostatic hypotension in elderly subjects with DM was 27.4%. Median of HbA1c levels was higher in subjects with than without orthostatic hypotension (7.6% vs. 7.1%; p<0.05). There was an association between HbA1c levels of ≥7.35% and the incidence of orthostatic hypotension (OR 1.987, 95% CI 1.2-3.2). The duration of having DM was a confounding variable. Conclusion: orthostatic hypotension is more common in elderly subjects with DM. There is an association between the incidence of orthostatic hypotension and increased HbA1c levels in elderly patients with diabetes mellitus

The Role of Incentive Spirometry in Primary Spontaneous Pneumothorax

Pneumothorax is the presence of air in the pleural space. Its management consists of noninvasive and invasive therapies and it is determined based on clinical manifestations, type and size of pneumothorax. We present a case of a patient with diagnosis of primary spontaneous pneumothorax treated with incentive spirometry (noninvasive therapy). A 20 year old man came to respirology clinic with chief complaint of shortness of breath. He was recently diagnosed with left pneumothorax based on previous chest X-ray in another health care facilities and was advised to undergo tube thoracostomy but he refused the procedure. On physical examination, vital signs were normal. Chest X-ray showed 33% of pneumothorax or 1.2 cm. He was asked to perform incentive spirometry therapy at home. During 12 days of therapy, shortness of breath slowly disappeared and on repeated chest X-ray, it showed minimal pneumothorax in the left upper hemithorax. Noninvasive treatment such as incentive spirometry can be considered in patient with minimal symptoms and no signs of life-threatening respiratory distress

Osteoarticular Tuberculosis: A Secondary Manifestations to Tuberculous Pleural Effusion

Tuberculosis appears to be increasing throughout the world after years of continuous decline, despite the introduction of effective chemotherapy. This resurgence is related to the increasing number of patients immunocompromised by chemotherapeutic agents used to treat other diseases or Acquired Immunodeficiency Syndrome (AIDS); the appearance of multiple drug-resistant strains of tuberculosis, and aging population. Musculoskeletal tuberculosis arises from haematogenous seeding of the bacilli soon after the initial pulmonary infection.1 Osteoarticular TB can occur in the knee - one study found of 1074 cases, 8.3 percent - or 90 cases - affected the knee.2 The clinical  symptoms are insidious onset, pain, swelling of the joint and limited range of movements. Investigations for suspected cases include: Mantoux test, radiological imaging, fine needle aspiration biopsy, surgical biopsy, bacteriological examination, histopathological examination, and polymerase chain reaction (PCR) of a suitable specimen. The mainstay of treatment is multidrug antitubercular chemotherapy. The main reason for poor outcome is delayed diagnosis.1 We report a case of osteoarticular manifestation of tuberculosis infection affecting the left knee presenting in a man with a history of tuberculosis pleural effusion. This case highlights, firstly, osteoarticular disease is always secondary to a primary lesion in the lung and, secondly, the diagnosis of tubercular arthritis can be challenging, particularly in the presence of confounding factors such as preexisting arthritis. Ethical approval was not required for this case study

The Differences Between Interleukin-6 and C-reactive Protein Levels Among Adult Patients of Dengue Infection with and without Plasma Leakage

Aim: to determine the differences in IL-6 and CRP levels among groups of dengue infection patients with and without plasma leakage. Methods:a cross-sectional study was conducted in adult patients with dengue infection who were treated at Cipto Mangunkusumo and Persahabatan Hospital between 1 March 2014 and 1 April 2015. The study analyzed differences in IL-6 and CRP levels on the 3rd and 5th day of fever in both groups, as well as differences in each group. Interleukin-6 and CRP levels in both groups, was analyzed using unpaired t-test or MannWhitney and in each group, the data was subsequently analyzed using paired t-test or Wilcoxon test. Results: the samples of study consisted of 24 subjects with plasma leakage and 20 subjects without plasma leakage. The level of IL-6 for groups with and without plasma leakage for the 3rd and the 5th day of fever were 8.56 (1.85-96.15) vs. 3.80 (1.94-81.93) pg/mL (p=0.069) and 4.30 (1.60-70.28) vs. 2.76 (1.26-11.67) pg/mL (p=0.025), respectively; while for CRP level, there were 10.1 (4.3-36.5) vs 6.8 (3.0-21.6) mg/L (p=0.014) and 5.0 (2.0-20.1) vs 2.9 (0.1-9.9) mg/L (p=0.048). The level of IL-6 on the 3rd and the 5th day of fever in the group with and without plasma leakage were 8.56 (1.85-96.15) vs. 4.30 (1.60-70.28) pg/mL (p=0.037) and 3.80 (1.94-81.93) vs. 2.76 (1.26-11.67) pg/mL (p=0.005). The level of CRP on the 3rd and 5th day of fever in the group with and without plasma leakage were 10.1 (4.3-36.5) vs. 5.0 (2.0-20.1) mg/L (p=0.0001) and 6.8 (0.3-21.6) vs. 2.9 (0.1-9.9) mg/L (p=0.0001). Conclusion:there was no difference in IL-6 level on the 3rd day of fever between the two groups; while on the 5th day of fever, the IL-6 level was higher in the group with plasma leakage. The level of CRP on the 3rd and the 5th day of fever were higher in the group with plasma leakage. The levels of IL-6 and CRP on the 3rd day of fever were higher than the levels on the 5th day of fever in both groups

