abstract book - universitas udayana

1

A B S T R A C T B O O K

1

ContentsTuesday, 23 August 2016 ............................................................................................... 25Wednesday, 24 August 2016 .......................................................................................... 35Thursday, 25 August 2016 .............................................................................. 43KEYNOTE LECTURE 1.1............................................................................................... 47KEYNOTE LECTURE 1.2............................................................................................... 49KEYNOTE LECTURE 2.1............................................................................................... 50KEYNOTE LECTURE 2.2............................................................................................... 52KEYNOTE LECTURE 3.1............................................................................................... 53KEYNOTE LECTURE 3.2............................................................................................... 54SS 1.1 CARDIOVASCULAR (1) ..................................................................................... 55SS 1.2 CARDIOVASCULAR (1) ..................................................................................... 56SS 1.3 CARDIOVASCULAR (1) ..................................................................................... 57SS 2.1 ENDOCRINE (1) ................................................................................................. 58SS 2.2 ENDOCRINE (1) ................................................................................................. 59SS 2.3 ENDOCRINE (1) ................................................................................................. 60SS 3.1 HEMATOLOGY & ONCOLOGY (1) .................................................................... 61SS 3.2 HEMATOLOGY & ONCOLOGY (1) .................................................................... 62SS 3.3 HEMATOLOGY & ONCOLOGY (1) .................................................................... 63SS 4.1 GERIATRIC (1) ................................................................................................... 64SS 4.1 GERIATRIC (1) ................................................................................................... 65SS 4.2 GERIATRIC (1) ................................................................................................... 66SS 5.1 HEPATOLOGY (1) .............................................................................................. 67SS 5.2 HEPATOLOGY (1) .............................................................................................. 68SS 5.3 HEPATOLOGY (1) .............................................................................................. 69SS 7.1 Tropical and Infectious Diseases (1) - TB Diagnosis In HIV Patients: Role of Biomarker & Other Novel Tools ...................................................................................... 76SS 7.2 Tropical and Infectious Diseases (1)................................................................... 77SS 7.3 Tropical and Infectious Diseases (1)................................................................... 78SS 8.1 HYPERTENSION & KIDNEY (1) ........................................................................ 79SS 8.2 HYPERTENSION & KIDNEY (1) ........................................................................ 80SS 8.3 HYPERTENSION & KIDNEY (1) ........................................................................ 81SS 9.1 ALLERGY & IMMUNOLOGY .............................................................................. 83

2

SS 9.2 ALLERGY & IMMUNOLOGY .............................................................................. 84INDUSTRY SYMPOSIUM 1.1 (NOVO NORDISK) ......................................................... 85INDUSTRY SYMPOSIUM 1.2 (NOVO NORDISK) ......................................................... 86INDUSTRY SYMPOSIUM 2.1 (MUNDIPHARMA) .......................................................... 87INDUSTRY SYMPOSIUM 2.2 (MUNDIPHARMA) .......................................................... 88INDUSTRY SYMPOSIUM 2.3 (MUNDIPHARMA) .......................................................... 89INDUSTRY SYMPOSIUM 3.1 (ROCHE) ........................................................................ 90INDUSTRY SYMPOSIUM 3.2 (ROCHE) ........................................................................ 91INDUSTRY SYMPOSIUM 3.3 (ROCHE) ........................................................................ 94SPONSORED SYMPO 1 (MENARINI) ........................................................................... 95SPONSORED SYMPO 2 (MENARINI) .......................................................................... 96SPONSORED SYMPO 3 (MENARINI) ........................................................................... 97SS 10.1 CARDIOVASCULAR (2) .................................................................................. 98SS 10.2 CARDIOVASCULAR (2) .................................................................................. 99SS 10.3 CARDIOVASCULAR (2) ................................................................................ 100SS 11.1 ENDOCRINE (2) ............................................................................................ 101SS 11.2 ENDOCRINE (2) ............................................................................................ 102SS 11.3 ENDOCRINE (2) ............................................................................................ 103SS 12.1 HEMATOLOGY & ONCOLOGY (2) .............................................................. 104SS 12.2 HEMATOLOGY & ONCOLOGY (2) .............................................................. 106SS 13.1 GERIATRIC (2) .............................................................................................. 107SS 13.2 GERIATRIC (2) .............................................................................................. 109SS 13.3 GERIATRIC (2) .............................................................................................. 110SS 14.1 HEPATOLOGY (2) ..........................................................................................111SS 14.2 HEPATOLOGY (2) ......................................................................................... 112SS 14.3 HEPATOLOGY (2) ......................................................................................... 114SS 15.1 RHEUMATOLOGY (2) ................................................................................... 117SS 15.2 RHEUMATOLOGY (2) ................................................................................... 118SS 15.3 RHEUMATOLOGY (2) ................................................................................... 120SS 16.1 Tropical and Infectious Diseases (2) - The Spread of Artemisinin Resistance ...................................................................................................................................... 121Erni Juwita Nelwan (Indonesia) .................................................................................... 121SS 16.2 Tropical and Infectious Diseases (2).............................................................. 122

3

SS 16.3 Tropical and Infectious Diseases (2).............................................................. 123SS 17.1 ........................................................................................................................ 124SS 17.2 ......................................................................................................................... 125SS 18.1 PULMONOLOGY (1) ...................................................................................... 126SS 18.2 PULMONOLOGY (1) ...................................................................................... 127SS 18.3 PULMONOLOGY (1) ...................................................................................... 129Wednesday, 24 August 2016 ........................................................................................ 130KEYNOTE LECTURE 4.1............................................................................................. 130KEYNOTE LECTURE 4.2............................................................................................. 131KEYNOTE LECTURE 5.1............................................................................................. 132KEYNOTE LECTURE 5.2............................................................................................. 133SS 19.1 CARDIOVASCULAR (3) ................................................................................. 134SS 19.2 CARDIOVASCULAR (3 .................................................................................. 135SS 19.3 CARDIOVASCULAR (3) ................................................................................. 137SS 20.1 ENDOCRINE (3) ............................................................................................ 138SS 20.2 ENDOCRINE (3) ............................................................................................ 139SS 20.3 ENDOCRINE (3) ............................................................................................ 140SS 21.2 HEMATOLOGY & ONCOLOGY (3) .............................................................. 142SS 21.2 HEMATOLOGY & ONCOLOGY (3) .............................................................. 143SS 22.1 GASTROENTEROLOGY (1) .......................................................................... 144SS 22.2 GASTROENTEROLOGY (1) .......................................................................... 145SS 22.3 GASTROENTEROLOGY (1) .......................................................................... 146SS 23.1 HEPATOLOGY (3) ......................................................................................... 147SS 23.2 HEPATOLOGY (3) ......................................................................................... 149SS 23.3 HEPATOLOGY (3) ......................................................................................... 150SS 24.1 RHEUMATOLOGY (3) ................................................................................... 151SS 24.2 RHEUMATOLOGY (3) ................................................................................... 152SS 24.3 RHEUMATOLOGY (3) ................................................................................... 153SS 25.1 Tropical and Infectious Diseases (3)............................................................. 154SS 25.2 Tropical and Infectious Diseases (3)............................................................. 155SS 25.3 Tropical and Infectious Diseases (3)............................................................. 156SS 26.1 New Understanding in Residual Vascular Disease ......................................... 157SS 26.2 New Understanding in Residual Vascular Disease ......................................... 158

4

SS 26.3 New Understanding in Residual Vascular Disease ......................................... 159SS 27.1 HYPERTENSION / KIDNEY (2) ...................................................................... 160SS 27.2 HYPERTENSION / KIDNEY (2) ...................................................................... 161SS 27.3 HYPERTENSION / KIDNEY (2) ...................................................................... 162INDUSTRY SYMPOSIUM 4.1 ...................................................................................... 163INDUSTRY SYMPOSIUM 4.2 ...................................................................................... 167SPONSORED SYMPO1.1............................................................................................ 168SPONSORED SYMPO1.2............................................................................................ 169SPONSORED SYMPO1.3............................................................................................ 171SS 28.1 CARDIOVASCULAR (4) ................................................................................. 172SS 28.2 CARDIOVASCULAR (4) ................................................................................. 173Medical Uversity of Sriwijaya ........................................................................................ 173SS 28.3 CARDIOVASCULAR (4) ................................................................................. 174SS 29.1 ENDOCRINE (4) ............................................................................................. 175SS 29.2 ENDOCRINE (4) ............................................................................................. 176SS 29.3 ENDOCRINE (4) ............................................................................................. 177SS 30.1 HEMATOLOGY & ONCOLOGY (4) ................................................................ 178SS 30.1 HEMATOLOGY & ONCOLOGY (4) ................................................................ 179SS 30.2 HEMATOLOGY & ONCOLOGY (4) ................................................................ 181SS 31.3 GASTROENTEROLOGY (2) .......................................................................... 182SS 31.4 GASTROENTEROLOGY (2) .......................................................................... 184SS 31.5 GASTROENTEROLOGY (2) .......................................................................... 185SS 32.1 PSYCHOSOMATIC (1) ................................................................................... 186SS 32.2 PSYCHOSOMATIC (1) ................................................................................... 189SS 32.3 PSYCHOSOMATIC (1) ................................................................................... 190SS 33.1 Tropical and Infectious Diseases (4)............................................................. 191SS 33.2 Tropical and Infectious Diseases (4)............................................................. 192SS 33.3 Tropical and Infectious Diseases (4)............................................................. 193SS 34.1 HYPERTENSION / KIDNEY (3) ...................................................................... 194SS 34.2 HYPERTENSION / KIDNEY (3) ...................................................................... 195SS 34.3 HYPERTENSION / KIDNEY (3) ...................................................................... 197KEYNOTE LECTURE 6.1............................................................................................. 198KEYNOTE LECTURE 6.2............................................................................................. 200

5

KEYNOTE LECTURE 7.1............................................................................................. 201KEYNOTE LECTURE 7.2............................................................................................. 202SS 35.1 CARDIOVASCULAR (5) ................................................................................ 203SS 35.2 CARDIOVASCULAR (5) ................................................................................ 205SS 35.3 CARDIOVASCULAR (5) ................................................................................ 206SS 36.1 ENDOCRINE (5) ............................................................................................. 207SS 36.2 ENDOCRINE (5) ............................................................................................. 208SS 36.3 ENDOCRINE (5) ............................................................................................. 209SS 37.1 HEMATOLOGY & ONCOLOGY (5) ................................................................ 211SS 37.2 HEMATOLOGY & ONCOLOGY (5) ................................................................ 212SS 37.3 HEMATOLOGY & ONCOLOGY (5) ................................................................ 214SS 38.1 PULMONOLOGY (2) ...................................................................................... 216SS 38.2 PULMONOLOGY (2) ...................................................................................... 218SS 38.3 PULMONOLOGY (2) ...................................................................................... 219SS 39.1 PSYCHOSOMATIC (2) ................................................................................... 220SS 39.3 PSYCHOSOMATIC (2) ................................................................................... 223SS 40.1 Tropical and Infectious Diseases (5).............................................................. 224SS 40.2 Tropical and Infectious Diseases (5).............................................................. 225SS 40.3 Tropical and Infectious Diseases (5).............................................................. 226KEYNOTE LECTURE 8.1............................................................................................. 227KEYNOTE LECTURE 8.2............................................................................................. 228Oral Presentation 1, Tuesday, 23 August 2016 ............................................................ 229Oral Presentation 2, Tuesday, 23 August 2016 ............................................................ 230Oral Presentation 3, Tuesday, 23 August 2016 ............................................................ 231Oral Presentation 4, Tuesday, 23 August 2016 ............................................................ 232Oral Presentation 5, Tuesday, 23 August 2016 ............................................................ 232Oral Presentation 6, Tuesday, 23 August 2016 ............................................................ 233Oral Presentation 7, Tuesday, 23 August 2016 ............................................................ 234Oral Presentation 8, Tuesday, 23 August 2016 ............................................................ 235Oral Presentation 9, Wednesday, 24 August 2016 ....................................................... 236Oral Presentation 10, Wednesday, 24 August 2016 .................................................... 237Oral Presentation 11, Wednesday, 24 August 2016 .................................................... 238Oral Presentation 12, Wednesday, 24 August 2016 .................................................... 239

