Association of Fibrinogen Level and Index of Microcirculatory Resistance In Acute ST-Segment Elevation Myocardial Infarction Patient Undergoing Primary Percutaneus Coronary Intervention

Background: Primary percutaneus coronary intervention (PPCI) is a first of choice to return patients blood flow and perfusion with ST-segment elevation myocardial infarction (STEMI), however reperfusion in macrocirculation level is not always accompanied by a sufficient microcirculation reflow due to Microvascular Obstruction (MVO). Previous study demonstrated thathigh fibrinogen concentration may affect rheological parameters of the blood and play an important role in the pathomechanism of myocardial non-reperfusion phenomenon following successful mechanical recanalisation of the infarct-related coronary artery. Another study show eda more compact, lysis-resistant fibrin network in no reflow group, but without significant relation to fibrinogen level. However, there is a lack of data regarding fibrinogen and MVO. The aim of this study is to evaluate association between fibrinogen and MVO by index of microcirculatory resistance (IMR). Methods. 55 STEMI patients undergoing primary PCI were consecutively included. The fibrinogen was evaluated using clauss method and IMR was done right after PPCI to evaluate MVO. Results. From fifty-five patients included in the study, there were 87,3% men, with mean age 53,18.9 years old, and smoker show the biggest proportion compare with risk factor for coronary artery disease. All the patient undergo primary percutaneus coronary intervention with mean door-to-ballon time of 89.04+37.114 minute and ischemia time of 458,69+170,709 minute. Mean IMR was 55,2 + 47,454 and mean fibrinogen level was 350,8+103,19. From the scaterred plot fibrinogen prone to had a weak negative correlation with IMR and statistically non-significant(r = -0,137; p=0,319). Conclusion. There is no correlation between fibrinogen level and IMR value in STEMIpatients undergoing PPC

Ventricle Dyssynchrony in Right Ventricle Apex and Right Ventricle Outflow Tract Pacing: Evaluation by Tissue Doppler Imaging

Background : Pacemaker lead implantation at right ventricular apex (RVA) or right ventricular outflow tract (RVOT) have different haemodynamic consecuences, due to ventricular dyssynchrony difference. Tissue Dop-pler Imaging (TDI) clearly shown ventricle dyssynchrony, this modality is better than convensional echo. This research was performed using TDI to describe ventricle dyssynchrony in RVA and RVOT pacing. Method and Result: Twenty four patients with VVI/VVIR pacemaker in-serted at the Catheterization Laboratory National Cardiac Centre Harapan Kita Hospital were evaluated using TDI modality for ventricle dyssynchrony. Subject characteristic consist of 13 men (54,8%) and 11 (45,8%) women, with average of age were 61,38 12,41 years. Base rhythm were Sick Sinus Syndrome/SSS (37,5%) and Total Atrioventricular Block/TAVB (62,5%). The duration of implantation was 24,83 16,88 months, with minimal duration of pacing 1 month and maximal duration 63 months. The average of ventricular ejection fraction was 0,450,15. Chi Square ana-lyze have shown that there were no difference dyssynchrony between RVA and RVOT pacing, p=0,408 for inter ventricular delay and p=0,423. for intra ventricular delay. QRS duration after pacing have shown signifi-cant difference between the two groups (p=0.01). Conclusion : There were no difference in ventricular dyssynchrony be-tween RVA and RVOT pacing, but QRS duration at the RVOT pacing is significantly shorter than RVA pacing

The Protective Effect of Vitamin E for Reducing Intra-Hospital Mortality in Acute Limb Ischemia Patients

Background Management of acute limb ischemia (ALI) is still a huge challenge. Current advances of endovascular therapeutic approach in management of ALI have decreased the overall amputation rate, nevertheless, mortality rate remains high which may be caused by metabolic consequences of reperfusion injury. Aim To understand the role of vitamin E to intra-hospital and 30-day mortality among acute limb ischemia patients. Methods This retrospective cohort study included all patients with ALI between 2015 to 2018. Vitamin E 2x400 mg orally for seven days was given based on physician preference after ALI diagnosis was confirmed. Data were collected from Vascular Registries of National Cardiovascular Center Harapan Kita (NCCHK), Jakarta, Indonesia. Univariate analysis and logistic regression models were used to explore factors that contribute to intra-hospital and 30-day mortality. Results                                        A total of 160 patients with ALI involving 192 limbs were admitted to our hospital. Mostly were male (63.1%) and mean age were 56±13 years old. Majority of the patients had unilateral lesion (80%), and were diagnosed with Rutherford stage IIA (36.3%), followed by stage IIB (33.8%), stage I (20%), and stage III (10%) respectively. Intra-hospital and 30-day mortality were 28.1% and 36.9%, respectively. Low treatment of vitamin E increased intra-hospital mortality (HR 5,6 95%CI 1.7-18.3), however, it did not affect 30-day mortality. Other factors including IABP insertion, arrhythmia, bleeding requiring transfusion and acute renal failure were associated with higher intra-hospital and 30-day mortality. In addition, menopause (HR 3.2; CI 1.16-8.85) was also a predictor of 30-day mortality. Conclusion Vitamin E administration reduced intra-hospital mortality but not on 30-day mortality in acute limb ischemia patients. Keywords: Acute Limb Ischemia, vitamin E, mortality, reperfusion injur