Comparison of Specific Immunoglobulin E with the Skin Prick Test in the Diagnosis of House Dust Mites and Cockroach Sensitization in Patients with Asthma and/or Allergic Rhinitis

Background: nowadays, specific IgE measurement has been conducted in Indonesia, however there is still lack of data regarding diagnostic test to detect inhalant allergen in patients with respiratory allergies.This study aimed to determine the accuracy of specific IgE test in diagnosing specific sensitization of inhalant allergen in patients with respiratory allergies. Methods: this was a cross sectional study in patients with respiratory allergies and part of epidemiology study regarding to specific IgE sensitization in Allergy-Immunollogy Division, Cipto Mangunkusumo Hospital, Jakarta within November-December 2016. Measurement of specific IgE sensitization using Immunoblot method (Euroline®, Euroimmun AG, Germany). The tested allergen is house dust mites [Dermatophagoides pteronyssinus (Der p), Dermatophagoides farinae (Der f), Blomia tropicalis (Blo t)] and cockroach  [Blatella germanica (Bla g)]. The result is compared with gold standard, skin prick test. The diagnostic result includes sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-). Results: a total of 101 patients were enrolled; 77 (76.2%) were women. Patients mean age was 38.8 years old. Based on SPT, sensitization was highest for Blo t (76.2%), followed by Der p (70.3%), Der f (69.3%), and Bla g (41.6%). Specific IgE-sensitization was highest for Der f (52.9%), followed by Der p (38.2%), Blo t (33.3%) and Bla g (10.8%). Der p allergen had 50.7% sentivity, 90% specificity, 92.3% PPV, 43.5% NPV, 5.1 LR+ and 0.1LR-. Der f showed 71.4% sensitivity, 87.1% specificity, 82.6% PPV, 57.4% NPV, 5.5 LR+ and 0.3 LR-. Blo t allergen had 41.6% sensitivity, 91.7% specificity, 94.1% PPV, 32.8% NPV, 5.0 LR+, and 0.6 LR-. Bla g allergen had 23.8% sensitivity, 98.3% specificity, 90.9% PPV, 64.4% NPV, 14.5 LR+ and 0.8 LR-. Conclusion: serum specific IgE testing to common inhalant allergen in patients with respiratory allergy showed only low-to-moderate sensitivity, but high specificity and PPV. This new assay can be used to diagnose allergen sensitization in the population with high prevalence of TDR and cockroach

Correlation of Forced Expiratory Volume in 1 Second Prediction with Mean Pulmonary Arterial Pressure Using Echocardiography in Stable Chronic Obstructive Pulmonary Disease

Introduction. Pulmonary hypertension is the most common complication of chronic obstructive pulmonary disease (COPD). Mortality rate will increase when COPD complication with pulmonary hypertension. Right heart catheterization (RHC) is the most common tool to measure mean pulmonary arterial pressure (mPAP) either in COPD patients with exacerbations treated in intensive care unit. Data of pulmonary hypertension in stable COPD group is still relatively rare. Alternatively to RHC, nowadays echocardiography is used to measure mean pulmonary arterial pressure in stable COPD group. Methods. A cross-sectional study was conducted on fifty-eight stable male COPD patients (mean age: 67,6) underwent spirometry. Mean pulmonary arterial pressure was measured using transthoracic echocardiography at short axis view in aortic level. Results. Mean value of forced expiratory volume in 1 second (FEV1)% was 26,6 % (SD 4,7) with median value of mean pulmonary arterial pressure was 37,61 mmHg (range 18,3-59). As many as 74% subjects were pulmonary hypertension; 24 % mild, 31 % moderate and 19% severe respectively. The correlation test showed a significant strong-negative correlation (r = -0,948, p <0,001). The best cut-off point of FEV1% prediction, which had a clinical value correlated with mPAP, was 55,3% with the sensitivity 93 %. Conclusions. Forced expiratory volume in one second (FEV1)% prediction has a significant correlation with mean pulmonary arterial pressure in stable COPD patients. The cut-off point FEV1% prediction 55,3% has a good capability to discriminate pulmonary hypertension in stable COPD patient