6

Oral Presentation 13, Wednesday, 24 August 2016 .................................................... 240Oral Presentation 14, Wednesday, 24 August 2016 .................................................... 241Oral Presentation 15, Wednesday, 24 August 2016 .................................................... 242OP 022 ......................................................................................................................... 244OP 034 ......................................................................................................................... 245OP 049 ......................................................................................................................... 246OP 052 ......................................................................................................................... 247OP 061 ......................................................................................................................... 248OP 063 ......................................................................................................................... 249OP 065 ......................................................................................................................... 250OP 047 ......................................................................................................................... 251OP 050 ......................................................................................................................... 252OP 058 ......................................................................................................................... 253OP 029 ......................................................................................................................... 257OP 082 ......................................................................................................................... 259OP 069 ......................................................................................................................... 261OP 006 ......................................................................................................................... 262OP 084 ......................................................................................................................... 264OP 098 ......................................................................................................................... 266OP 103 ......................................................................................................................... 268OP 24 ........................................................................................................................... 270OP 046 ......................................................................................................................... 271OP 104 ......................................................................................................................... 272OP 009 ......................................................................................................................... 273OP 097 ......................................................................................................................... 274OP 075 ......................................................................................................................... 275OP 010 ......................................................................................................................... 276OP 021 ......................................................................................................................... 277OP 028 ......................................................................................................................... 278OP 053 ......................................................................................................................... 279OP 073 ......................................................................................................................... 280OP 107 ......................................................................................................................... 281OP 108 ......................................................................................................................... 282

7

OP 094 ......................................................................................................................... 283OP 001 ......................................................................................................................... 284OP 003 ......................................................................................................................... 285OP 008 ......................................................................................................................... 286OP 013 ......................................................................................................................... 287OP 015 ......................................................................................................................... 288OP 027 ......................................................................................................................... 289OP 031 ......................................................................................................................... 290OP 076 ......................................................................................................................... 291OP 093 ......................................................................................................................... 292OP 091 ......................................................................................................................... 293OP 081 ......................................................................................................................... 294OP 071 ......................................................................................................................... 295OP 077 ......................................................................................................................... 297OP 090 ......................................................................................................................... 299OP 092 ......................................................................................................................... 300OP 037 ......................................................................................................................... 301OP 041 ......................................................................................................................... 302OP 045 ......................................................................................................................... 303OP 068 ......................................................................................................................... 304OP 019 ......................................................................................................................... 305OP 014 ......................................................................................................................... 306OP 074 ......................................................................................................................... 307OP 087 ......................................................................................................................... 308OP 048 ......................................................................................................................... 309OP 059 ......................................................................................................................... 310OP 066 ......................................................................................................................... 311OP 080 ......................................................................................................................... 312OP 088 ......................................................................................................................... 313OP 101 ......................................................................................................................... 315OP 005 ......................................................................................................................... 316OP 012 ......................................................................................................................... 317OP 016 ......................................................................................................................... 323

8

OP 018 ......................................................................................................................... 324OP 044 ......................................................................................................................... 325OP 113 .......................................................................................................................... 326OP 105 ......................................................................................................................... 327OP 007 ......................................................................................................................... 329OP 017 ......................................................................................................................... 330OP 079 ......................................................................................................................... 332OP 086 ......................................................................................................................... 333OP 096 ......................................................................................................................... 334OP 102 ......................................................................................................................... 336OP 002 ......................................................................................................................... 337OP 040 ......................................................................................................................... 339OP 055 ......................................................................................................................... 340OP 078 ......................................................................................................................... 341OP 109 ......................................................................................................................... 342OP 035 ......................................................................................................................... 344OP 056 ......................................................................................................................... 348OP 060 ......................................................................................................................... 349OP 106 ......................................................................................................................... 350OP 111 .......................................................................................................................... 352OP 011 .......................................................................................................................... 354OP 030 ......................................................................................................................... 358OP 067 ......................................................................................................................... 359OP 070 ......................................................................................................................... 360OP 085 ......................................................................................................................... 362OP 020 ......................................................................................................................... 363OP 032 ......................................................................................................................... 364OP 036 ......................................................................................................................... 365OP 057 ......................................................................................................................... 366OP 083 ......................................................................................................................... 367OP 110 .......................................................................................................................... 368OP 043 ......................................................................................................................... 369OP 064 ......................................................................................................................... 370

9

OP 039 ......................................................................................................................... 371List of Poster The 33rd WCIM Bali 2016 Tuesday, 23 August 2016 ........................... 372List of Poster The 33rd WCIM Bali 2016 Wednesday, 24 August 2016 ....................... 396PO 001 ......................................................................................................................... 420PO 002 ......................................................................................................................... 421PO 003 ......................................................................................................................... 422PO 004 ......................................................................................................................... 425PO 005 ......................................................................................................................... 427PO 006 ......................................................................................................................... 428PO 007 ......................................................................................................................... 429PO 008 ......................................................................................................................... 430PO 009 ......................................................................................................................... 431PO 010 ......................................................................................................................... 432PO 011 .......................................................................................................................... 433PO 012 ......................................................................................................................... 434PO 013 ......................................................................................................................... 436PO 014 ......................................................................................................................... 437PO 15 ........................................................................................................................... 438PO 016 ......................................................................................................................... 439PO 017 ......................................................................................................................... 440PO 018 ......................................................................................................................... 442PO 019 ......................................................................................................................... 443PO 020 ......................................................................................................................... 444PO 021 ......................................................................................................................... 445PO 022 ......................................................................................................................... 446PO 023 ......................................................................................................................... 447PO 024 ......................................................................................................................... 448PO 025 ......................................................................................................................... 449PO 026 ......................................................................................................................... 450PO 027 ......................................................................................................................... 452PO 028 ......................................................................................................................... 453PO 029 ......................................................................................................................... 454PO 030 ......................................................................................................................... 456

10

PO 031 ......................................................................................................................... 457PO 032 ......................................................................................................................... 458PO 033 ......................................................................................................................... 459PO 034 ......................................................................................................................... 460PO 035 ......................................................................................................................... 461PO 036 ......................................................................................................................... 462PO 037 ......................................................................................................................... 463PO 038 ......................................................................................................................... 464PO 039 ......................................................................................................................... 465PO 040 ......................................................................................................................... 466PO 041 ......................................................................................................................... 467PO 042 ......................................................................................................................... 468PO 043 ......................................................................................................................... 469PO 044 ......................................................................................................................... 470PO 045 ......................................................................................................................... 471PO 046 ......................................................................................................................... 472PO 047 ......................................................................................................................... 473PO 048 ......................................................................................................................... 474PO 049 ......................................................................................................................... 475PO 050 ......................................................................................................................... 476PO 051 ......................................................................................................................... 477PO 052 ......................................................................................................................... 478PO 053 ......................................................................................................................... 479PO 054 ......................................................................................................................... 480PO 055 ......................................................................................................................... 481PO 056 ......................................................................................................................... 483PO 057 ......................................................................................................................... 484PO 059 ......................................................................................................................... 485PO 060 ......................................................................................................................... 486PO 061 ......................................................................................................................... 487PO 062 ......................................................................................................................... 488PO 063 ......................................................................................................................... 489PO 064 ......................................................................................................................... 490

11


12

PO 099 ......................................................................................................................... 526PO 100 ......................................................................................................................... 527PO 101 ......................................................................................................................... 528PO 102 ......................................................................................................................... 529PO 103 ......................................................................................................................... 530PO 104 ......................................................................................................................... 531PO 105 ......................................................................................................................... 534PO 106 ......................................................................................................................... 535PO 107 ......................................................................................................................... 536PO 108 ......................................................................................................................... 537PO 109 ......................................................................................................................... 538PO 110 .......................................................................................................................... 539PO 111 .......................................................................................................................... 540PO 112 .......................................................................................................................... 541PO 113 .......................................................................................................................... 542PO 114 .......................................................................................................................... 543PO 115 .......................................................................................................................... 544PO 116 .......................................................................................................................... 545PO 117 .......................................................................................................................... 546PO 118 .......................................................................................................................... 547PO 120 ......................................................................................................................... 549PO 121 ......................................................................................................................... 550PO 122 ......................................................................................................................... 551PO 123 ......................................................................................................................... 552PO 124 ......................................................................................................................... 553PO 125 ......................................................................................................................... 554PO 126 ......................................................................................................................... 556PO 127 ........................................................................................................................ 557PO 128 ......................................................................................................................... 558PO 129 ......................................................................................................................... 559PO 130 ......................................................................................................................... 560PO 131 ......................................................................................................................... 563PO 132 ......................................................................................................................... 564

13


14


15

PO 207 ......................................................................................................................... 649PO 208 ......................................................................................................................... 650PO 209 ......................................................................................................................... 651PO 210 ......................................................................................................................... 652PO 211 .......................................................................................................................... 653PO 212 ......................................................................................................................... 654PO 213 ......................................................................................................................... 655PO 214 ......................................................................................................................... 656PO 215 ......................................................................................................................... 658PO 216 ......................................................................................................................... 659PO 217 ........................................................................................................................ 660PO 218 ......................................................................................................................... 661PO 219 ......................................................................................................................... 662PO 220 ......................................................................................................................... 663PO 221 ......................................................................................................................... 664PO 222 ......................................................................................................................... 666PO 223 ......................................................................................................................... 667PO 224 ......................................................................................................................... 668PO 225 ......................................................................................................................... 669PO 226 ......................................................................................................................... 671PO 227 ......................................................................................................................... 672PO 228 ......................................................................................................................... 673PO 229 ......................................................................................................................... 674PO 230 ......................................................................................................................... 675PO 231 ......................................................................................................................... 676PO 232 ......................................................................................................................... 677PO 233 ......................................................................................................................... 678PO 234 ......................................................................................................................... 679PO 235 ......................................................................................................................... 680PO 236 ......................................................................................................................... 681PO 237 ......................................................................................................................... 683PO 238 ......................................................................................................................... 685PO 239 ......................................................................................................................... 686

16


17

PO 274 ......................................................................................................................... 722PO 275 ......................................................................................................................... 724PO 276 ......................................................................................................................... 725PO 277 ......................................................................................................................... 726PO 295 ......................................................................................................................... 744PO 297 ......................................................................................................................... 746PO 299 ......................................................................................................................... 748PO 300 ......................................................................................................................... 749PO 301 ......................................................................................................................... 750PO 302 ......................................................................................................................... 751PO 303 ......................................................................................................................... 752PO 304 ......................................................................................................................... 754PO 305 ......................................................................................................................... 755PO 306 ......................................................................................................................... 756PO 307 ......................................................................................................................... 757PO 308 ......................................................................................................................... 758PO 309 ......................................................................................................................... 759PO 310 ......................................................................................................................... 760PO 311 .......................................................................................................................... 761PO 312 ......................................................................................................................... 762PO 313 ......................................................................................................................... 763PO 314 ......................................................................................................................... 764PO 315 ......................................................................................................................... 765PO 316 ......................................................................................................................... 766PO 317 ........................................................................................................................ 767PO 318 ......................................................................................................................... 768PO 319 ......................................................................................................................... 769PO 320 ......................................................................................................................... 770PO 321 ......................................................................................................................... 771PO 322 ......................................................................................................................... 772PO 323 ......................................................................................................................... 775PO 324 ......................................................................................................................... 776PO 325 ......................................................................................................................... 777

18


19

OP 359 ......................................................................................................................... 821PO 360 ......................................................................................................................... 822PO 361 ......................................................................................................................... 823PO 362 ......................................................................................................................... 824PO 363 ......................................................................................................................... 825PO 364 ......................................................................................................................... 826PO 365 ......................................................................................................................... 827PO 366 ......................................................................................................................... 828PO 367 ......................................................................................................................... 829PO 368 ......................................................................................................................... 830PO 369 ......................................................................................................................... 831PO 370 ......................................................................................................................... 832PO 371 ......................................................................................................................... 833PO 372 ......................................................................................................................... 835PO 373 ......................................................................................................................... 836PO 374 ......................................................................................................................... 837PO 375 ......................................................................................................................... 838PO 376 ......................................................................................................................... 839PO 377 ......................................................................................................................... 840PO 378 ......................................................................................................................... 841PO 379 ......................................................................................................................... 842PO 380 ......................................................................................................................... 843PO 381 ......................................................................................................................... 844PO 382 ......................................................................................................................... 845PO 383 ......................................................................................................................... 846PO 384 ......................................................................................................................... 848PO 385 ......................................................................................................................... 850PO 386 ......................................................................................................................... 851PO 387 ......................................................................................................................... 852PO 388 ......................................................................................................................... 853PO 389 ......................................................................................................................... 854PO 390 ......................................................................................................................... 855PO 391 ......................................................................................................................... 856

