The safety of modified digital subtraction angiography in RSPAD Gatot Soebroto: a comprehensive outlook

INTRODUCTION. There are no recent estimates of the complication rate associated with Intra Arterial Heparin Flushing (IAHF). The purpose of this study was to estimate the rate of complication occurring during and after Intra Arterial Heparin Flushing.

METHOD. This report is a descriptive study based on analysis of interventional radiology database. The study involved patients who underwent IAHF procedure started from January 2018 until December 2018 in Rumah Sakit Pusat Angkatan Darat Gatot Soebroto (Indonesian Army Central Hospital). Subjects were assessed for their age, sex, medical history, diagnosis, intra-procedural complication, and post-procedural complication.

RESULT. All IAHF procedures were performed via transfemoral catheterisation and using a vascular closure device to help achieve homeostasis. Our population included 1223 (70,57%) male and 510 (29,43%) Female, with age ranging from 21 to 80 years old. The majority of the subject was in 51-60 years old age group (35,31%). All IAHF were technically successful. No intraprocedural complication was noted, there was no occurrence of iatrogenic vessel injury (dissection) and no neurological deficit secondary to IAHF procedures. There was some local complication after IAHF procedure such as hematoma 44 persons (2,54%), oedema around the puncture site six patients (0,35%), and bleeding at the puncture site three patients (0,17%). Beside local complication, there were several systemic complications such as allergy in 10 persons (0,58%). No neurological complication was reported after IAHF.

CONCLUSION. We concluded that IAHF has a relatively low rate of acute complication. Most complications were related to local hemostasis control, and no severe sequelae were found.

Factors related to the use of internet in Bali by women as a source of information about pregnancy, childbirth, and baby care: a cross-sectional study

Purpose: This study aims to identify the relationship between sociodemographic and obstetric factors with the use of the internet by women as a source of information about pregnancy, childbirth, and baby care.

Method: This cross-sectional study involved 185 women who had babies aged 0-3 months. Data were collected in August and September 2018. Data were collected by interviews using questionnaires. Data analysis was conducted by chi-square and logistic regression

Results: The age factor (p = 0.255), education (p = 0.071), occupation (p = 0.100), income (p = 0.077) and parity (p = 0.380) were not related to the use of the internet. The factor of service provider is significantly related to internet usage (p = 0.031).

Conclusion: The use of the internet by women in Bali to search information about pregnancy, childbirth, and baby care is not related to most sociodemographic and obstetric characteristics. The results of this study could be taken into consideration by health practitioners to create innovative programs in the field of maternal and child health services.

Transarterial Chemoembolization in Hepatocellular Carcinoma: A Clinical Efficacy Study of Ganoderma Lucidum Extract Polysaccharide Peptide β-Glucan

Background: Hepatocellular carcinoma (HCC) is a primary liver malignancy with high prevalence rate, associated primarily with the Hepatitis B Virus. HCC is the third leading cause of death worldwide. The prevalence in Indonesia is estimated at 100 per100,000 inhabitants. Treatment is generally ineffective as patients are already at advanced stages when diagnosed. Trans-arterial Chemoembolization (TACE) is a promising treatment, and β-Glucan combined therapy is expected to treat HCC more efficiently. This study evaluated the treatment response of TACE in HCC combined with β-Glucan orally.

Methods: A randomized clinical trial was conducted on 63 patients with HCC. The subjects of the study were randomly assigned into two groups: 32 administered TACE plus β-Glucan, and 31 with TACE plus placebo.

Results: In the β-Glucan group, there were four patients (12.50%) with complete response, 16 (50%) partial response, 3 (9.38%) no response, and 9 (28.12%) in deteriorated response. In the placebo group, there were 0 complete response, 11(35.48%) partial, 2(6.45%) no response, and 18 (58.07%) deteriorated response. The survival rate of the β-Glucan group was longer (median 39 weeks) than the placebo group (median 26 weeks). CD4, CD8 and IL-2 post-TACE increased significantly (p<0.05). The placebo group had 4.143 times, significantly higher hazard risk (p<0.05).

