Implant users: Over five years after insertion (Further analysis of previous study data)

This secondary analysis report presents the characteristics of a subgroup of 235 women who are overdue in getting Norplant® implants removed after five years, factors related to the risk of nonremoval after five years, and issues related to accessing information about removal of implants. The main source of data for the present study is the “Norplant Implants® Assessment Study: Insertion, Use, and Removal” carried out in Indonesia in April 1996. This study consisted of a representative sample of 2,979 current and former Norplant users who had an insertion from April 1, 1987, to March 31, 1991, five or more years prior to 1996. The selected sample represented 14 provinces, 50 districts, 150 subdistricts, and 300 villages using stratified, multistage probability proportional to size. The secondary analysis used simple cross tabulations of characteristics and the current use status to study the characteristics of the sample women. The relative risk ratio values were calculated to understand factors related to the risk of not getting implants removed after five years

Evaluating Resistance to Acetyl Salicylic Acid Using Platelet Function Test in Patients with Ischemic Stroke at Cipto Mangunkusumo Hospital

Aim: to identify the prevalence of laboratoric ASA resistance using platelet function tests in patients with ischemic stroke at Cipto Mangunkusumo Hospital and its associated factors. Methods: this study was a cross-sectional study involving 50 patients with ischemic stroke who only received ASA treatment. Evaluation of resistance to ASA was performed using Verifynow® platelet function test. ASA resistance was defined as ASA reaction unit (ARU) ≥550. Results: there were 7 patients with ASA resistance. The mean age of subjects in ASA resistance group was 51.3±9.2 years; while in ASA responsive group was 57.8±9.7 years. In ASA resistance group, there were 85.7% male patients, 57.1% active smoker and 100% subjects with hypertension. Conclusion: the prevalence of laboratoric ASA resistance in patients with ischemic stroke evaluated using platelet function test at Cipto Mangunkusumo Hospital is 14%. The prevalence is more likely to occur in male patients who were active smoker, at younger age and with comorbidity of hypertension. Key words: ischemic stroke, ASA resistance, platelet function test

PENTOXIFYLLINE IN ACUTE ISCHEMIC STROKE PATIENTS WITH BLOOD HYPERVISCOSITY

Objective: This study evaluated the efficacy of pentoxifylline, a hemorrheologic agent, for treating acute ischemic stroke in patients with bloodhyperviscosity.Methods: Patients were randomly allocated within 3 days of stroke onset to study or control treatment. All the patients received the standard acuteischemic stroke treatment. The study treatment was intravenous pentoxifylline 1200 mg/day for 5 consecutive days and oral pentoxifylline 800 mgin two divided doses for 23 days. Blood viscosity was evaluated on days 7 and 30. The outcomes were assessed by the National Institutes of HealthStroke Scale (NIHSS), modified Rankin Scale, and Barthel index (BI) criteria.Results: The median baseline viscosity was 6.89 poise in the study and 6.46 poise in the control groups and had decreased in all the patients ondays 7 and 30. The decrease in the study group on day 7 (1.13 poise) was greater than that in the control group (0.57 poise); the difference was notsignificant. The NIHSS score improved by 32% in the study group (relative risk [RR]=1.00, 95% confidence interval [CI]: 0.421–3.556; p=1.00). At1-month, 67% of the study group had a good functional outcome (RR=1.026, 95% CI: 0.656–1.605; p=0.909).Conclusion: Pentoxifylline decreased blood viscosity and improved clinical outcome in this patient series

The Effect of Enhanced External Counterpulsation Therapy and Improvement of Functional Capacity in Chronic Heart Failure patients: a Randomized Clinical Trial

