From Basic to Clinical Practice in Internal Medicine

Acta Medica Indonesiana, today is The Indonesian Journal of Internal Medicine, addresses all the concerns of science on Internal Medicine. In this edition, we publish a study conductedby Putra ST.1, a cohort retrospective study on teenager subjects who were breast-fed as infants and the effects on the development of atherosclerosis. This study supported the idea that breastfeeding may have protective effect on the development of atherosclerosis. We publish the study since it included the health issues of teenagers.We also publish a study from Yogyakarta conducted by Hartopo AB, et al. which found that neutrophil to lymphocytes ratio of more than 6.2 is correlated to the increased in-hospital adverse events. The subjects were patients with ST elevation myocardial infark (STEMI). Based on the results of the study, the neutrophil/lymphocyte ratio can be utilized as a predictor of adverse events in patients with STEMI

PENINGKATAN MUTU PRODUK DAN PRODUKTIVITAS KOPI LENGKUAS MELALUI TEKNOLOGI MASERASI

Abstrak: Kopi lengkuas merupakan salah satu produk yang dihasilkan oleh Kelompok Masyarakat (Pokmas) APP Al-Ihsan. Metode ekstraksi yang digunakan selama ini yaitu menggunakan teknologi sederhana dengan pelarut air. Untuk optimalisasi proses ekstraksi dan efisiensi waktu dan tenaga diperlukan alat ekstraksi yang sesuai untuk lengkuas. Hal ini diperlukan dukungan sarana produksi untuk alat ekstraksi lengkuas dalam pembuatan kopi lengkuas. Kegiatan ini bertujuan untuk meningkatkan mutu produk dan produktivitas kopi lengkuas melalui peningkatan pengetahuan. Metode kegiatan ini menggunakan pendekatan pelatihan dan pendampingan. Pendekatan pelatihan yaitu melalui Pelatihan Teknologi Maserasi Ekstrak Lengkuas untuk meningkatan mutu produk. Sedangkan metode pendampingan yaitu berupa pendampingan desain alat dan pendampingan dalam penggunaan alat dan teknologi maserasi ekstrak lengkuas untuk menghasilkan produk kopi lengkuas yang berkualitas. Mitra kegiatan ini adalah Pokmas APP Al-Ihsan Desa Matanair Kecamatan Rubaru Kabupaten Sumenep yang dengan jumlah anggota 20 orang. Hasil yang diperoleh dari kegiatan ini adalah peningkatan kuantitas ekstrak lengkuas sebesar 85 % per produksi dan peningkatan pemberdayaan mitra yaitu adanya peningkatan pengetahuan serta pemahaman mitra masyarakat sebesar 85% terhadap teknologi maserasi ekstrak lengkuas.Abstract: Galangal coffee is one of the products produced by Pokmas APP Al-Ihsan. The extraction method used so far is using simple technology with water as a solvent. To optimize the extraction process and save time and energy, appropriate extraction tools are needed for galangal. This requires support for production facilities for galangal extraction tools in making galangal coffee. This activity aims to improve the quality and productivity of galangal coffee. This activity method uses a training and mentoring approach. The training approach is through Galangal Extract Maceration Technology Training. Meanwhile, the mentoring method is in the form of assistance with skills in using the galangal extract maceration tool to produce quality galangal coffee products. The partner for this activity is Pokmas APP Al-Ihsan, Matanair Village, Rubaru District, Sumenep Regency, with 20 members. The results obtained from this activity are an increase in the quantity of galangal extract by 85% per production and an increase in partner empowerment, namely an increase in knowledge and understanding of community partners by 85% regarding galangal extract maceration technology

Correlation Between High-sensitivity C Reactive Protein and Local Arterial Stiffness Measured by Radio Frequency Echotracking System in Type 2 Diabetic Patients

Aim: to identify the correlation between hsCRP and arterial stiffness in type-2 diabetic patients. Methods: a cross-sectional study was conducted to assess the plasma levels of hsCRP and carotid arterial stiffness in 40 patients with type-2 diabetes mellitus. The common carotid artery stiffness was evaluated using radio frequency echo-tracking system to determine the local carotid pulse wave velocity (carotid-PWV). Results: median value of hsCRP in this study was 4.5 (0.2 to 18.9) mg/L and the average value of local carotid stiffness was 8.8±1.7 m/sec. High sensitive CRP showed a strong correlation with carotid-PWV (r=0.503, P=0.001). hsCRP level was independently associated with carotid-PWV after adjustment for age, body mass index, and mean arterial pressure (r=0.450, P=0.005). Conclusion: hs-CRP has moderate positive correlation with arterial stiffness in patients with type-2 diabets mellitus. Key words: arterial stiffness, C-reactive protei