Conclusion: HCC therapy with a combination of TACE and β-Glucan is beneficial to increase the therapeutic response, immunity and survival rate.

A Randomised Controlled Trial: The effect of oral astaxanthin as an anti-inflammatory agent on serum level of e-selectin in acne vulgaris

Background: E-selectin plays a pivotal role in the inflammatory response of acne. Astaxanthin (AST), an supplement claimed having anti-inflammatory and antioxidant properties, has potential in inflammatory skin therapy. This study aims to determine the effect of oral AST as an anti-inflammatory agent on the serum level of e-selectin in acne vulgaris. 

Methods: This is a double-blind, randomized controlled trial study with a pretest and posttest control group design. The participants were 34 acne vulgaris patients with inflammatory lesions (papulopustular acne). The participants are randomly assigned to the treatment or control group to receive oral tablet of 4 mg of AST or placebo in addition to standard acne therapy of tretinoin cream 0.025% and clindamycin cream 1.2%. Each group was measured for the serum level of E-selectin before therapy (pretest) and after one month of therapy (posttest). 

Results: The pretest and posttest level of the mean serum e-selectin in the treatment  group were 50.21 ± 21.12 ng/ml and 50.04 ± 22.99 ng/ml, respectively. There is no significant difference between the pretest and posttest of the mean e-selectin level in the treatment group (p=0.943). While, the pretest and posttest of mean serum e-selectin level in control group were 57.84 ± 20.71 ng/ml and 55.87 ± 15.98 ng/ml, respectively. There is no significant difference between the pretest and posttest of the mean e-selectin level in the control group (p=0.453). There was a decrease in the mean serum e-selectin level of the treatment and control groups one month after therapy. However, the decrease of the mean e-selectin level between treatment and control group is not significantly different (p=0.547).

Conclusion: The addition of oral AST to standard acne therapy shows no significant difference in reducing the serum e-selectin level compared to placebo.

Case report: a 33-year-old man with recurrent ureteropelvic junction obstruction

Introduction: Ureteropelvic Junction Obstruction (UPJO) is the obstruction of upper urinary tract, present in fetal life until adulthood. Congenital UPJO mostly results from an intrinsic process with dilatation of renal collecting system. Acquired UPJO in adulthood may present without dilatation of renal collecting system, correlated with urolithiasis, infection, postoperative peripyelo-inflammatory fibrotic complication, and urothelial malignancy. In the past, Pyeloplasty, classic dismembered (Anderson-Hynes) or laparoscopic, is the gold standard treatment. In this study we would like to report and discuss comprehensive etiologies, diagnostic, and its treatment based from real case.

Case Presentation: We report case: a 33-year-old Indonesian man with left flank colic pain (VAS:8/10), nausea, and hematuria that did not disappear with medication. He had stone history in right proximal ureter with hydronephrosis and hydroureter, Ureterorenoscopy had been performed two years ago. Other vital signs and hemodynamics were stable. Abdominal USG demonstrated bilateral hydronephrosis and hydroureter. Abdominal X-Ray showed right ureter stone. Right-Left Ureterorenoscopy + Double-J-Stent were performed. The diagnosis was Bilateral Nephrolithiasis, Stenosis, and Proximal Ureter Obstruction leading to Recurrent UPJO. Three months later there was still pain, the patient was undergone Cystoscopy + URS + Laser Endopyelotomy + DJ-Stent Replacement (from 6 to 7 Fr). One month later, DJ-stents were removed but the stenotic ureter remained so Laparoscopic End-to-End Proximal Ureter Anastomosis Resection and DJ-stent Insertion were finally performed. Patient’s complaints were slightly reduced.