Aim: to investigate the efficacy of enhanced external counterpulsation (EECP) therapy to improve functional capacity in patients with chronic heart failure (CHF). Methods: a double-blind random clinical trial was performed in 99 patients with CHF who had received EECP therapy at Jade Cardiovascular Clinic, Manado, North Sulawesi, Indonesia between January 2014 and June 2015. Subjects were categorized into 2 groups, i.e. 49 subjects had sham EECP therapy and 50 subjects had EECP therapy. All subjects performed six-minute walking test (6MWT) before and after receiving EECP therapy. Results: there was no significant difference between both groups regarding the basic characteristics of patients with CHF. The 6MWT result before EECP therapy showed that there were 30 patients (61.2%) with walk distance of <300 meter in the sham EECP group; while in the group receiving EECP therapy, we found 34 patients (68%); p=0.24. Post-EECP therapy, there were 33 patients (67.3%) with walk distance of <300 meters in EECP sham group; while in the group receiving EECP alone, there was only 1 patient (2%); p <0.01.The 6MWT walk distance in sham group before EECP therapy was 252.65 (SD 97.55) meters and it was 243.65 (SD 86.96) meters following the EECP therapy; p=0.18. In EECP group, the 6MWT walk distance before therapy was 256.88 (SD 85.56) meters and after EECP therapy the walk distance was 449.46 (SD 92.08) meters; p<0.01. Conclusion: EECP therapy is effective to improve functional capacity in patients with CHF.Key words: chronic heart failure, six-minute walk test, enhanced external counterpulsation (EECP) therapy

EFFECTS OF ORAL ALFACALCIDOL ON MATURATION OF DENDRITIC CELLS IN GRAVES' DISEASE PATIENTS: A DOUBLE-BLINDED RANDOMIZED CLINICAL TRIAL

Maturity level of dendritic cells (DC) plays a pivotal role in initiating and regulating autoimmunity. In graves' disease (GD), DCs have more active immune responses than those in healthy subjects. Our previous study demonstrated immunoregulatory effects of in vitro 1,25-D3 on maturation of DC in GD patients. This study aims to evaluate the effect of oral 1α-D3 on DC maturation in GD patients. Methods: Twenty five GD patients with thyrotoxicosis were divided into two groups: 12 GD patients receiving oral 1α-D3 and 13 GD patients receiving placebo, in addition to treatment of propylthiouracil. Comparison of DC maturation were performed before and after the oral 1α-D3. DC maturation was assessed based on the expression of DC markers (HLA-DR, CD80, CD40, CD83, CD14 and CD206) and the ratio of cytokines interleukin-12/IL-10.Results: After 8 weeks, 8 out of 12 GD patients in treatment group and 6 out of 13 GD patients in placebo group still had high fT4 level. The expression of CD80 decreased (p=0.48) and CD206 increased (p=0.47) insignificantly among treatment group. The IL-12/IL-10 ratio decreased along with the improvement of fT4 level in both groups. No difference of the IL-12/IL10 ratio between treatment and placebo group. Conclusion: The effects of oral 1α-D3 on DC maturation of GD patients have not been clearly demonstrated in this study yet. Â

Effect of Metformin on Handgrip Strength, Gait Speed, Myostatin Serum Level, and Health-related Quality of Life: A Double Blind Randomized Controlled Trial among Non-diabetic Pre-frail Elderly Patients

Background: sarcopenia contributes to the development of frailty syndrome. Frailty syndrome is potentially improved by modifying insulin resistance, inflammation, and myostatin level. This study is aimed to investigate the effect of metformin on handgrip strength, gait speed, myostatin serum level, and health-related quality of life (HR-QoL) among non-diabetic pre-frail elderly patients. Methods: a double blind randomized controlled trial study was conducted on non-diabetic elderly outpatients aged ≥ 60 years with pre-frail status based on phenotype and/ or index criteria (Cardiovascular Health Study and/ or Frailty Index 40 items) consecutively recruited from March 2015 to June 2016 at Cipto Mangunkusumo Hospital. One-hundred-twenty subjects who met the research criteria were randomized and equally assigned into 3 x 500 mg metformin or placebo group. The study outcomes were measured at baseline and after 16 weeks of intervention. Results: out of 120 subjects, 43 subjects in metformin group and 48 subjects in placebo group who completed the intervention. There was a significant improvement on the mean gait speed of metformin group by 0.39 (0.77) second or 0.13 (0.24) meter/second that remained significant after adjusting for important prognostic factors (p = 0.024). There was no significant difference on handgrip strength, myostatin serum level, and HR-QoL between both groups. Conclusion: 3 x 500 mg metformin for 16 weeks was statistically significant and clinically important in improving usual gait speed as one of the HR-QoL dimensions, but did not significantly improve the EQ-5D index score, handgrip strength, nor myostatin serum level