Impact of Frailty on the First 30 Days of Major Cardiac Events in Elderly Patients with Coronary Artery Disease Undergoing Elective Percutaneous Coronary Intervention

Aim: to obtain the proportion of frailty and the incidence of 30-day major adverse cardiovascular events (MACE) as well as to review the impact of frailty on the prognosis of elderly patients with coronary heart disease who underwent elective PCI. Methods: this is a prospective cohort study to assess the frailty of elderly patients with coronary artery disease that underwent elective PCI in Cipto Mangunkusumo Hospital using the frailty phenotype criteria. They were subsequently followed-up for 30 days to see whether there was any MACE developed. Results: there were 100 elderly patients with coronary artery disease who underwent elective PCI between September 2014 and June 2015. The mean age of patients was 66.95 (SD 4.875) years and 69% of the patients were males. Frailty was present in 61% of the patients. MACE were occurred in 8.19% of frail patients and 5.12% were occurred in non-frail patients. The association between frailty and MACE was demonstrated by the result of crude HR of 1.6 (CI 95% 0.31-8.24). In our study, the 30-day survival rate was 95% in frail patients and 98% in non-frail patients. Conclusion: there is a 1.6-fold increased risk of 30-day MACE in elderly frail patients undergoing elective PCI; however, it is not statistically significant

Hyperuricemia as a Risk Factors of Major Adverse Cardiac Events in Patients with Acute Coronary Syndrome: a Retrospective Cohort Study

Aim: to investigate the MACE-free survivals difference between hyperuricemic and normouricemic patients and to determine its role as risk factor for MACE occurrence in hospitalized acute coronary syndrome patients. Methods: retrospective cohort study with survival analysis approach was conducted in 251 patients with acute coronary syndrome who were treated in ICCU Cipto Mangunkusumo Hospital during period from January 2009 to December 2011. Clinical data, laboratory results, electrocardiography result, echocardiography result, and coronary angiography were collected. Patients were observed and followed on major adverse cardiac event during 7 days of hospitalization in ICCU. Major adverse Cardiac Event is an event as a complication occur after acute coronary syndrome such as cardiogenic syock, acute heart failure, stoke, reinfarct during early ward treatment, sudden cardiac death, repeat PCI during ward ulang and perform coronary artery bypass graft (CABG) surgery. Difference in survival is shown in Kaplan-meier curve and difference in survival between groups were tested with Log-rank test, and multivariate analysis with Cox proportional hazard regression to calculate adjusted HR on major adverse cardiac event with confounding variables as covariates. Results: there was a significant difference in survival between hyperuricemia group and non-hyperuricemia group (Log-rank test (p<0.001)) with crude HR 2.7 (CI 95% 1.6–4) and adjusted HR 2.67 (CI 95% 1.6-4.3).There was significant difference in survival between hyperuricemia group (mean survival 6.05 days with SE 0.2 (CI 95% 5.6-6.4) and non-hyperuricemia group (mean survival 7.33 days with SE 0.1 (CI 95% 7.0-7.6). Conclusion: survival of patients suffering from ACS with hyperuricemia is worse compared to those without hyperuricemia during ICCU hospitalization.Key words: hyperuricemia, acute coronary syndrome, major adverse cardiac event, surviva

Transcatheter Closure of Post-operative Residual Ventricular Septal Defect Using a Patent Ductus Arteriosus Closure Device in an Adult: a Case Report

Transcatheter closure of perimembranous and muscular ventricular septal defect (VSD) has been performed widely and it has more advantages compare to surgery. However, transcatheter closure of residual VSD post operation of complex congenital heart disease is still challenging because of the complexity of anatomy and concern about device stability, so the operator should meticulously choose the most appropriate technique and device. We would like to report a case of transcatheter closure of residual VSD post Rastelli operation in a patient with double outlet right ventricle (DORV), sub-aortic VSD, severe infundibulum pulmonary stenosis (PS) and single coronary artery. The patient had undergone operations for four times, but he still had intractable heart failure that did not response to medications. On the first attempt. we closed theVSD using a VSD occluder, unfortunately the device embolized into the descending aorta, but fortunately we was able to snare it out. Then we decided to close the VSD using a patent ductus arteriosus (PDA occluder). On transesophageal echocardiography (TEE) and angiography evaluation, the device position was stable. Post transcatheter VSD closure, the patient clinical condition improved significantly and he could finally be discharged after a long post-surgery hospitalization. Based on this experience we concluded that the transcatheter closure of residual VSD in complex CHD using PDA occluder could be an effective alternative treatment. Key words: residual VSD, PDA occluder, transcatheter closure, heart failure, Rastelli