Conclusion: The Recurrent UPJO cause inadequate urinary flow leading to renal impairment. Clinical signs, symptoms, etiologies, and diagnostic imaging have significant role in determining the diagnosis. Early surgical intervention is the definitive treatment to reduce renal damage and its complications. Further researches to establish the causes, clinical manifestations, diagnostic imagings, and alternative treatments of UPJO are highly expected.

Surgery in foreign body ingestion and aspiration: descriptive study

Background: Foreign bodies in upper digestive tract, as well as respiratory tract, are common cases in daily life. This incident can occur in all age groups, ranging from children to elderly. Endoscopy and bronchoscopy are the first treatment option, nevertheless, case with complications which endoscopy or bronchoscopy cannot be done, it requires another extraction procedure specifically surgery.

Method: We conducted a retrospective review of patients who came to consult to Thoracic Cardiovascular Surgery Department by ENT Department. The data obtained are from 2009-2019.

Result: Out of 290 patients recorded, experiencing foreign body impaction in both digestive and respiratory tract for the last 10 years, the highest number was digestive tract with 243 cases (83.8%) and 47 respiratory tract cases (16.2%). From 17 patients who underwent surgery, 70.6% men and 29.4% women. The age group of children and adults had the same number as seven patients (41.2%) and elderly with three patients (17.6%). The highest number of surgical procedure was thoracotomy with 10 patients (58.8%) while cervical esophagotomy with seven patients (41.2%).

Conclusion: The failure of the extraction procedure using endoscopy or bronchoscopy in the case of a foreign body leads to surgery as a definitive therapy for patients. The age group of children and adults have same number. Cases of impaction in the esophagus are the most common. The most common surgical procedure performed is thoracotomy. In this study the success rate of extraction by surgery reached 100% without additional morbidity and mortality.

Parent's motivations on sports participation of their children with Down’s syndrome in Russia

Background: Regular physical exercises can improve physical and mental health and especially important for individuals with extensive disorders, such as Down’s syndrome. For the success of rehabilitation, it is necessary to involve the parents of children with Down’s syndrome in the process. By understanding the parents' motivation, a successful training program will be possible.

Aim: This study is aimed to determine the importance degree of various parents’ motivations in sports participation of their children with Down’s syndrome.

Method: A survey was conducted in 137 families from 22 regions of Russia in November 2016. The survey included 23 motivational statements and parents were asked to rate the importance of each statement on a scale of 1 to 10. The results were divided into 5 groups based on the importance of the motivational statements: “absolutely important”, “important”, “difficult to say”, “not important”, and “absolutely not important”. Statistical analysis was done using average values method.

Result: Parents considered the following reasons to let their children participate in sports as “absolutely important”: to implement healthy and active lifestyle; to develop interaction skills in a group, independence, and dexterity; to improve the skills of large-scale body movements and coordination of movements; and to encourage socialization. None of the motivational statements were considered as “absolutely not important”.

Conclusion: This study found that parents considered the majority of the motivational statements as important. Considering the parents’ motives will encourage the sports participation of children with Down’s syndrome.

Efficacy of revision urethroplasty in the treatment of recurrent urethral strictures at a tertiary hospital (Kenyatta National Hospital–KNH), in Nairobi Kenya: 2015-2018

Background: Urethral strictures cause malfunction of the urethra. Urethroplasty is a cost-effective treatment option. Its success rate is greater than 90% where excision and primary anastomosis(EPA)is performed and 80-85% following substitution urethroplasty. Definitive treatment for recurrent urethral strictures after urethroplasty is not defined. Repeat urethroplasty is a viable option with unknown efficacy.

Method: Retrospective analysis of patients who underwent revision urethroplasty for unsuccessful urethroplasty at KNH from 2015 to 2018 was performed. Patients’ age, demographic data, stricture length, location, aetiology, comorbidities and type of urethroplasty was evaluated from records with complete data. Male patients aged 13 to 80years were evaluated. Comparison of urethroplasty outcome between two patient cohorts was made: Fresh urethroplasty patients versus failed urethroplasty who underwent revision so as to determine efficacy of the later. Principal outcome measure was urethral patency, while Subsidiary outcome measures were associated complications. Outcomes were compared using statistical package SPSS version 23.0.