EFFECTS OF IN VITRO 1,25 DIHYDROXYVITAMIN D ON MATURATION OF DENDRITIC CELLS IN GRAVES' DISEASE PATIENTS

Objective: The autoimmune reaction in Graves' disease (GD) is induced by self-antigen, which is presented by dendritic cells (DCs). DCs in GD havemore active immune responses than those in healthy subjects. The ability of DC as antigen-presenting cell is determined by its maturity level. InGD, vitamin D level is inversely proportional to antibody titer and proportionally associated with remission status. Studies on healthy subjects and autoimmune patients (systemic lupus erythematosus (SLE), multiple sclerosis (MS), and Crohn's disease) have demonstrated immunoregulatoryeffects of vitamin D, mainly through inhibition of DC maturation, which may decrease the DC's immunogenic profile. This study aims to identify theeffect of 1,25-D3 in vitro on DC maturation in patients with GD.Methods: This is an experimental study, which was conducted in 12 GD patients with thyrotoxicosis. Monocyte-derived DC of GD patients wascultured, with or without 1,25-D3 in vitro at monocytic phase. The DC maturation was then stimulated by lipopolysaccharide (LPS) and evaluatedbased on the expression of DC markers (human leukocyte antigen-D-related [HLA-DR], CD80, CD40, CD83, CD14, and CD206) and the ratio of cytokineinterleukin-12 (IL-12)/IL-10 levels in the supernatants.Results: Following the LPS stimulation, DC with 1,25-D3 showed lower expressions of HLA-DR, CD80, CD40, and CD83, and higher expressions ofCD14 and CD206 compared to DC without 1,25-D3. DC with 1,25-D3 had lower ratio of IL-12/IL-10 levels than those without 1,25-D3.Conclusion: In vitro 1,25-D3 supplementation inhibits DC maturation in patients with GD.Keywords: Vitamin D, Graves' disease, Dendritic cells

The Role of Cytotoxic T-lymphocyte-associated Protein 4 (CTLA-4) Gene, Thyroid Stimulating Hormone Receptor (TSHR) Gene and Regulatory T-cells as Risk Factors for Relapse in Patients with Graves Disease

Background: graves’ disease (GD) is the most common condition of thyrotoxicosis. The management of GD is initiated with the administration of antithyroid drugs; however, it requires a long time to achieve remission. In reality more than 50% of patients who had remission may be at risk for relapse after the drug is stopped. This study aimed to evaluate the role of clinical factors such as smoking habit, degree of ophtalmopathy, degree of thyroid enlargement; genetic factors such as CTLA-4 gene on nucleotide 49 at codon 17 of exon 1, CTLA-4 gene of promotor -318, TSHR gene polymorphism rs2268458 of intron 1; and immunological factors such as regulatory T cells (Treg) and thyroid receptor antibody (TRAb); that affecting the relapse of patients with Graves’ disease in Indonesia. Methods: this was a case-control study, that compared 72 subjects who had relapse and 72 subjects without relapse at 12 months after cessation of antithyroid treatment, who met the inclusion criteria. Genetic polymorphism examination was performed using PCR-RFLP. The number of regulatory T cells was counted using flow cytometry analysis and ELISA was used to measure TRAb. The logistic regression was used since the dependent variables were categorical variables. Results: the analysis of this study demonstrated that there was a correlation between relapse of disease and family factors (p=0.008), age at diagnosis (p=0.021), 2nd degree of Graves’ ophthalmopathy (p=0.001), enlarged thyroid gland, which exceeded the lateral edge of the sternocleidomastoid muscles (p=0.040), duration of remission period (p=0.029), GG genotype of CTLA-4 gene on the nucleotide 49 at codon 17 of exon 1 (p=0.016), CC genotype of TSHR gene on the rs2268458 of intron 1 (p=0.003), the number of regulatory T cells (p=0.001) and TRAb levels (p=0.002). Conclusion: genetic polymorphisms of CTLA-4 gene on the nucleotide 49 at codon 17 of exon 1, TSHR gene SNP rs2268458 of intron 1, number of regulatory T cells and TRAb levels play a role as risk factors for relapse in patients with Graves’ disease

Nilai Rerata Vascular Pedicle Width, Vascular Pedicle-Cardiac Ratio Vascular Pedicle-Thoracic Ratio Orang Dewasa Normal Indonesia Studi Di RS Dr. Cipto Mangunkusomo