20

PO 392 ......................................................................................................................... 857PO 393 ......................................................................................................................... 858PO 394 ......................................................................................................................... 859PO 395 ......................................................................................................................... 860PO 396 ......................................................................................................................... 861PO 397 ......................................................................................................................... 862PO 398 ......................................................................................................................... 863PO 399 ......................................................................................................................... 864PO 400 ......................................................................................................................... 865PO 401 ......................................................................................................................... 866PO 402 ......................................................................................................................... 867PO 403 ......................................................................................................................... 868PO 404 ......................................................................................................................... 869PO 405 ......................................................................................................................... 870PO 406 ......................................................................................................................... 871PO 407 ......................................................................................................................... 872PO 408 ......................................................................................................................... 873PO 409 ......................................................................................................................... 874PO 410 ......................................................................................................................... 875PO 411 .......................................................................................................................... 876PO 412 ......................................................................................................................... 877PO 413 ......................................................................................................................... 878PO 414 ......................................................................................................................... 879PO 415 ......................................................................................................................... 880PO 416 ......................................................................................................................... 881PO 417 ......................................................................................................................... 882PO 418 ......................................................................................................................... 883PO 419 ......................................................................................................................... 884PO 420 ......................................................................................................................... 885PO 421 ......................................................................................................................... 886PO 422 ......................................................................................................................... 887PO 423 ......................................................................................................................... 888PO 424 ......................................................................................................................... 890

21


22


23

PO 491 ......................................................................................................................... 964PO 492 ......................................................................................................................... 965PO 493 ......................................................................................................................... 966PO 494 ......................................................................................................................... 967PO 495 ......................................................................................................................... 968PO 496 ......................................................................................................................... 969PO 497 ......................................................................................................................... 970PO 498 ......................................................................................................................... 971PO 499 ......................................................................................................................... 972PO 501 ......................................................................................................................... 973PO 502 ......................................................................................................................... 974PO 503 ......................................................................................................................... 975PO 504 ......................................................................................................................... 976PO 505 ......................................................................................................................... 977PO 506 ......................................................................................................................... 978PO 507 ......................................................................................................................... 979PO 508 ......................................................................................................................... 980PO 509 ......................................................................................................................... 981PO 510 ......................................................................................................................... 982PO 511 .......................................................................................................................... 983PO 512 ......................................................................................................................... 984PO 513 ......................................................................................................................... 985PO 514 ......................................................................................................................... 986PO 515 ......................................................................................................................... 987PO 516 ......................................................................................................................... 988PO 517 ......................................................................................................................... 989PO 518 ......................................................................................................................... 990PO 519 ......................................................................................................................... 991PO 520 ......................................................................................................................... 992PO 521 ......................................................................................................................... 993PO 522 ......................................................................................................................... 994PO 523 ......................................................................................................................... 995PO 524 ......................................................................................................................... 996

24

PO 525 ......................................................................................................................... 997PO 526 ......................................................................................................................... 998PO 527 ....................................................................................................................... 1000PO 528 ....................................................................................................................... 1001PO 529 ....................................................................................................................... 1002PO 530 ....................................................................................................................... 1003PO 531 ....................................................................................................................... 1004PO 532 ....................................................................................................................... 1005

25

Tuesday, 23 August 201608.00 - 09.00 KEYNOTE LECTURE 1 (Room: NDH 4) Moderator: Idrus Alwi (Indonesia)08.00 - 08.30 Managing Patients with Multimorbidity – The Role of Internists Hans-Peter Kohler (Switzerland)08.30 - 09.00 Autoimmunity - The Epidemic in Our Time Klas Sjöberg (Sweden)

08.00 - 09.00 KEYNOTE LECTURE 2 (Room: NDH 1-2) Moderator: Siti Setiati (Indonesia)08.00 - 08.30 Chronic Kidney Disease: What The Internist Can Do Virginia Hood (USA)08.30 - 09.00 Challenge to the Aging Society - The Role of Internal Medicine Yasuo Ikeda (Japan)

08.00 - 09.00 KEYNOTE LECTURE 3 (Room: NDH 3) Moderator: Aru W. Sudoyo (Indonesia) 08.00 - 08.30 Health and Global Climate Change Nitin S. Damle (USA)08.00 - 08.30 Issues in Patient Safety: The Role of Indonesian Medical Association Herkutanto (Indonesia)

26

09.00 - 10.30 SS 1 CARDIOVASCULAR (1) Update in the Management of Heart Failure (Room: NDH 4) Moderator: Abdul Majid (Indonesia)09.00 - 09.20 Update in the Diagnosis of Heart Failure Ali Ghanie (Indonesia)09.20 - 09.40 Current Management of Heart Failure Idrus Alwi (Indonesia)09.40 - 10.00 The Role of Metabolic Agents in the Management of Heart Failure David Sim Kheng Leng (Singapore)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 2 ENDOCRINE (1) Current Update and Management of Diabetes as a Global Epidemic (Room: NDH 1-2) Moderator: Pradana Soewondo (Indonesia)09.00 - 09.20 Global Epidemic of Diabetes: Focus in Asia Sidartawan Soegondo (Indonesia)09.20 - 09.40 Transitional Care of Adolescents Diabetes Nanis Sacharina Marzuki (Indonesia)09.40 - 10.00 Epigenetic and Metabolism, Benefits for Diabetic and Obese Patient Alejandro Cárdenas Cejudo (Mexico)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 3 HEMATOLOGY & ONCOLOGY (1) Multidisciplinary Team in Colorectal Cancer: is it Better? (Room: NDH 3) Moderator: Abdul Muthalib (Indonesia)09.00 - 09.20 Colorectal Cancer: an Overview Aru W. Sudoyo (Indonesia)09.20 - 09.40 The Role of The Surgeon in a Colorectal Cancer MDT Ibrahim Basir (Indonesia)09.40 - 10.00 The Singapore Experience Robert Lim (Singapore)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

27

09.00 - 10.30 SS 4 GERIATRIC (1) Update of Comprehensive Management for the Elderly (Room: Uluwatu: 1) Moderator: Siti Setiati (Indonesia)09.00 - 09.20 Comprehensive Management for the Elderly in the Community Hadi Martono W (Indonesia)09.20 - 09.40 Comprehensive Management for the Elderly in the Hospital Czeresna Heriawan Soejono (Indonesia)09.40 - 10.00 Comprehensive Management for the Elderly in Home Care Service William Hall (USA)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 5 HEPATOLOGY (1) What’s New in The Management of Chronic Viral Hepatitis ? (Room: Uluwatu 5) Moderator: Poernomo Boedi Setiawan (Indonesia)09.00 - 09.20 Preventing Long Term Complications of Chronic Hepatitis B Laurentius A. Lesmana (Indonesia)09.20 - 09.40 Use of Direct Acting Antiviral Agents (DAA) in Chinese with Chronic Hepatitis C in 2016 and beyond. George K. Lau (Hong Kong)09.40 - 10.00 Acute on Chronic Liver Failure Shiv K. Sarin (India)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 6 RHEUMATOLOGY (1) Fighting Fractures: Recent Developments in Osteoporosis Manage ment (Room: Uluwatu 7) Moderator: Julie Li Yu (Philippines)09.00 - 09.20 Osteoporosis Problem in Autoimmune Disease Julie Li Yu (Philippines)09.20 - 09.40 What is New in Diabetoporosis? Em Yunir (Indonesia)09.40 - 10.00 Role of Vitamin D in Osteoporosis Treatment Laniyati Hamijoyo (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

28

09.00 - 10.30 SS 7 Tropical and Infectious Diseases (1) TB and HIV Infection (Room: Kintamani 1) Moderator: Nasronudin (Indonesia)09.00 - 09.20 TB Diagnosis in HIV Patients: Role of Biomarker Bachti Alisjahbana (Indonesia)09.20 - 09.40 Isozianid Preventive Therapy in HIV Patients: Will it be Useful in TB Endemic Area? Gurmeet Singh (Indonesia)09.40 - 10.00 Tackling Drug Resistant TB and TB/HIV Co-Infection Tuti Parwati Merati (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 8 HYPERTENSION & KIDNEY (1) Transplantation (Room: Kintamani 2) Moderator: Ginova Nainggolan (Indonesia)09.00 - 09.20 Indonesian Experience in Kidney Transplantation Tunggul Diapari Situmorang (Indonesia)09.20 - 09.40 Treatment of The Failing Kidney Graft Neil Sheerin (UK)09.40 - 10.00 Infection in Kidney Transplantation Lestariningsih (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 9 ALLERGY & IMMUNOLOGY Challenging Cases in Allergy/ Anaphylaxis: What Internists Should Know? (Room: Kintamani 3) Moderator: Erwanto Budi Winulyo (Indonesia)09.00 - 09.20 Management of Anaphylaxis in Drug Allergy Heru Sundaru (Indonesia)09.20 - 09.40 Asthma and Allergic Rhinitis: United Airway Disease Iris Rengganis (Indonesia)09.40 - 10.00 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

29

11.00 - 12.30 INDUSTRY SYMPOSIUM 1 (NOVO NORDISK) The Role of GLP-1 RA in The Continuum of Diabetes Care (Room: NDH 4) Moderator: Pradana Soewondo (Indonesia)11.00 - 11.20 GLP-1 RA from The Concept to Clinical Experience Sidartawan Soegondo (Indonesia)11.20 - 11.40 Results of Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes Wolfgang Schmidt (Germany)11.40 - 12.00 ----------------------------------------- 12.00 - 12.30 Discussion12.30 - 13.30 LUNCH BREAK / Poster Viewing / Exhibition

11.00 - 12.30 INDUSTRY SYMPOSIUM 2 (MUNDIPHARMA) (Room: NDH 1-2) Moderator: Nasronudin (Indonesia)11.00 - 11.20 The Role of Antiseptic & Antibiotic in Prevention of the Spreading of MDRO Khie Chen (Indonesia)11.20 - 11.40 The Role of Povidone Iodine Antisepsis Emerging and Re-Emerging Infectious Disease Maren Eggers (Germany)11.40 - 12.00 Improving Oral Mucositis Management for Patients with Cancer Jeeve Kanagalingam (Singapore)12.00 - 12.30 Discussion12.30 - 13.30 LUNCH BREAK / Poster Viewing / Exhibition

11.00 - 12.30 INDUSTRY SYMPOSIUM 3 (ROCHE) Rheumatoid Arthritis (Room: NDH 3) Moderator: Tjokorda Raka Putra (Indonesia)11.00 - 11.20 Understanding The Role of IL6 in RA: Comparison of Tocilizumab with other Biologic Ernest Choy (UK)11.20 - 11.40 Real World Evidence of Tocilizumab on Global RA Patients Handono Kalim (Indonesia)11.40 - 12.00 Maximizing the Experience of Tocilizumab on Indonesian RA Patients Harry Isbagio (Indonesia)12.00 - 12.30 Discussion12.30 - 13.30 LUNCH BREAK / Poster Viewing / Exhibition

30

11.00 - 12.30 SPONSORED SYMPO (MENARINI) The Role of Betablocker in Hypertension and Heart Failure Management (Room: Uluwatu: 1) Moderator: Sally Aman Nasution (Indonesia)11.00 - 11.20 The Role of Vasodilatory Betablockers in Hypertension Ketut Suwitra (Indonesia)11.20 - 11.40 New Insight into the Role of Betablockers for Heart Failure Idrus Alwi (Indonesia)11.40 - 12.00 Betablockers in the Elderly: The Rationale for the SENIORS Study and Its Main Result Teguh Santoso Sukamto (Indonesia)12.00 - 12.30 Discussion12.30 - 13.30 LUNCH BREAK / Poster Viewing / Exhibition