Association of Periodontitis and Arterial Stiffness in Type 2 Diabetic Patients

Background: periodontitis is a major cause of chronic infection in diabetic patients. Diabetic patients have four-fold risk of having cardiovascular disease. Chronic inflammation caused by periodontitis, a non-traditional cardiovascular risk factor is widely known to play a major role in atherogenesis. Among non-diabetics, an association has been found between periodontitis and arterial stiffness, but in diabetic patients the result is inconsistent. No study has investigated either the proportion of periodontitis or its correlation with arterial stiffness in type 2 diabetes population in Indonesia. Methods: this study was a cross-sectional study involving 97 patients with type 2 diabetics, who were recruited on Endocrinology Clinic from April to August 2017. Periodontitis was measured for pocket depth, clinical attachment loss and bleeding on probing by a periodontist. Carotid-femoral PWV (Pulse Wave Velocity) was measured using SphygmoCor Xcel with cuff-based tonometry technique. Results: periodontitis was found in 99% type 2 diabetic subjects and 78% of them had severe periodontitis. There was no significant correlation found between pocket depth, clinical attachment loss and cfPWV (r=0.024, p=0.407 and r=0.011, p=0.456); whereas there was a weak positive correlation between pocket depth and PWV (r=0.294, p=0.041) in well-controlled type 2 diabetics. Conclusion: most of type-2 diabetics had severe periodontitis; however, the correlation between periodontitis and arterial stiffness could not be concluded in this study

Helicobacter pylori infection appears essential for stomach carcinogenesis: Observations in Semarang, Indonesia

The gastric cancer incidence in Semarang, Indonesia, is exceedingly low: only approximately 1/100th of the level in Japan. To elucidate the reason, we carried out an ecological study recruiting 69 male and 102 female participants from the general populace in January 2005. Positive urea breath tests were 0% for both men and women, and Helicobacter pylori (H. pylori) IgG antibodies were found in 2% (0–5, 95% confidence interval) of men and 2% (0–4) of women, significantly lower than the 62% (58–65) and 57% (53–60), respectively, in Japan. Furthermore, there were no positive findings with the pepsinogen tests in Semarang, again significant in comparison with the 23% (22–25) and 22% (20–23) in Japan. Variation in smoking levels and consumption of NaCl, vegetables and fruit were found, but not to an extent that would allow explanation of the major differences in gastric cancer incidence. We may conclude that the very low prevalence of H. pylori infection and thus chronic atrophic gastritis account for the rarity of stomach cancer in Semarang, Indonesia. (Cancer Sci 2005; 96: 873–875

Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine 253 Extended Dual Antiplatelet for Diabetic Elderly Patients After Drug-eluting Stent Implantation: an Evidence-based Clinical Review

Antiplatelet is an important drug for patients with coronary heart disease undergoing drug-eluting stent implantation. Current guidelines recommend dual antiplatelet with aspirin and a P2Y12 inhibitor for at least 12 months. Continuation of DAPT beyond 12 months may be considered for preventing very late stent thrombosis. Several patient-related factors that contribute to stent thrombosis have been recognized, including diabetes and advanced age, but the optimal DAPT duration for these patients is still controversial. This article reviews the efficacy of extended (>12 months) compared to standard (12 months) DAPT for reducing myocardial infarction and stent thrombosis rates, especially in diabetic elderly patients. Literature screening was conducted at PubMed and Cochrane database using “dual antiplatelet”, “duration”, “adult-onset diabetes mellitus”, “elderly” and, “drug-eluting stent” as keywords. Article types were limited to meta-analysis, systematic review, randomized clinical trial, or clinical trial that compared the efficacy of extended to standard duration of  DAPT. Clinical outcomes used were myocardial infarction and stent thrombosis. The initial search was done to find relevant studies specifically assessing diabetic and elderly patients, then widened to diabetic and non-diabetic patients of any age above eighteen years. A total of 5 clinical trials and 1 meta-analysis were reviewed, showing an overall risk reduction of stent thrombosis and myocardial infarction. This review has several limitations, such as its potential selection bias and underrepresented proportion of diabetic and elderly patients. High-risk subgroups like diabetes mellitus has a tendency of increased ischemic risk, while advanced age could have both increased ischemic risk and bleeding risk. This review suggests that it is better to reserve extended dual antiplatelet therapy for patients with high ischemic risk and low bleeding risk (tailored therapy). Key words: adult-onset diabetes mellitus, drug-eluting stent, extended dual antiplatelet, elderly, myocardial infarction, stent thrombosis