Vascular pedicle width (VPW) adalah jarak tepi luar vena kava superior ke tepi luar arteri subklavia kiri. Pemeriksaan VPW di foto toraks bersifat non-invasif, cepat dan mudah untuk memprediksi hipervolemia.Penelitian ini bertujuan untuk mengetahui rerata nilai VPW orang dewasa normal Indonesia. VPW diukurdengan dua metode: pertama pengukuran VPW tunggal yang akurasinya terbatas di foto toraks digital karenarelatif tidak dipengaruhi faktor magnifikasi. Metode kedua untuk foto toraks nondigital yaitu pengukuranrasio:vascular pedicle-cardiac ratio (VPCR) dan vascular pedicle-thoracic ratio (VPTR). Pengukuran serupadilakukan terhadap&nbsp; topogram CT scan toraks AP terlentang dan CT scan toraks lalu dibandingkan akurasipengukuran di topogram dengan CT scan&nbsp; toraks sebagai standar baku. Sampel terdiri atas 104 foto toraksPA subyek normal dan 103 CT scan&nbsp; toraks subyek terpilih. Pada pemeriksaan toraks PA didapatkan rerata VPW 48,0&plusmn;5,5mm, rerata VPCR 40,3&plusmn;4,6%, dan rerata VPTR 17,2&plusmn;1,7%. Pada pemeriksaan topogram CTscan didapatkan rerata VPW 50,3&plusmn;6,2mm, rerata VPTR 45&plusmn;5,1%, dan rerata VPTR 19,8&plusmn;2,5%. Rerata VPWpada CT scan toraks 50,4&plusmn;6,1mm. Pengukuran di foto toraks AP 10% lebih besar dibandingkan pada fototoraks PA dan pengukuranVPW di foto toraks terbukti memiliki akurasi&nbsp; tinggi. Kata kunci: fototoraks, vascular pedicle width, vascular pedicle-cardiac ratio, vascular pedicle-thoracic ratio, hipervolemia. &nbsp; The Mean Value of Vascular Pedicle Width, Vascular Pedicle-Cardiac Ratio,Vascular Pedicle-Thoracic Ratio of Normal Indonesian Adult Study In dr. Cipto Mangunkusomo Hospita

The Role of Serum Expression Levels of Microrna-21 on Bone Mineral Density in Hypostrogenic Postmenopausal Women with Osteoporosis: Study on Level of RANKL, OPG, TGFβ-1, Sclerostin, RANKL/OPG Ratio, and Physical Activity

Background: MiR-21 is known to play a role in osteoclast proliferation and differentiation, but the role of serum miR-21 expression in osteoporosis remains unclear. Previous research found that serum miR-21 expression was positively correlated with bone mineral density in postmenopausal osteoporosis patients, but other factors involved in postmenopausal osteoporosis still unknown. This study aimed to determine the role of serum miR-21 expression, concentration of RANKL, OPG, TGF-β1, sclerostin and serum calcium, RANKL/OPG ratio, and physical activity on bone mineral density of spine in hypoestrogenic postmenopausal women with osteoporosis (PMOP) compared with no osteoporosis (PMNOP), with point of interest on the expression of serum miR-21. Methods: this study was conducted by comparative cross-sectional design. The subjects were divided into 2 groups of PMOP and PMNOP. We used an absolute quantification real-time PCR method to determine serum miR-21 expressions level. Results: Median of serum miR-21 expression at the PMOP group was significantly higher compared to PMNOP group (p = 0.001). Serum miR-21 expression, RANKL, RANKL/OPG ratio, and physical activity were significantly correlated with BMD values in the PMOP group. Moderate physical activity was significantly negatively correlated with serum miR-21 expression. We also obtained a linear regression equation BMD = 1.373-0.085*Ln.miR-21-0.176*Log10.RANKL (R2 = 52.5%). Conclusion: serum miR-21 expression in PMOP was higher compared with PMNOP. Serum miR-21 expression proved to have a negative effect on spinal BMD values in hypoestrogenic postmenopausal women with osteoporosis of 8.5%. Obtained equation of BMD = 1.373-0.085*Ln.miR-21-0.176*Log10.RANKL can explain the value of spinal BMD by 52.5%