31

13.30 - 15.00 SS 10 CARDIOVASCULAR (2) Current Management of Acute Coronary Syndrome (ACS) (Room: NDH 4) Moderator: Bambang Irawan Martahusada (Indonesia)13.30 -13.50 Current Guideline of Acute Coronary Syndrome Sally Aman Nasution (Indonesia)13.50 -14.10 The Role of Antiplatelet in the Management of Acute Coronary Syndrome Hanafi B Trisnohadi (Indonesia)14.10 -14.30 The Role of Anticoagulant in the Management of Acute Coronary Syndrome Abdul Majid (Indonesia)14.30 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 11 ENDOCRINE (2) Update on Management of Diabetic Complications (Nephropathy, Neuropathy and Retinopathy) (Room: NDH 1-2) Moderator: Adri Kok (South Africa)13.30 -13.50 New Approach in the Management of Diabetic Retinopathy (The Role of Anti-VEGF) Gitalisa Andayani (Indonesia)13.50 -14.10 Renal Concerns in Diabetes: Hypertension and Nephropathy Pranawa (Indonesia)14.10 -14.30 An Approach to Diabetic Polyneuropathy Adri Kok (South Africa)14.30 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 12 HEMATOLOGY & ONCOLOGY (2) Bleeding and Coagulation Disorders (Room: NDH 3) Moderator: Made Bakta (Indonesia)13.30 -13.50 Refractory Bleeding Andi Fachruddin Benyamin (Indonesia)13.50 -14.10 Diagnosis and treatment of DIC Hideo Wada (Japan) 14.10 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

32

13.30 - 15.00 SS 13 GERIATRIC (2) Frailty Syndrome and Sarcopenia in the Elderly (Room: Uluwatu: 1) Moderator: Tuty Kuswardhani Suastika (Indoensia)13.30 -13.50 Frailty in Indonesia Elderly: Result of INA in the Fragile Study Siti Setiati (Indonesia)13.50 -14.10 Diagnostic Tools for Frailty in the Elderly Philip Poi (Malaysia)14.10 -14.30 Update on the Management of Frailty: Focus on the Role of Metformin Purwita Wijaya Laksmi (Indonesia)14.30 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 14 HEPATOLOGY (2) Management Complications of Liver Cirrhosis (Room: Uluwatu 5) Moderator: I Dewa Nyoman Wibawa (Indonesia)13.30 -13.50 Update of Hepatic Encephalopathy C. Rinaldi A. Lesmana (Indonesia)13.50 -14.10 Bacterial Infections in Liver Cirrhosis Irsan Hasan (Indonesia)14.10 -14.30 Current Treatment of Portal Hypertension Shiv K. Sarin (India)14.30 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 15 RHEUMATOLOGY (2) Management of Gout: Old Disease with a Big Problem (Room: Uluwatu 7) Moderator: Bagus Putu Putra Suryana (Indonesia)13.30 -13.50 What’s New in Pathophysiology and Diagnosis of Gout? Elsa Van Duuren (South Africa)13.50 -14.10 Gout Problem in Chronic Kidney Disease Bagus Putu Putra Suryana (Indonesia)14.10 -14.30 Problems of Daily Gout Treatment in Indonesia Faridin HP (Indonesia) 14.30 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

33

13.30 - 15.00 SS 16 Tropical and Infectious Diseases (2) Update in Malaria (Room: Kintamani 1) Moderator: Carta Agrawanto Gunawan (Indonesia)13.30 -13.50 The Spread of Artemisinin Resistance Erni Juwita Nelwan (Indonesia)13.50 -14.10 Primaquine: Should we Deployed it with or without G6PD Testing? Kevin Baird (Indonesia)14.10 -14.30 The Management of Severe Malaria in Limited Resource Area. Paulus Novian Harijanto (Indonesia)14.30 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 17 Redefining Cardiovascular Prevention in a World of Increasing Cardiovascular Risk (BOEHRINGER INGELHEIM) (Room: Kintamani 2) Moderator: Abdul Muthalib (Indonesia)13.30 -13.50 The Powerful 24 Hours of Blood Pressure Reduction with Single Pill Combination Idrus Alwi (Indonesia)13.50 -14.10 Primary Stroke Prevention in Atrial Fibrillation Optimizing The Use of NOAC in Clinical Practice Teguh Santoso Sukamto (Indonesia)14.10 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 18 PULMONOLOGY (1) Facing COPD as a Systemic Disease (Room: Kintamani 3) Moderator: Alwinsyah Abidin (Indonesia)13.30 -13.50 Current Diagnosis of COPD and Asthma and ACOS Cleopas Martin Rumende (Indonesia)13.50 -14.10 Optimalization Benefit of ICS in COPD Management Arto Yuwono Soeroto (Indonesia)14.10 -14.30 Managing Airway Problem and Systemic Inflammation of COPD Zen Ahmad (Indonesia) 14.30 -15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

34

15.30 - 17.00 ORAL PRESENTATION 1 (Room: NDH 4) Moderator: William Hall (USA)

ORAL PRESENTATION 2 (Room: NDH 1-2) Moderator: Adri Kok (South Africa)

ORAL PRESENTATION 3 (Room: NDH 3) Moderator: Hideo Wada (Japan)

ORAL PRESENTATION 4 (Room: Uluwatu 1) Moderator: Philip Poi (Malaysia)

ORAL PRESENTATION 5 (Room: Uluwatu 5) Moderator: Shiv K. Sarin (India)

ORAL PRESENTATION 6 (Room: Uluwatu 7) Moderator: Elsa Van Duuren (South Africa)

ORAL PRESENTATION 7 (Room: Kintamani 1) Moderator: Neil Sheerin (UK)

ORAL PRESENTATION 8 (Room: Kintamani 2) Moderator: Julie Li Yu (Philippines)

35

Wednesday, 24 August 201608.00 - 09.00 KEYNOTE LECTURE 4 (Room: NDH 4) Moderator: Ari Fahrial Syam (Indonesia)08.00 - 08.30 Implementation of Quality Standards in Internal Medicine L. Harry Van Hulsteijn (Netherlands)08.30 - 09.00 Leadership in the Event of Catastrophe; Experiences from Haiti and other Earthquakes Rolf A.Streuli (Switzerland)

08.00 - 09.00 KEYNOTE LECTURE 5 (Room: NDH 1-2) Moderator: Zubairi Djoerban (Indonesia)08.00 - 08.30 HIV in Asia Pasific: From Problem to Policy to Action Samsuridjal Djauzi (Indonesia) 08.30 - 09.00 I.M in Charge: Bringing out the Internist in Subspecialist Sandra V. Navarra (Philippines)

36

09.00 - 10.30 SS 19 CARDIOVASCULAR (3) Stable Coronary Artery Disease (SCAD) (Room: NDH 4) Moderator: Marulam M. Panggabean (Indonesia)09.00 - 09.20 Diagnostic Approach for Stable Coronary Artery Disease Ika Prasetya Wijaya (Indonesia)09.20 - 09.40 Update Management in Stable Coronary Artery Disease Mariano Lopez (Philippines)09.40 - 10.00 The Role of Imaging in Stable Coronary Artery Disease Sally Aman Nasution (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 20 ENDOCRINE (3) Current Understanding of Thyroid Disease and Its Management (Room: NDH 1-2) Moderator: Tjokorda Gde Dalem Pemayun (Indonesia)09.00 - 09.20 Comprehensive Approach of Thyroid Nodules Chia Su Ynn (Singapore)09.20 - 09.40 The Concept of Vitamin D Sufficiency and Insufficiency in Graves Disease Zafar Ahmed Latif (Bangladesh)09.40 - 10.00 Interventional Treatment of Benign Thyroid Nodules Dante Saksono Harbuwono (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 21 HEMATOLOGY & ONCOLOGY (3) How to Prolonged Survival in Thalassemia β Major : The Role of Internist in the Transition Period (Room: NDH 3) Moderator: Mediarty Syahrir (Indonesia)09.00 - 09.20 Epidemiology of Thalassemia in South East Asia. Suthat Fucharoen (Thailand)09.20 - 09.40 Adult with Transfusion Dependant Thalassemia: How to Provide a Safe and Adequate Blood Transfusion Djumhana Atmakusuma (Indonesia)09.40 - 10.00 Iron Toxicity as Complication of Transfusion Dependant Thalassemia & Non Transfusion Dependant Thalassemia Wanchai Wanachiwanawin (Thailand)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

37

09.00 - 10.30 SS 22 GASTROENTEROLOGY (1) Diversity of Helicobacter Pylori (Room: Uluwatu: 1) Moderator: A. Aziz Rani (Indonesia)09.00 - 09.20 Update of Diagnosis and Treatment for H Pylori Infection I Dewa Nyoman Wibawa (Indonesia)09.20 - 09.40 Risk Factor and Prevalence of H Pylori Infection in Indonesia Ari Fahrial Syam (Indonesia)09.40 - 10.00 Gastrointestinal Complication of H Pylori Infection Yoshio Yamaoka (Japan)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 23 HEPATOLOGY (3) Current Management of Hepatocellular Carcinoma (Room: Uluwatu 5) Moderator: Laurentius A. Lesmana (Indonesia)09.00 - 09.20 Screening and Diagnosis of HCC ` Rino Alvani Gani (Indonesia)09.20 - 09.40 Non- Operative Management Masathosi Kudo (Japan)09.40 - 10.00 Operative Management: Resection vs. Transplantation Stephen K.Y Chang (Singapore)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 24 RHEUMATOLOGY (3) Advanced Management of Systemic Lupus Erythematosus (Room: Uluwatu 7) Moderator: Kong Kok Ooi (Singapore)09.00 - 09.20 B Cell Role in Pathophysiology of SLE Joewono Soeroso (Indonesia)09.20 - 09.40 What’s new in the treatment of SLE Kong Kok Ooi (Singapore)09.40 - 10.00 Clinical Challenges in Lupus Sandra V. Navarra (Philippines) 10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

38

09.00 - 10.30 SS 25 Tropical and Infectious Diseases (3) Antimicrobial Resistance (Room: Kintamani 1) Moderator: Suharyo Hadisaputro (Indonesia)09.00 - 09.20 MDR, XDR, PDR Gram-Negative Bacterial Infections: Clinical Impact Suharto (Indonesia)09.20 - 09.40 Drug Development and Antibiotic Pipeline Combating Antimicrobial Resistance Po Ren Hsueh (Taiwan)09.40 - 10.00 Optimizing PK/PD to Improve Clinical Response Usman Hadi (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 26 New Understanding in Residual Vascular Disease (ABBOTT) (Room: Kintamani 2) Moderator: Ali Ghanie (Indonesia)09.00 - 09.20 What is the Relationship between Triglyceride and Atherosclerotic Vascular Disease? Idrus Alwi (Indonesia)09.20 - 09.40 Managing Bleeding Risk in Thrombotic Diseases Karmel L Tambunan (Indonesia)09.40 - 10.00 New Paradigm in Hypertension Management with Dual Approach Role of Eprosartan Teguh Santoso Sukamto (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 27 HYPERTENSION / KIDNEY (2) Treatment of CKD Patient (Room: Kintamani 3) Moderator : Zulkhair Ali (Indonesia)09.00 - 09.20 How to Retard The Progression of Renal Disease Paweena Susantitaphong (Thailand)09.20 - 09.40 Role of Complement in Progression of Renal Disease Neil Sheerin (UK)09.40 - 10.00 When to Start Renal Replacement Therapy Ketut Suwitra (Indonesia)10.00 - 10.30 Discussion10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

39

11.00 - 12.30 INDUSTRY SYMPOSIUM 4 Unmet Needs in Diabetes Treatment (NOVO NORDISK) (Room: NDH 4) Moderator: Sidartawan Soegondo (Indonesia)11.00 - 11.20 Diabetes Therapy Today and in the Future Roy Panusunan Sibarani (Indonesia)11.20 - 11.40 Improving Clinical Outcomes through New Generation Basal Insulin Wolfgang Schmidt (Germany)11.40 - 12.00 Discussion12.00 - 12.30 -------------------------12.30 - 13.30 LUNCH BREAK / Poster Viewing / Exhibition

11.00 - 12.30 Panel Discussion: Decision Making in Clinical Management of Adult Patients (Room: NDH 1-2) Panelists: Nitin S. Damle (USA) William Hall (USA) Virginia Hood (USA)11.40 - 12.00 Discussion12.30 - 13.30 LUNCH BREAK / Poster Viewing / Exhibition