Result: 235 patients who met inclusion criteria underwent urethroplasty, 71.5% (n=168) had a successful outcome, while28.5% (n=67) failed and were subjected to revision urethroplasty. Another 58% were successful upon revision but experienced significant morbidity. Majority of urethral strictures were bulbomembranous. Trauma was the leading cause of urethral strictures followed by idiopathic strictures. EPA was the commonest surgery while Tissue transfer featured prominently in revision urethroplasty. A significant correlation was evident between stricture length, prior surgery, and procedure choice and urethroplasty outcome.

Conclusion: Revision urethroplasty is feasible after failed urethroplasty but less efficacious. Stricture length, number of prior surgeries and procedure choice affected outcome.EPA and Tissue Transfer techniques are essential surgical armamentarium in revision setting.

The association between Body Mass Index (BMI) and Activity of Daily Living (ADL) in the population-based elderly at Buleleng and Tabanan regencies, Bali, Indonesia

Background: High Body Mass Index (BMI) is known associated with mortality and morbidity among the elderly. However, other studies also show the opposite result in high BMI as protective against Activity Daily Living (ADL). Accurate quantification of the role of BMI in the incidence of disability in ADL is desirable in the face of the increasing prevalence of individuals with overweight and obesity and prolonged life span in the population. This study aims to investigate the association between Body Mass Index and Activity of Daily Living in population-based elderly.

Method: A cross-sectional analytic study was conducted in the urban and rural area of Bali Province, particularly in Buleleng and Tabanan regencies. BMI and Barthel Index score were recorded among respondents. Data were analyzed using SPSS version 17 for Windows and aP-value less than 0.05 was considered statistically significant.

Results: A total of 167 respondents, 100 and 67 from the urban and rural area of Bali Province respectively, was predominant by 93 (55.7%) females and followed by 74 (44.3%) males. Spearman test found a significant weak positive correlation between weight and Activity of Daily Living (r= 0.168; p<0.05). In addition, a significant weak positive correlation was also found between BMI and ADL (r= 0.158; p<0.05).

Conclusion: Our study showed increased values of BMI is a protective effect on ADL.

Extracutaneous manifestations of adult psoriatic patients attending Dermatology Teaching Center in Slemani, Iraq

Background: Psoriasis is debilitating, albeit remained underdiagnosed and undertreated, disease typically known for its cutaneous manifestations. Recent evidence pointed towards multisystemic comorbidities that we aim to elucidate further in this study.

Methods: A cross-sectional descriptive study was conducted in Dermatology Teaching Center in Slemani city from April to September 2019. One hundred dermatologist-confirmed psoriasis patients aged 18 years old and above were subjected to structured interview, physical examination and blood investigations to determine the presence of psoriasis extracutaneous manifestations.

Results: There were a total of 100 patients with a mean age of 47.2 ± 15. Majority of the patients comprised of middle age group (42.0%), female (67.0%), with 10-20 years disease duration (36.0%). Only a few of them are currently smoking (16.0%) and consume alcohol (6.0%). Patients with extracutaneous involvement primarily had multiple (37.0%) as opposed to singular (24.0%). Metabolic syndrome was the most prevalent (30.0%) extracutaneous manifestation in this study.

Conclusions: Extracutaneous manifestations of psoriasis were ubiquitous and often coexisted. Emerging progressive comorbidities prompted greater recognition and integrated multidisciplinary approach.

A rare case report of symptomatic Bochdalek hernia in an adult

Background: Bochdalek hernia is the most common type of congenital diaphragmatic hernia and is commonly diagnosed prenatally or in the immediate postnatal period. Adult cases are extremely rare and mostly asymptomatic. Symptomatic cases are even more exceptional with a wide variety of gastrointestinal or respiratory symptoms, which makes it difficult to diagnose.