Implementasi Kebijakan Remunerasi di Rumah Sakit Pemerintah

ABSTRACTBackground: Since 2008, Hospital A began implementing remuneration. However, this system gets the refusal of some parties. Therefore, aims this research was to determine the remuneration policy implementation at the Hospital A Jakarta. Method: The study was conducted with a qualitative approach through in-depth interviews and focus group discussions, each with 10 medical personnel involved. Result: The results of this study indicate that aspects of the environment in general have a positive perception of the organization while the relationship between negative perceptions obtained. Negative perceptions are also found on the organization’s resources and budget allocation accuracy especially bureaucratic commitment is relatively low. Meanwhile, the characteristic aspects and capabilities of implementing agencies received a positive perception. Secondary data showed an increase in financial performance and hospital services after the implementation of the remuneration. Conclusion: Implementation of the remuneration policy in Hospital A goes pretty well with a few flaws that need attention. Therefore, the necessary changes to the paradigm of gradual and continuous work culture of employees, improving the quality and quantity of communication between the organization and management of the employees regarding transparency, optimization remuneration policy dissemination and implementation of monitoring and evaluation on a regular basis with the involvement of all stakeholders. Keyword : Implementation, Policy, Remuneration, Hospital ABSTRAKLatar Belakang: Sejak tahun 2008, Rumah Sakit A mulai menerapkan kebijakan remunerasi. Akan tetapi sistem ini mendapat penolakan dari sejumlah pihak. Oleh karena itu, tujuan studi ini adalah untuk mengetahui implementasi kebijakan remunerasi di Rumah Sakit A di Jakarta. Metode: Studi dilakukan dengan pendekatan kualitatif melalui wawancara mendalam dan diskusi kelompok terfokus, masing-masing dengan 10 tenaga medis yang terkait. Hasil: Hasil penelitian ini menunjukkan bahwa aspek kondisi lingkungan secara umum memiliki persepsi positif sedangkan hubungan antar organisasi didapatkan persepsi yang negatif. Persepsi yang negatif juga dijumpai pada sumber daya organisasi khususnyaketepatan alokasi anggaran dan komitmen birokrasi yang relatif rendah. Sementara, aspek karakteristik dan kapabilitas instansi pelaksana mendapat persepsi positif. Data sekunder menunjukkan adanya peningkatan kinerja pelayanan dan keuangan rumah sakit setelah pelaksanaan remunerasi. Kesimpulan: Impelementasi kebijakan remunerasi di Rumah Sakit A berlangsung cukup baik dengan beberapa kekurangan yang perlu mendapatkan perhatian. Oleh karena itu, diperlukan perubahan bertahap dan berkesinambungan terhadap paradigma budaya kerja karyawan, peningkatan kualitas dan kuantitas komunikasi antar organisasi maupun manajemen dengan karyawan menyangkut tranparansi, pengoptimalan sosialisasi kebijakan remunerasi serta pelaksanaan monitoring dan evaluasi secara berkala dengan melibatkan semua pemangku kepentingan. Kata kunci: Implementasi, kebijakan, remunerasi, rumah raki

“Endovascular Stent Graft” pada Diseksi Aorta Tipe B

Pada tahun 1970, Nicholls, seorang dokter kerajaan Inggris, melakukan otopsi terhadap King George II yang mengalami kematian mendadak. Ternyata penyebab kematian sang Raja adalah efusi masif perikardium, rongga perikard dipenuhi bekuan darah, akibat robekan dinding aorta. Hirs dkk (1958) pernah membuat penelusuran terhadap 505 penderita dengan gejala klinis serupa, ia memperlihatkan tingginya angka kematian serta sulitnya menegakkan diagnosis, sehingga pasien umumnya meninggal. Kemajuan modalitas pencitraan berperan sangat penting dalam mendiagnosis diseksi akut aorta secara dini, dan kemajuan teknik terapi akhirnya mampu meningkat-kan harapan hidup pasien dengan kelainan ini

Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series [version 2; peer review: 2 approved]