11.00 - 12.30 SPONSORED SYMPO Evolving Strategies to Improve CV Outcomes in High Risk Patients: Update in Lipid Management (PFIZER) (Room: NDH 3) Moderator: Ketut Suastika (Indonesia)11.00 - 11.20 Guidance in CV Risk Management: How to Deal with International Guidelines? Teguh Santoso Sukamto (Indonesia)11.20 - 11.40 High Intensity Statins in DM & CKD: Guidelines, Evidence, Experence Soebagijo Adi Soelistijo (Indonesia)11.40 - 12.00 Separating Facts from Myths: Safety Concern of High Intensity Statins Idrus Alwi (Indonesia)12.00 - 12.30 Discussion12.30 - 13.30 LUNCH BREAK / Poster Viewing / Exhibition

40

13.30 - 15.00 SS 28 CARDIOVASCULAR (4) Update on Therapy for Atrial Fibrillation (Room: NDH 4) Moderator : Ika Prasetya Wijaya (Indonesia)13.30 - 13.50 Atrial Fibrillation for Internist Lukman Hakim Makmun (Indonesia)13.50 - 14.10 Current Guideline in Atrial Fibrillation Taufik Indrajaya (Indonesia)14.10 - 14.30 Stroke Prevention in Atrial Fibrillation Marulam M. Panggabean (Indonesia)14.30 - 15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 29 ENDOCRINE (4) What’s New in the Treatment of Obesity? (Room: NDH 1-2) Moderator: Slamet Suyono (Indonesia)13.30 - 13.50 Can GLP-1RA Be Used for Treatment of Obesity in non Diabetic Patients? Wolfgang Schmidt (Germany)13.50 - 14.10 Clinical Update on Non-Alcoholic Fatty Liver Disease Aslam Amod (South Africa)14.10 - 14.30 Gut Microbiota: New Approach for Obesity Treatment Rina Agustina (Indonesia)14.30 - 15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 30 HEMATOLOGY & ONCOLOGY (4) Palliative Care in Cancer Patients (MUNDIPHARMA) (Room: NDH 3) Moderator: A. Harryanto Reksodiputro (Indonesia)13.30 - 13.50 Pain Through the Patients Lens: Cancer Pain is as Real as the cancer itself Aru W. Sudoyo (Indonesia)13.50 - 14.10 A Perspective on Cancer Pain Management Guideline Asrul Harsal (Indonesia)14.10 - 14.30 Oxycodone : New Formulation of Time - Tested Molecule to Optimize Cancer Pain Management Christopher Gharibo (USA)14.30 - 15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

41

13.30 - 15.00 SS 31 GASTROENTEROLOGY (2) Current Management of Gastrointestinal Bleeding (Room: Uluwatu: 1) Moderator: I Dewa Nyoman Wibawa (Indonesia)13.30 - 13.50 Management of Variceal Bleeding Hernomo Ontoseno Kusumobroto (Indonesia)13.50 - 14.10 Management of Non Variceal Bleeding Marcellus Simadibrata (Indonesia)14.10 - 14.30 Diagnostic Aprroach of Obscured GI Bleeding Murdani Abdullah (Indonesia)14.30 - 15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 32 PSYCHOSOMATIC (1) Treatment for Anxiety & Depressive Disorders in Chronic Disease (Room: Uluwatu 5) Moderator: Muhammad Ali Apriansyah (Indonesia)13.30 - 13.50 Psychosomatic Depression in Chronic Kidney Disease: What’s should Internist Know? Hamzah Shatri (Indonesia)13.50 - 14.10 Comorbid Anxiety Disorders with Coronary Heart Disease: Should Immediately be Treated? E. Mudjaddid (Indonesia)14.10 - 14.30 Treatment of Depression in Diabetes Patients: An Update Agus Siswanto (Indonesia)14.30 - 15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

13.30 - 15.00 SS 33 Tropical and Infectious Diseases (4) Invasive Fungal Infection (Room: Uluwatu 7) Moderator: Suharto (Indonesia)13.30 - 13.50 Risk Factors for the Development of Invasive Fungal Infections Suhendro (Indonesia)13.50 - 14.10 Invasive Candidiasis: How Can We Appropriately Use the Available Diagnostic Tools? Erni Juwita Nelwan (Indonesia)14.10 - 14.30 Antifungal Stewardship in Invasive Candidiasis Budi Riyanto (Indonesia)14.30 - 15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

42

13.30 - 15.00 SS 34 HYPERTENSION / KIDNEY (3) Hypertension in Specific Population (Room: Kintamani 1) Moderator : Ketut Suwitra (Indonesia)13.30 - 13.50 Treatment of Hypertension in CKD Patient Paweena Susantitaphong (Thailand)13.50 - 14.10 Treatment of Hypertension in Diabetic patient Zulkhair Ali (Indonesia)14.10 - 14.30 Hypertension and Pregnancy Gde Raka Widiana (Indonesia)14.30 - 15.00 Discussion15.00 - 15.30 Coffee Break / Poster Viewing / Exhibition

15.30 - 17.00 ORAL PRESENTATION 9 (Room: NDH 4) Moderator: Rodolfo Bado (Argentina)

ORAL PRESENTATION 10 (Room: NDH 1-2) Moderator: Aslam Amod (South Africa)

ORAL PRESENTATION 11 (Room: NDH 3) Moderator: Suthat Fucharoen (Thailand)

ORAL PRESENTATION 12 (Room: Uluwatu: 1) Moderator: Yoshio Yamaoka (Japan)

ORAL PRESENTATION 13 (Room: Uluwatu 5) Moderator: Kong Kok Ooi (Singapore)

ORAL PRESENTATION 14 (Room: Uluwatu 7) Moderator: Sandra V. Navarra (Philippines)

ORAL PRESENTATION 15 (Room: Kintamani 1) Moderator:Paweena Susantitaphong (Thailand)

43

Thursday, 25 August 2016 08.00 - 09.00 KEYNOTE LECTURE 6 (Room: NDH 1-2) Moderator: Sally Aman Nasution (Indonesia)08.00 - 08.30 Anti Microbial Resistance - A Man Made Crisis Quazi Tarikul Islam (Bangladesh)08.30 - 09.00 Essentials in Internal Medicine Rodolfo Bado (Argentina)

08.00 - 09.00 KEYNOTE LECTURE 7 (Room: NDH 3) Moderator: Tuty Kuswardhani Suastika (Indonesia)08.00 - 08.30 Problem of Treating Tuberculosis over Years H.A.M. Nazmul Ahasan (Bangladesh)08.30 - 09.00 Successful Aging William Hall (USA)

44

09.00 - 10.30 SS 35 CARDIOVASCULAR (5) Peripheral Artery Disease (Room: NDH 4) Moderator: Refli Hasan (Indonesia)09.00 - 09.20 Diagnostic Approach for Peripheral Artery Disease Budi Yuli Setianto (Indonesia)09.20 - 09.40 Update Management in Peripheral Artery Disease Dono Antono (Indonesia)09.40 - 10.00 Peripheral Artery Disease Treatment in Type 2 Diabetes Shaiful Azmi (Malaysia)10.00 - 10.30 Discussion 10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 36 ENDOCRINE (5) Regenerative Medicine in DM (Room: NDH 1-2) Moderator: Ketut Suastika (Indonesia)09.00 - 09.20 Beta cell and Stem Cell Therapy in Diabetes Angela Koh Fang Yung (Singapore)09.20 - 09.40 The Genetic Medicine in Endocrinology and Metabolism. Tjin-Shing Jap (Taiwan)09.40 - 10.00 Beneficial Impact of Helminths on Adiposity and Insulin Resistance Dicky Levenus Tahapary (Indonesia)10.00 - 10.30 Discussion 10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 37 HEMATOLOGY & ONCOLOGY (5) Thrombosis in Women (Room: NDH 3) Moderator: Lugyanti Sukrisman (Indonesia)09.00 - 09.20 Oral Contraception as a Risk Factor for Thrombosis : A Systemic Review and Management Lugyanti Sukrisman (Indonesia)09.20 - 09.40 Management of VTE in Pregnancy Catharina Suharti (Indonesia)09.40 - 10.00 Thrombophilia as a Contributive Factor in Primary and Secondary Infertility: Clinical Experience with Anticoagulants Karmel L Tambunan (Indonesia)10.00 - 10.30 Discussion 10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

45

09.00 - 10.30 SS 38 PULMONOLOGY (2) Managing Pneumonia in the Era of Antibiotics Resistance (Room: Uluwatu: 1) Moderator: Zulkifli Amin (Indonesia)09.00 - 09.20 Are All HCAP the Same? M. Harun Iskandar (Indonesia)09.20 - 09.40 Bronchiectasis: New interest in an old disease John Kolbe (New Zealand)09.40 - 10.00 Development and Prevention of Antibiotics Resistance Cleopas Martin Rumende (Indonesia)10.00 - 10.30 Discussion 10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 39 PSYCHOSOMATIC (2) Depression and Anxiety in Cancer Patients (Room: Uluwatu 5) Moderator: Wika Hanida Lubis (Indonesia)09.00 - 09.20 Evidence-based Treatment of Anxiety in Patient with Cancer Arina Widya Murni (Indonesia)09.20 - 09.40 Adequacy of Cancer Pain Therapy Using Pain Management Index in Hospitalized Cancer Patients Rudi Putranto (Indonesia)09.40 - 10.00 Role of Psychosomatic Medicine Related with Cancer Treatment Atsuko Koyama (Japan)10.00 - 10.30 Discussion 10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

09.00 - 10.30 SS 40 Tropical and Infectious Diseases (5) Travel Medicine (Room: Uluwatu 7) Moderator: Leonard Nainggolan (Indonesia)09.00 - 09.20 The Pre-travel Consultation to Tropical Countries: What should We Aware of? Erni Juwita Nelwan ( Indonesia)09.20 - 09.40 Travel Immunizations for Vaccine Preventable Diseases Iris Rengganis (Indonesia)09.40 - 10.00 Risk for Leptospirosis Infection in Adventurous Travel Activity Muhammad Hussein Gasem (Indonesia)10.00 - 10.30 Discussion 10.30 - 11.00 Coffee Break / Poster Viewing / Exhibition

46

11.00 - 12.00 KEYNOTE LECTURE 8 (Room: NDH 1-2) Moderator: Andi Fachruddin Benyamin (Indonesia)11.00 - 11.30 Emerging Therapies forDiabetes Mellitus Adri Kok (South Africa)11.30 - 12.00 Multidisciplinary Approach to Cancer: Role of the Internist - Aru W. Sudoyo (Indonesia)12.00 - 12.30 Closing Ceremony (NDH 1-2) Hand over Flag for next WCIM 2018 WCIM Award12.30 - 13.30 LUNCH

47

Tuesday, 23 August 2016

KEYNOTE LECTURE 1.1Managing Patients with Multimorbidity – The Role of Internists

Hans-Peter Kohler (Switzerland)

Professor of Medicine, Secretary General, International Society of Internal Medicine (ISIM), University of Bern, Switzerland

Multimorbidity and population ageing is turning into a major medical issue for both, individuals and health care providers. According to World Health Organization (WHO) statistics, older people are the fastest growing age group worldwide. By 2050, two billion people – or nearly one out of every four people – will be older than 60 years. The current fragmented health care system does not meet the complex needs of multimorbid patients. Integrated health care models with well-balanced treatment plans tailored towards the needs of the individual person are required.

Complex disease patterns require practices and approaches (in diagnostics and therapy) which differ substantially from traditional approaches focused on a single disease. This fact implies the important role of Internists in primary care in the community as well as in hospitals, out-patient clinics and emergency units. Only Internists are capable to cope with the disease pattern among the elderly since multimorbidity is characterised by complex interactions of co-existing diseases where a medical approach focused on a single disease does not suffice.

Internists represent the “General Manager” of the patient like a “CEO” but are also the managers of costly resources. First point of consultation should be an Internist/Generalist. This generalist decides whether a specialised medical consultation must be provided by a Specialist.