Case: A 58-year-old female had experienced nausea, vomiting, atypical chest pain, and productive cough for two weeks before admission. She was diagnosed and treated for pneumonia and dyspepsia before being referred to our hospital. Further investigation using computerized tomography (CT) scan of the thorax showed a defect at the posterior aspect of left hemidiaphragm with a protrusion of the stomach and its omentum to the left hemithorax.

Conclusion: Symptomatic adult case of Bochdalek hernia is rare and difficult to diagnose. The CT scan can be used to confirm the diagnosis.

Reincarnation-Balinese local wisdom as supportive therapy in the elderly with depression: a case study

Background: Reincarnation (reborn after death), is a Hindu belief in Bali where it is proven by 'ngaluwang' ritual. In this ritual, every person who has a newborn baby will ask the help of  'orang pintar' to find out whose atman (spirit) has manifested in the baby. By returning to the world, there is no more sadness or feeling of loss in the elderly who suffers from the death of a spouse or other family member. This case study aims to know the reincarnation as supportive therapy for the elderly with depression.

Case Description: A qualitative case study with in-depth interviews has been conducted by 2 (two) elderly people with a history of depressive disorders from the community. The first case came from a retired woman 72 years old and other case was derived from a female-farmer 80 years old. Face-to-face interview assessment has been evaluated to the cases and narrative synthesis about the findings has been written by qualitative approach.  From the case study, the elderly experienced improvement in depressive symptoms, where feelings of loss, sadness, loneliness, guilt and hopelessness disappeared after the return of dead family members’ spirits into the world. The reincarnation of a loved one makes sadness and loss cease to exist, so symptoms of depression are healed.

Obstructive jaundice as manifestation of relapsing Hodgkin’s Lymphoma: the success of chemotherapy (case report)

Background: Hodgkin's lymphoma is a hematologic malignancy of lymphocyte cells. Intrahepatic or extrahepatic disorders can cause jaundice associated with lymphoma. An extrahepatic obstructive jaundice due to lymphoma is still rarely reported, the incidence is only 1.3% out of 370 patients.

Case Description: A male patient, 44 years old, admitted to the hospital because his eyes and all over his body became yellowish. He also felt itchy on his skin, and his stool color was pale. The patient was diagnosed with a post-chemotherapy relapse of Hodgkin's lymphoma twice with different regimens. The first chemotherapy was with the CHOP regimen. We evaluated the patient nine months after the chemotherapy with abdominal CT-scan, and we found paraaortic lymphadenopathy with infiltration to the spleen and gaster. Then, the patient was re-chemotherapy using Mesna's ICE regimen. Seven months after the second chemotherapy, the patient was re-admitted to the hospital with jaundice throughout his body. His laboratory results were 25.3 mg/dl for total bilirubin, 21.5 for direct bilirubin, 199 U/L for AST, 213 U/L for ALT, 469 mg/dl for ALP, and 6,400/mm3 for leukocytes. We found gall bladder hydrops and Intra-Hepatic Bile Duct Dilatation (IHBD) during an abdominal ultrasound examination. The results of the PET-scan showed multiple metastases to the peritoneal/omentum and diffuse lymphomatous infiltration in the gastric. After that, the patient was given the third chemotherapy with gemcitabine and vinorelbine regimens. His laboratory results in three weeks post-chemotherapy were, 6.4 mg/dl for total bilirubin, 5.87 mg/dl for direct bilirubin, 82 U/L for AST, and 36 U/L for ALT. We also found significant clinical improvement after the third chemotherapy.

Conclusion: The diagnosis is difficult to establish because many other things can also cause obstructive jaundice. Chemotherapy is one therapeutic choice in the management of obstructive jaundice related to Hodgkin's lymphoma.