Background Suitable aortic neck is one of the essential components for thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR). Advanced techniques were developed to adjust and compromise the aneurysm neck angulation but with adding additional devices and complexity to the procedure. We proposed a simple technique to modify severe neck angulation and/or iliac artery tortuosity by using the multiple stiff wire (MSW) technique. Method Two femoral accesses were required for the MSW technique. A guidewire with a support catheter was inserted through the right and left femoral arteries and positioned in the abdominal or thoracic aorta. Wire exchanges were done with extra stiff wire in both femoral accesses. It can be considered to add multiple stiff wires to align the torturous neck / iliac artery. Delivery of the stent graft main body can be done via one of the accesses. Result Six patients with different aortic pathology were admitted to our hospital. Four patients undergo EVAR procedure and two patients undergo TEVAR procedure. All patients had aortic neck angulation problems with one patient having iliac artery tortuosity. MSW technique was performed on the patients with good results. Follow-up CTA after 3 months revealed a good stent position without stent migration and no endoleak was found in all but one patient. Conclusion MSW technique is a simple and effective technique to modify aortic neck/iliac artery angulation in TEVAR or EVAR procedure

Characteristics, treatment and in-hospital outcomes of patients with STEMI in a metropolitan area of a developing country: an initial report of the extended Jakarta Acute Coronary Syndrome registry

Objective: We studied the characteristics of patients with ST segment elevation myocardial infarction (STEMI) after expansion of a STEMI registry as part of the STEMI network programme in a metropolitan city and the surrounding area covering ∼26 million inhabitants. Design: Retrospective cohort study. Setting: Emergency department of 56 health centres. Participants: 3015 patients with acute coronary syndrome, of which 1024 patients had STEMI. Main outcome measure: Characteristics of reperfusion therapy. Results: The majority of patients with STEMI (81%; N=826) were admitted to six academic percutaneous coronary intervention (PCI) centres. PCI centres received patients predominantly (56%; N=514) from a transfer process. The proportion of patients receiving acute reperfusion therapy was higher than nonreperfused patients (54% vs 46%, p<0.001), and primary PCI was the most common method of reperfusion (86%). The mean door-to-device (DTD) time was 102±68 min. In-hospital mortality of nonreperfused patients was higher than patients receiving primary PCI or fibrinolytic therapy (9.1% vs 3.2% vs 3.8%, p<0.001). Compared with non-academic PCI centres, patients with STEMI admitted to academic PCI centres who underwent primary PCI had shorter mean DTD time (96±44 min vs 140±151 min, p<0.001), higher use of manual thrombectomy (60.2% vs13.8%, p<0.001) and drug-eluting stent implantation (87% vs 69%, p=0.001), but had similar use of radial approach and intraaortic balloon pump (55.7% vs 67.2%, and 2.2% vs 3.4%, respectively). In patients transferred for primary PCI, TIMI risk score ≥4 on presentation was associated with a prolonged door-in to doorout (DI-DO) time (adjusted OR 2.08; 95% CI 1.09 to 3.95, p=0.02). Conclusions: In the expanded JAC registry, a higher proportion of patients with STEMI received reperfusion therapy, but 46% still did not. In developing countries, focusing the prehospital care in the network should be a major focus of care to improve the DI-DO time along with improvement of DTD time at PCI centres. Trial registration number: NCT02319473

Endovenous laser therapy for varicose vein

<p>Laser has become a useful technology in treating venous incompetence especially superficial venous disease. Introduction of endovenous thermal ablation through endovenous laser therapy helped by duplex ultrasound guidance has provided an alternative for traditional saphenous vein stripping. High success rate, minor complications, and minimally invasive technique provide the advantages over traditional treatment. In this case illustrated, the endovenous laser therapy used for great saphenous varicose vein. Yet, future development in endovenous laser therapy is still needed and only long term follow-up and uniform reporting standards will provide the answers.<em><strong> (Med J Indones. 2013;22:117-20)</strong></em></p><p><strong>Keywords: </strong><em>Endovenous laser theraphy, great saphenous vein, varicose vein</em></p

Occluded renal artery and a contralateral moderate renal artery stenosis – Which side should be treated?

Renal artery stenosis is the most common secondary cause of hypertension. We present a case of a 22-year-old man with uncontrolled hypertension despite taking four antihypertensive medications including a diuretic agent. Duplex ultrasound showed bilateral renal artery stenosis with total occlusions of the right renal artery and moderate stenosis (60%) of left renal artery. Renogram showed decreased function of both kidneys especially in the right. Renal fractional flow reserve showed no significant hemodynamic disturbance in the left renal artery. Thus, percutaneous transluminal angioplasty with renal stenting was performed in the right renal artery. After one month of follow up, the patient showed no symptoms, good control of blood pressure and improvement of kidney function. Renal scintigraphy and renal fractional flow reserve measurement play an important role for clinical decision making regarding the need for renal revascularization