Primary care is the backbone of every health care system and is cost effective. Fragmentation in patient care is not future-orientated. We need to preserve the internist’s holistic capabilities. Unfortunately there is an increasing lack of Generalists/Internists globally. The reasons are complex. First of all an improvement of the payment system is needed. Compared to specialist doctors, General Internists are usually payed much less despite of their important role in providing cost-effective care as first point of consultation. In addition to that, the implementation and strengthening of curricula in “General Internal

48

Medicine” at universities and teaching hospitals is also important. Last but not least, research in “polymorbidity” to develop “evidence based guidelines” in the elderly patient is needed since there is only little scientific knowledge available for appropriate diagnostic reasoning, care and treatment for multimorbid patients.

In summary, a career as a Generalist/Internist must became more attractive and the growth of new subspecialties focusing on one organ system must be reconsidered since every health care system has limited financial resources. The role of Internists will become even more important in the future since population ageing and multimorbidity will have profound implications for every health care system.

49

KEYNOTE LECTURE 1.2Autoimmunity - The Epidemic in Our Time Klas Sjöberg (Sweden)

During the recent decades predominantly the westernized societies have experienced a vast increase in autoimmune diseases. Neurological, endocrine, rheumatic but last but not least gastrointestinal autoimmune diseases all become more and more frequent. Inflammatory bowel disease (IBD), both ulcerative colitis (UC) and Crohn’s disease (CD), have increased ten-fold (Molodecky-12). Besides heredity, that facilitates the development, several environmental factors have been suggested to contribute to disease onset, such as smoking, stress, hygiene, infections, but also antibiotic use (especially in childhood) and nutrition (Bach-02). When it comes to food, especially vitamin D deficiency could be critical in view of the impact this vitamin has for immune function. The north south-gradient that has been observed in type 1 diabetes and IBD could also be explained by concomitant variations in vitamin D levels. Recent observations in MS suggest that a diet with a high salt intake could be immune activating as well (via the Th17-pathway). Many of these factors are thought to mediate their effect through increased intestinal permeability and dysbiosis, i.e. a disrupted gut microbiota (Kanai-14). A low-fibre, high-fat and carbohydrate diet has been suggested to contribute to a reduction of commensals and microbiome diversity and consequently development of IBD (Leone-13).

However, although multiple mechanisms are discussed, the exact mechanisms that result in autoimmunity, such as IBD have not yet been clarified. The speech will focus on the recent discoveries in the field in an attempt to present what is currently known and which factors that could be contributing to the ongoing epidemic.

50

KEYNOTE LECTURE 2.1Chronic Kidney Disease: What The Internist Can Do Virginia Hood (USA)

MBBS, MPH, MACP, FRACP, FRCPEdCKD affects 10-15% of adults globally but less than 10% of those affected are aware. CKD is a major risk factor for cardiovascular disease (CVD), causes excess morbidity and mortality and can result in end stage kidney disease (ESKD) requiring expensive renal replacement therapy (RRT).

Internists must play an increasing role in the care of these individuals to slow progression of CKD, CVD and manage complications of impaired kidney function.

A check list for internists includes:

• Recognize CKD in those at risk (diabetes, hypertension, obesity/metabolic syndrome, family history, age, CVD)

Check serum creatinine and urine albumin/creatinine yearly in those at risk• Document stage of CKD from eGFR and add stage 3-5 to a problem list• Identify causes from clinical history, findings, urinalysis, renal imaging, and biopsy if

indicated. Correct reversible causes - obstruction, medications• Control factors that lead to progression of CKD: BP to < 140/90 mmHg; less

than130/80 mmHg if there is proteinuria or albuminuria > 3g/g creatinine; use ACEi or ARB if proteinuria or albuminuria >1g/g creatinine; control blood sugars, stop tobacco; caution with medications; consider allopurinol if gout is present

• Control factors that worsen CVD risk: those listed above plus lipids• Prevent acute kidney injury; avoid NSAIDs; use radiocontrast agents with caution• Consider complications likely present in stages 3-5- need for appropriate drug dosing,

- reduce intake of sodium, potassium, phosphorus (P), including food additives

- anemia: maintain hemoglobin 9-11g/L, monitor hemoglobin and iron every 6-12 months; supplement with iron and erythrocyte stimulating agents (ESA) if needed

- bone/mineral disorders: monitor calcium, P and iPTH every 6-12 months: reduce P in diet to < 1g/day, avoid foods with P additives, ensure adequate Vitamin D3, consider giving 1,25 D3 analogues if iPTH > 2-3 times normal

- acidosis: give sodium bicarbonate, ½ teas/day, to keep serum CO2 at 24 meq/l

• Explain consequences to patients (medications, tests, diet, complications, prognosis, what each person can do for themselves)

• Seek consultation with nephrology for - help with disease diagnosis

51

- management of HTN

- complications at any stage

- stage CKD 4,5 to discuss ESKD treatment – RRT or conservative therapies

52

KEYNOTE LECTURE 2.2Challenge to the Aging Society - The Role of Internal Medicine Yasuo Ikeda (Japan)

MD , FACPPresident of International Society of Internal Medicine

We are confronting unprecedented aging society and a low birthrate in Japan. It is estimated that population of age over 65yr may exceed 40% in 2050. Aged people tend to be multimorbid with increase incidence of cancer and neurological disorders. First-in class, innovative therapeutic agents have been recently developed to solve the unmet medical needs. Medical costs have been dramatically increasing in Japan. In fact, average medical expenses in aged people ( over 65yr ) are 646,100 Japanese yens per person per year, while people younger than 65yr pay 163,400 yens per person.

To overcome these difficult situations, several policies have been proposed by Japanese government. Here, I am going to introduce our recent academic approach to improve medical systems , especially, renovation of medical specialty system.

In May 2015, Japanese Medical Specialty Board (JMSB) was newly established. JMBS, closely working with individual academic medical societies, functions as a neutral organization to standardize medical specialty board in Japan. Certification of individual medical board and accreditation of training programs have been authorized by JMSB.

At present, individual training hospitals are developing their residency programs to learn not only the recent advance of medicine but also the importance of medical care of aged people and underpopulated area. Japanese Society of Internal Medicine (JSIM) plays key roles in renovation of medical specialty system. How JSIM contribute to this movement is going to be introduced in detail in this lecture.

53

KEYNOTE LECTURE 3.1Health and Global Climate Change Nitin S. Damle (USA)

MD MS FACPPresidentAmerican College of Physicians

ABSTRACT

The United Nations Intergovernmental Panel on Climate Change states that it “Is the Greatest Global Threat of our Time”. It is clear that the climate is changing at a pace and in pattern that is not explainable under natural phenomena. That build up of CO2 and other gases (methane and nitrous oxide) from the burning of fossil fuels is the main driver of this phenomena and the harm to humans and the ecosystem has begun. But there is a chace to stem the changes if aggressive action is taken now.

The four major indicators of global climate change are: a) Global Temperature Rise, b) Sea Level Rise, c) Ocean Acidification, d) Ice Mely and Loss of Glacier Mass.

The Five major effect of global change are: a) Forest Fires b) Drought c) Floods d) Heat Waves e) Extreme Weather.

The health effects include a) Heat Releted b) Respiratory Illnesses c) Air Pollution d) Tick Borne infection e) Waterborne infection f)Food insecurity g) Mental Illness.

There needs to be global effort to anthropogenic greenhose gas emissions with the following principles :

• The developed countries need to take a leading role in developing / implementing and monitoring the success of mitigation measures.

• Health co-benefits are an intergral part of global climate change discussions • Expaded use of low carbon or carbon neutral energy • Improve carbon sinks by decreasing deforestation and increasing reforestation• Increase fuel efficiency standards • Energy efficiency standards for buildings• Financial incentives for proper land management Global Climate Change is real, happening now and there is an opportunity to mitigate its effects and prevent serious worldwide health consequences.

54

KEYNOTE LECTURE 3.2Issues in Patient Safety: The Role of Indonesian Medical Association Herkutanto (Indonesia)Indonesian Medical Association

Patient safety is currently have an important role since the WHO officially declare the patient safety movement globally. Researches reveals medical errors occurrence is higher than aircraft accident. Hence, it allerts countries to call on patient safety initiatives.

Indonesia begun patient safety initiatives since 2006, and the statute require hopitals and medical practitioners to implement patient safety at the macro (national) level, meso (institutional) level, and the micro (individual) level. The Indonesian Medical Association (IMA) take crucial role at all levels. At the national level, IMA instumentally contributes to National Policy Formulation on patient safety, besides it send official representative in the National Patient Safety Committee. At the institutional level, it empower other associations under the IMA umbrella to adopt patient safety for thier members according to their specific medical discipline. At the individual level, the IMA conduct the continuing professional develompent activities to maintain professionalism of medical practitioners, and require every professional training occasions to include patinet safety subjects.

55

SS 1.1 CARDIOVASCULAR (1)Update in the Diagnosis of Heart Failure Ali Ghanie (Indonesia)

56

SS 1.2 CARDIOVASCULAR (1)Current Management of Heart Failure Idrus Alwi (Indonesia)

57

SS 1.3 CARDIOVASCULAR (1)The Role of Metabolic Agents in the Management of Heart Failure David Sim Kheng Leng (Singapore)

In the last 40 years, pharmacological therapy for chronic heart failure has rapidly expanded beyond diuretics and digoxin. Standard pharmacological therapy includes beta blockers and renin angiotensin-aldosterone system antagonists. Even with existing contemporary pharmacological therapy, which has substantially improved outcomes, prognosis is fairly poor. The treatment of heart failure continues to evolve with the integration of the results from landmark clinical trials into contemporary therapy. Development of novel therapeutic strategies for the treatment of this disease is crucial. Some of these new approaches will be briefly discussed.

58

SS 2.1 ENDOCRINE (1)Global Epidemic of Diabetes: Focus in Asia Sidartawan Soegondo (Indonesia)

59

SS 2.2 ENDOCRINE (1)Transitional Care of Adolescents Diabetes Nanis Sacharina Marzuki (Indonesia)

Eijkman Institute for Molecular Biology

ABSTRACT

There are substantial differences between pediatric and adult care, and there are considerable characteristic discrepancies in the development stage of an adolescent and emerging adult. Abrupt switch of both types of cares in diabetic patients will result in poor metabolic control, increase loss to follow up, and increase hospitalization. As such lead to awareness of the need of transitional care, which is expected to merge those two teams with ease and smooth and provide comprehensive diabetes care.

In order to achieve its goals the transitional care for adolescents and young adults with diabetes needs to be well planned, structured, and purposeful; and involves diabetes care providers (both pediatric and adult), patients, and their families. Several bodies involving in diabetes care have published recommendations and resources, which have common themes, including early preparation, patient education, and open conversation among pediatric and adult providers, patients, and their families. The transition care is also structured into several steps according to developmental stage of the patients, and its planning is advised to be started 1 year before the anticipated timing to move to adult care.

Despite different transition methods have been used worldwide, physical, psychosocial, and practical aspects of barriers were reported. Efforts have been attempted to overcome the barriers and to improve the transition process. The interventions comprised involving a transition coordinator, joint attendance of pediatric and adult diabetes cares providers at the last pediatric clinic, arranging an appointment for first visit in adult clinic, and providing a transition clinic. Although the outcome is still questionable, most of the patients appreciated the efforts. It seems that it is still challenging to choose suitable model of transitional care for adolescent and young adult with diabetes in each clinical setting.

60

SS 2.3 ENDOCRINE (1)Epigenetic and Metabolism, Benefits for Diabetic and Obese Patient Alejandro Cárdenas Cejudo (Mexico)

The Heritable trans-generational changes in gene expression, without effects in the sequence of DNA, through methylation (gene-off) or demethylation (gene-on), impacts the reproductive integrity of cells, the transcription and codification of proteins in the nucleus of every cell and of course in many of the metabolic functions inside the human body, related to this changes.

The changes in phenotype, without changes en genotype, that’s the question.

Environment, habits, pesticides, risk factors as tobacco consumption, the overweight, sedentary life, over-oxidation, generation of ROS (Reactive Oxygen Species), trans-genic products, stress, age, alcohol, drugs, medicines, geographic determinants, sun radiation, contact with bacterial and viral contexts, cholesterol and diseases, are remarkable influences for us.

Some of the best resources to confront this aggressive situation is to adopt a healthy style of live, eating the right way and doing exercise.

Exercise can change the behavior of methilation in the gene, letting that the transcription to be a success for the protective proteins production in an excellent metabolic situation, favoring the quality of life and survival.