The Differences in Serum Quantitative Specific IgE Levels Induced by Dermatophagoides pteronyssinus, Dermatophagoides farinae and Blomia tropicalis Sensitization in Intermittent and Persistent Allergic Asthma

Background: house dust mites (HDM) are an important inhalant allergen in allergic asthma. However, molecular diagnostic study of specific IgE to HDM allergens has not been done in Indonesia. In addition, the association of quantitative specific IgE measurement with asthma severity has not been investigatedd. This study aimed to investigate the difference of serum quantitative specific IgE levels induced by Dermatophagoides (D.) pteronyssinus, D. farinae and Blomia tropicalis sensitization in intermittent and persistent allergic asthma.Methods: this was a cross-sectional study on adult allergic asthma patients who were invited for serum specific IgE testing. This study was a part of a larger study within the Division of Allergy and Immunology, Cipto Mangunkusumo Hospital. Asthma severity was defined based on Global Initiative on Asthma (GINA) 2015 criteria and were grouped as intermittent or persistent. Quantitative specific IgE testing was done on blood serum using a multiple allergosorbent test (Polycheck Allergy, Biocheck GmbH, Munster, Germany). The HDM allergens tested were D. pteronyssinus, D. farinae, and Blomia tropicalis. Difference between two groups were analyze using Mann-Whitney test.Results: a total of 87 subjects were enrolled in this study; 69 (79.3%) were women. Mean patients’ age was 40, 2 years. Sixty-three (72.4%) subjects had asthma and allergic rhinitis. Fifty-eight (66.7%) subjects were classified as persistent asthma. The prevalence of sensitization was 62.1% for D. farinae, 51.7% for D. pteronyssinus, and 48.3% for Blomia tropicalis. The median of specific IgE levels were significantly higher in persistent asthma compares to intermittent asthma induced by D. farinae (median 1.30 vs. 0.0 kU/L; p=0.024) and B. tropicalis (median 0.57 vs. 0.0 kU/L; p=0.015) sensitization. Level of Specific IgE  D. pteronyssinus was also to be higher in persistent asthma than the level measured in intermittent asthma (0.67 vs. 0.00 kU/L; p=0.066).Conclusion: Sensitization of HDM allergens was shown to be highest for D. farinae 62.1%, followed by D. pteronyssinus 51.7% and Blomia tropicalis 48.3%. Specific IgE level induced by D. farinae and Blomia tropicalis sensitization were significantly higher in patients with persistent asthma compared to intermittent asthma, whereas specific IgE level induced by D. pteronyssinus sensitization was higher in persistent asthma although not statistically significant

Diagnostic Accuracy of Platelet/Lymphocyte Ratio for Screening Complex Coronary Lesion in Different Age Group of Patients with Acute Coronary Syndrome

Background: with the increasing number of patients with acute coronary syndrome (ACS) with complex coronary lesion and the increasing needs of coronary artery bypass grafting (CABG) procedures, there is an increasing need for a tool to perform early stratification in high-risk patients, which can be used in daily clinical practice, even at first-line health care facilities setting in Indonesia. It is expected that early stratification of high-risk patients can reduce morbidity and mortality rate in patients with ACS. This study aimed to identify diagnostic accuracy of platelet/lymphocyte ratio (PLR) and the optimum cut-off point of PLR as a screening tool for identifying a complex coronary lesion in patients ?45 and >45 years old. Methods: this was a retrospective cross-sectional study, conducted at the ICCU of Cipto Mangunkusumo Hospital. Data was obtained from medical records of adult patients with ACS who underwent coronary angiography between January 2012 - July 2015. The inclusion criteria were adult ACS patients (aged ?18 years old), diagnosed with ACS and underwent coronary angiography during hospitalization. Diagnostic accuracy was determined by calculating sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). The cut-off point was determined using ROC curve. Results: the proportion of ACS patients with complex coronary lesion in our study was 47.2%. The optimum cut-off point in patients aged ?45 years was 111.06 with sensitivity, specificity, LR+ and LR of 91.3%, 91.9%, 11.27 and 0.09, respectively. The optimum cut-off points in patients aged >45 years was 104.78 with sensitivity, specificity, LR+ and LR of 91.7%, 58.6%, 2.21 and 0.14, respectively. Conclusion: the optimum cut-off point for PLR in patients aged ? 45 years is 111.06 and for patients with age >45 years is 104.78 with diagnostic accuracy, represented by AUC of 93.9% (p<0.001) and 77.3% (p<0.001), respectively for both age groups