Dr. Alejandro Cardenas Cejudo

Internal Medicine

President

Exercise is Medicine in México AC

61

SS 3.1 HEMATOLOGY & ONCOLOGY (1)Colorectal Cancer: an Overview Aru W. Sudoyo (Indonesia)

62

SS 3.2 HEMATOLOGY & ONCOLOGY (1)The Role of The Surgeon in a Colorectal Cancer MDT Ibrahim Basir (Indonesia)

Sinceearlyeffortsofcancertreatmentaroundtheendof19thcentury,theroleofsurgeonhasalwaysbeenpivotal.PrecisealgorithmforsurgeryfordifferentstagesofCRCisdescribedinallprominentguidelines.Combinedwithadvancingchemotherapy,surgicalresectionmaybecurativeinselectedcasesofmetastaticCRC.Atpresent,multidisciplinaryapproachoversthebestclinicaloutcomeforCRC.TheauthorwillalsodiscusstheemergingpopularityoflaparoscopicCRCsurgeryandshareinstitutionalexperienceonmultimodalCRCtreatment.

63

SS 3.3 HEMATOLOGY & ONCOLOGY (1)The Singapore Experience Robert Lim (Singapore)

Multidisciplinary Team in Colorectal Cancer: is it Better?

Colorectal cancer is amongst the most common cancers worldwide and this is also reflected in Asia. Increasingly, better outcomes are achieved through interdisciplinary coordinated treatment plans. Recognizing these benefits and establishing multidisciplinary efforts pave the way for improving the results of our treatments for patients, ranging from surgical to medical oncology and radiation oncology aspects. This presentation will explore the Singapore experience of multidisciplinary care for colorectal cancer.

64

SS 4.1 GERIATRIC (1)Comprehensive Management for the Elderly in the Community Hadi Martono W (Indonesia)

Comprehensive Management of Community Geriatric Service

Community geriatric service should be basically done according to proposed organizational structure of the provision of geriatric service.It’s therefore a part of a complete geriatric service, consist of hospital based g.s.,hospital based community g.s and community based geriatric service.

The community based geriatric service itself is differentiated by government driven and community driven.The government driven geriatric service should include health service in its broader terms,that is bio-psycho-socials.It is provided through coordination in interdisciplinary manner by the primary health service and other government official service,such as social,economic.religion,education,sport etc.While the community driven,consist of all health service provided by the private sectors.In these services some service is also Important,such as:private doctors,home nursing,nursing homes,meals on wheels etc.It should be noted however that both service should include health prevention,promotion,curative and rehabilitative activity. In these community driven activity included what is called “integrated health post”,a basic geriatric health service done by community health cadres,thet provides basic health monitoring,some integrated health and wealth gathering activities to geriatric populations those are relatively in good health.

While the hospital based community geriatric service, principally provide service that is a prolongation of service that the already went home patients from hospital is is or will be given service needed that can not be given by available service in community.This hospital based community g.s also do the transfer knowledge from hospital geriatric expertise to health officials or laymen about geriatric science.

It is hoped that if the complete geriatric service,from hospital based to community based is provided properly and appropriately,the health needs of geriatric population will be completely covered.

(Keywords:Community based geriatric service,government driven and community driven,”integrated health post”,hospital based geriatric service.Complete coverage of geriatric service.)

----------------------------------------

65

SS 4.1 GERIATRIC (1)Comprehensive Management for the Elderly in the Hospital Czeresna Heriawan Soejono (Indonesia)

66

SS 4.2 GERIATRIC (1)Comprehensive Management for the Elderly in Home Care Service William Hall (USA)

67

SS 5.1 HEPATOLOGY (1) Preventing Long Term Complic ations of Chronic Hepatitis B Laurentius A. Lesmana (Indonesia) Hepatitis B infection (HBV) is a major public health problem as around 240 million people are chronically infected with HBV.

Chronc Hepatitis B ( CHB) is the leading cause of liver cirrhosis and hepatic events,including various cirrhotic complications and hepatocellular carcinoma (HCC) in Asia. A high level of HBV-DNA has been consistently related to be an independent risk factor for the development of cirrhosis and HCC.

Decompensation may manifest with jaundice,ascites ,variceal bleeding or hepatic encepahalopathy.Earlier studies have shown that the prognosis of decompensated cirrhosis is usual poor with a 5-year survival rate at 14 -35 % under conventional standard of care.

Antiviral therapy is effective in suppressing HBV-DNA and reducing the risk of hepatic events and HCC. The approval of oral anti viral agents has greatly improved the prognosis, as demonstrated in several cohort studies and randomized clinical trials involving lamivudune, adefovir entecavir,telbivudine,or tenofovir .

Oral antiviral agents are effective in restoring liver function liver and improving survival in patients with decompensated cirrhosis.

In Asian studies, current Nucleos(t)ide analogs (NA) therapy consistently resulted in a significantly lower HCC incidence in patients with cirrhosis and in non-cirrhotic patients. For patients of Caucasian origin, no appropriate comparative studies available to evaluate the impact of NA treatment on HCC.

In summary. NA therapy may reduce the risks of liver cirrhosis and HCC in CHB in Asian studies whereas to date there are no comparative studies on the impact of NA on HCC of Caucasian origin.

68

SS 5.2 HEPATOLOGY (1)Use of Direct Acting Antiviral Agents (DAA) in Chinese with Chronic Hepatitis C in 2016 and beyond.George K. Lau (Hong Kong)

69

SS 5.3 HEPATOLOGY (1)Acute on Chronic Liver Failure Shiv K. Sarin (India)

\M. D., D.M., D.Sc, F.N.A. Senior Professor, Department of HepatologyInstitute of Liver and Biliary Sciences (ILBS)New Delhi, [email protected]; [email protected]

ABSTRACT

Liver failure can present as acute liver failure (ALF; in the absence of any pre-existing liver disease), acute-on-chronic liver failure (ACLF; in the presence of chronic liver disease (CLD) cirrhosis), or an acute worsening of decompensated cirrhosis. ACLF is a distinct clinical entity. According to this APASL consensus, ACLF is an acute hepatic insult manifesting as jaundice (serum bilirubin ≥5 mg/dl [≥85 ɥmol/l]) and coagulopathy (INR ≥1.5 or prothrombin activity <40%) complicated within 4 weeks by clinical ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease or cirrhosis, and is associated with a high 28-day mortality. The APASL definition is a simple bedside tool, which enables a clinician to stratify a patient presenting with liver failure for early intervention to slow the progress or reverse the failure and improve survival. On the other hand the CLIF SOFA definition involves an acute deterioration of pre-existing chronic liver disease, usually related to a precipitating event and associated with increased mortality at 3 months due to multi-system organ failure. Spesis and organ failure are integral part of the defintion of ACLF accordingly.

Acute insults include alcohol, hepatotropic viruses and drugs whereas the underlying chronic liver disease is generally cirrhosis due to alcohol, hepatitis B or C, or NASH. Chronic liver disease/ cirrhosis could be diagnosed by presence of signs or iamging features of PHT, transjugular liver biopsy or HVPG. The pathophysiology of ACLF relates to persistent inflammation, immune dysregulation with initial wide-spread immune activation, a state of systematic inflammatory response syndrome and subsequent sepsis due to immune paralysis. The disease severity and outcome can be predicted by both hepatic and extrahepatic organ failure(s). A short ‘golden window’ precedes sepsis development and organ(s) failure, and provides opportunity for immunomodulation with GCSF and other interventions; extrahepatic organ failure indicates severity of illness, prognosis and helps guide management. Clinical recovery is expected with the use of nucleoside analogues for hepatitis B, and steroids for severe alcoholic hepatitis and possibly, severe autoimmune hepatitis. Artificial liver support systems help remove toxins and metabolites and serve as a bridging therapy in ACLF prior to liver transplantation. Hepatic regeneration during ongoing liver failure, although challenging, is possible

70

through the use of growth factors. Liver transplantation is the definitive treatment and a good outcome is achieved with early transplantation in carefully selected patients. Pre-emptive antivirals for hepatitis B prior to chemotherapycaution in using potentially hepatotoxic drugs [can prevent the development of ACLF.

The APASL ACLF Research Consortium (AARC) established in 2012, has more than 52 collaborative centers and have collected nearly 2,800 patients in a short span. The consortium is likely to add much more data and new science in this emerging field.

71

SS 6.1 RHEUMATOLOGY (1) Osteoporosis Problem in Autoimmune Disease Julie Li Yu (Philippines)University of Santo Tomas, Manila, Philippines

A complex interaction between the immune system and bone may explain why chronic inflammatory arthropathies like rheumatoid arthritis and ankylosing spondylitis are highly associated with osteoporosis. It was implicated in the field of osteoimmunology that wide array of cytokines are responsible for localized and generalized bone resorption.

Rheumatoid arthritis is an autoimmune disease characterized by inflammation and destruction of joints, bone, and cartilages. Overactive osteoclasts induced by inflammatory cytokines, ie. TNF, IL-6, IL-17, RANKL, contribute to the pathogenesis of osteoporosis in rheumatoid arthritis. The RANKL/OPG pathway is actively involved in pathogenesis of bone resorption in RA.

Chronic systemic inflammation may contribute to bone loss in systemic lupus erythematosus. Increased levels of tumor necrosis factor and oxidized LDL are increased in active lupus. Oxidized LDL induces activation of T cells which in turn induces production of TNF and RANKL, both of which are responsible for the differentiation and maturation of osteoclasts. Also, interplay of host and environmental factors contribute to bone loss in SLE. Low levels of 25(OH)D, 1,25 (OH)2D, use of sunscreens, glucocorticoids, and hydroxychloroquine all adversely affect bone mass in lupus patients.

Ankylosing spondylitis, on the other hand, is associated with increased risk of vertebral fractures by several fold compared to the general population. Similarly, markers of bone resorption are upregulated in these patients. There seems to be a varied pattern of bone density among AS patients, in that there might be evidence of bone loss in the hip but not in the lumbar spine, where bone mass maybe normal or even high due to the presence of syndesmophytes.

In epidemiologic studies, incidence of osteoporosis and fragility fractures in patients with rheumatic diseases varies according to clinical risk factors, disease related factors, medication use, and bone mass/quality of the individual. Bone loss is similarly observed in either the spine and/or the hips.

Similar general lifestyle measures are recommended in patients with rheumatic diseases: optimal calcium and vitamin D intake, adequate sun exposure in the absence of contraindication, prevention of falls and immobility. Bisphosphonates have been the general recommendation in the prevention and treatment of glucocorticoid induced bone loss for which patients with rheumatic diseases are at high risk of.

72

SS 6.2 RHEUMATOLOGY (1)What is New in Diabetoporosis? Em Yunir (Indonesia)

Em Yunir, MDDivision of Endocrine and Metabolism, Departement of Internal Medicine, Faculty of Medicine, University of Indonesia,Jakarta

According to World Health Organization (WHO), osteoporosis is defined as a Bone Mineral Density (BMD) that lies 2.5 standard deviations or more below the average value for young healthy ( T-score of <-2.5 SD).(1) WHO conference in 1993 defines osteoporosis as a systemic skeletal disease characterized by decreased bone mass and altered micro-architecture of bone tissue, leading to enhanced bone fragility and risk of fractures.(2)

There are many risk factors that can contribute to osteoporosis risk of fracture. The natural risk factors are age, gender, menopause status, body mass index, genetic inheritance, and lack of physical activity. Osteoporosis can also result from some specific diseases or medications, such as long term steroid usage, hypogonadism, vitamin D deficiency, hyperparathyroidism, hypothyroidism, thyroxin usage, and diabetes mellitus.(3, 4)

Meta-analysis by Janghorbani et al found that both type 1 diabetes melitus (T1DM) and type 2 diabetes mellitus (T2DM) were associated with significantly increased risk of hip fracture. (5) T1DM generally present a significant reduction in BMD but T2DM have increased or normal BMD. In T2DM have trabecular bone structure in normal limit or enhanced, but the cortical bone is compromised.(6, 7) (8)

Type2 diabetes melitus may affect the quality of bone tissue by means of various mechanisms, including hyperglycemia, increasing deposition of advanced glycosylation end products (AGEs) in collagen, reducing serum levels of IGF-1, hypercalciuria, renal failure, macro and microangiopathy complication, also increasing of inflammation. Reduced serum levels of IGF-1 may precipitate an increase in AGE level, that can lead to osteoporosis and bone fracture.(8-10)

The drugs for diabetic management can also affect bone metabolism. Metformin has a direct effect on bone tissue by reducing AGE accumulation, whereas insulin acts directly on osteoclast activity.(9) Thiazolidinediones (TZDs), can causes bone loss and further increases fracture risk, placing TZDs in the category of drugs causing secondary osteoporosis.(4) Peroxisome Proliferator Activated Receptor γ (PPAR-γ) activation with TZDs may have a negative effect in bone quality by switching mesenchymal progenitor cells to adipose rather than bone tissue and leads to unbalanced bone remodeling, where is bone resorption increases and bone formation decreases. TZD also decrease

73

osteoblastogenesis.(11) Treatment with insulin in elderly also showed a significant association with bone fractures, because of insulin could increase the risk of falls due to hypoglycemic episodes.(12)

New prospects include the incretins, a class of antidiabetic drugs which may play a role linking nutrition and bone metabolism.(9) Dipeptidyl peptidase-4 (DPP-4) inhibitors, which enhance serum incretin concentration, have been reported to reduce clinical fractures.(13) GIP one of the incretins can increases collagen type 1 expression and alkaline phosphatase activity in osteoblast-like cells, and protects osteoblast from apoptosis and also inhibits PTH-induced bone resorption.(14) GIP is also inhibits bone breakdown through a direct effect on osteoclast-resorptive activity and suggest one mechanism for the postprandial reduction in markers of bone breakdown.

With a worldwide increasing prevalence of diabetes, the contribution of diabetes to the incidence of low-trauma fracture or osteoporotic fractures to be important medical, social, and economic concerns to society.

These findings emphasize the need for fracture prevention strategies in patients with diabetes.

DAFTAR PUSTAKA

1. WHO. WHO scientific group on the assessment of osteoporosis at primary health care level.2004.

2. Ivanova S, Vasileva L, Ivanova S, Peikova L, Obreshkova D. Osteoporosis: Therapeutic Options. Folia Med. 2015;57:181-90.

3. Cui R, Zhou l, li Z, li Q, Qi Z, Zhang J. Assessment risk of osteoporosis in chinese people: relationship among body mass index, serum lipid profiles, blood glucose, and bone mineral density. Clinical Interventions in Aging. 2016;11:887-95.

4. Lecka-Czernik B. Bone loss in diabetes: use of antidiabetic thiazolidinediones and secondary osteoporosis. Curr Osteoporos Rep. 2010;8:178-84.

5. Janghorbani M, Rob M. Van Dam, Walter C. Willett, Frank B. Hu. Systematic review of type 1 and type 2 diabetes mellitus and risk of fracture. Am J Epidemiol. 2007;166:495-505.

6. Lipscombe LL, Booth GL, Jamal SA, Hawker GA. The risk of hip fractures in older individuals with diabetes: A population-based study. Diabetes Care. 2007;30:835-41.

7. Dytfeld J, Michalak M. Type 2 diabetes and risk of low-energy fractures in postmenopausal women: meta-analysis of observational studies. Aging Clin Exp Res. 2016.

74

8. Yu EW, Putman MS, Derrico N, Abrishamanian-Garcia G, Finkelstein JS, Bouxsein ML. Defects in cortical microarchitecture among African-American women with type 2 diabetes. Osteoporos Int. 2015;26(2):673-79.

9. Montagnani A, Gonnelli S, Alessandri M, Nuti R. Osteoporosis and risk of fracture in patients with diabetes: an update. Aging Clin Exp Res. 2011;23:84-90.

10. Sroga GE, Wu P, Vashishth D. Insulin-Like growth factor 1, glycation and bone fragility: Implications for fracture resistance of bone. PLoS One. 2015;10(1).

11. Beck GR, Khazai NB, Bouloux GF, Camalier CE, Lin Y, Garneys LM, et al. The effects of thiazolidinediones on human bone marrow stromal cell differentiation in vitro and in thiazolidinedione-treated patients with type 2 diabetes. Transl Res. 2013;161(3):145-55.

12. Lipscombe LL, Booth GL, Jamal SA, Hawker GA. The risk of hip fractures in older individuals with diabetes a population-based study. Diabetes Care. 2007;30:835-41.

13. Hayakawa N, Suzuki A. Diabetes mellitus and osteoporosis. Effect of antidiabetic medicine on osteoporotic fracture. Clin Calcium. 2012;22(9):1383-90.

14. Zhong Q, Itokawa T, Sridhar S, Ding K-H, Kang DX, Bollag WB ea. Effects of glucose-dependent insulinotropic peptide on osteoclast function. Am J Physiol Endocrinol Metab. 2007;292:543-8.

75

SS 6.3 RHEUMATOLOGY (1)Role of Vitamin D in Osteoporosis Treatment Laniyati Hamijoyo (Indonesia)

Rheumatology Division, Internal Medicine DepartmentUniversity of Padjadjaran/ Hasan Sadikin Hospital Bandung Indonesia

Adequate calcium and vitamin D are well known as the part of osteoporosis treatment, to optimize the bone health. Compliance of Vitamin D supplementation is important for effective prevention of osteoporosis fracture. The functions of vitamin D are the regulation of intestinal calcium absorption and the stimulation of bone resorption leading to the maintenance of serum calcium concentration.

In vitamin D deficiency states, decreased calcium absorption occurs from the intestines, causing increased osteoclast production, which enhances the mobilization of calcium from the bone. During periods of decreased dietary intake, 1,25(OH)2D interacts with receptors in osteoblasts, ultimately leading to increased formation of osteoclasts. The mature osteoclast then releases enzymes to breakdown bone matrix ultimately releasing calcium and other minerals into the circulation. If the serum free calcium level remains low, the parathyroid gland is stimulated. Release of parathyroid hormone (PTH) causes increased renal reabsorption of calcium and also stimulates osteoclast production, leading to increased serum levels of calcium. If vitamin D deficiency is not corrected, calcium continues to be pulled from the bone and rickets can occur in children, while osteomalacia and osteoporosis can occur in adults.

Supplementation with vitamin D has been shown to improve musculoskeletal function and reduce the risk of falling in elderly women. Human muscle contains vitamin D receptors that may lead to increasing muscle strength and improving stability. The supplementation of 700 units/ day of vitamin D and 500 mg of calcium was shown to reduce falls by as much as 65% over three years in less active women over the age of 65. A meta-analysis of randomized, controlled fracture prevention trials with vitamin D reported that oral vitamin D supplementation between 700 to 800 units per day appeared to reduce the risk of hip and any non-vertebral fractures in ambulatory or institutionalized elderly persons. An oral vitamin D dose of 400 IU/d was not sufficient for fracture prevention. Another meta-analysis was done suggested that oral vitamin D appears to reduce the risk of hip fractures only when calcium supplementation is added.

Keyword: calcium, osteoporosis, vitamin D

76

SS 7.1 Tropical and Infectious Diseases (1) TB Diagnosis In HIV Patients: Role of Biomarker & Other Novel Tools

Bachti Alisjahbana (Indonesia)Internal Medicine Department, Hasan Sadikin Hospital, Medical Faculty, Universitas Padjadjaran. Indonesia

Tuberculosis (TB) is the most comon cause of morbidity and mortality in patient with HIV (PLHIV) or AIDS. TB is 20-30 times more common occuring among them and 5-10% PLHIV with latent TB infection will develop active TB disease each year. Active TB screening should be performed in PLHIV using the best modalities available, however, our technological capacity in this respect is still limited. Even in person without HIV, Mycobacterium tuberculosis (Mtb) often harbour latently and can reactivate to cause TB disease, as we see in routine patient care in high endemic country like Indonesia. TB diagnostic is still problematic because if Mtb present, they are often well hidden in tissue macrophages. In HIV patient it is even more difficult because tuberculosis coinfection is often paucibacillary, making conventional diagnostics more difficult to do. Various Improved diagnostic tools are now becoming more available. Nucleic acid amplification technique using Xpert Mtb/Rif is already used for clinical specimens and it increases the likelyhood for detecting TB. However it is still less sensitive than conventional liquid culture and still leaves many patient unproven bacteriologically. Other biomarkers targeting at Mtb particles, immune response indicator or metabolites will eventually provide additional possiblities. Among them are the Urine LAM, which has caught attention of many HIV care giver. Interferon gamma release assay which can detect latent TB replacing the mantoux test. These are already widely utilized and gradually show their benefits. The most recent development of metabolomic and transcriptomic approaches are now very widely studied as it provides greater level discriminative power. Much exploration is still needed to be able to have this utilized reliably for diagnosis of all persumptive TB patient with HIV that we faced everyday.

77

SS 7.2 Tropical and Infectious Diseases (1)Isozianid Preventive Therapy in HIV Patients: Will it be Useful in TB Endemic Area? Gurmeet Singh (Indonesia)

Respirology and Critical Illness Division, Department of Internal MedicineUniversitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Abstract

New cases of latent TB infection (LTBI) are emerging in many countries, even in those with a low incidence of tuberculosis (TB), causing a renewed interest in LTBI screening and treatment. People who are suspected to have a high risk of reactivation are those whom have come in contact with pulmonary TB patients; are immune-compromised; and migrants, especially those from an area with high TB incidence.[1] People living with Human Immunodeficiency Virus (HIV) patients have a risk of contracting TB 20 to 37 times higher than those who are not, making HIV the strongest risk factor for developing TB.[2] For those with a high risk of developing active TB, Isoniazid preventive therapy (IPT) is recommended to prevent active TB infection. Isoniazid preventive therapy has been proven to reduce TB incidence in individuals and within populations.[3]

The World Health Organization (WHO) implemented IPT in their Three I’s strategy (IPT, Intensified TB case finding, and Infection control) to decrease the impact of TB on people living with HIV patients.[3] The dose recommended for IPT is 300 mg of Isoniazid every day for six months. For areas with high rate of TB prevalence and transmission, it is recommended to take IPT for 36 months.[2,3] If positive for active TB, treatment for TB should be started. If negative or they have no symptoms, IPT can be started.[2,3] Although IPT may not reduce the incidence of TB in community, it can reduce the mortality and morbidity of TB.[4]

References

1. Stagg HR, Zenner D, Harris RJ, Muñoz L, Lipman MC, Abubakar I. Treatment of Latent Tuberculosis Infection: A Network Meta-analysis. Ann Intern Med. 2014;161:419-428.

2. World Health Organization. Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource constrained settings [Internet]. 2011 [cited 2016 Jul 22]. Available from: www.who.int/tb/challenges/hiv/en/index.html

3. Hart L. Isoniazid Preventive Therapy for the Prevention of Tuberculosis in People Living with HIV/AIDS [Internet]. USA: FHI 360. 2011 [cited 2016 Jul 22]. Available from: www.FHI360.org

4. Health Department Republic of South Africa. Guidelines for Tuberculosis Preventive Therapy Among HIV Infected Individuals in South Africa [Internet]. 2010 [cited 2016 Jul 22]. Available from: http://www.who.int/hiv/pub/guidelines/south_africa_hiv_tb.pdf

78

SS 7.3 Tropical and Infectious Diseases (1)Tackling Drug Resistant TB and TB/HIV Co-Infection Tuti Parwati Merati (Indonesia)

79

SS 8.1 HYPERTENSION & KIDNEY (1) Indonesian Experience in Kidney Transplantation Tunggul Diapari Situmorang (Indonesia)

Kidney Transplantation: Indonesian ExperienceTunggul D Situmorang – Consultant Nephrologist

Abstract

Since the first success of Kidney Transplantation (KTx) in 1954 by Joseph Murray et all. in Boston,USA., the outcome of KTx have improved continuously. KTx has become the treatment of choice for many patients with end stage of renal disease (ESRD).In Indonesia KTx was initiated by Prof dr RP Sidabutar in 1977 at Rumah Sakit Cipto Mangunkusumo (RSCM) with sibling live related donor (LRD).Since then, KTx have been performed in a non-regular basis in several major hospital in Indonesia. Up to now, there are 10 declared KTx center in Indonesia. RSCM and RS PGI Cikini (RSC) are two centers with the most number which were performed by the same team.Most recent data up to June 2016 documented only less than 800 cases of KTx performed in Indonesia. This total number of cases performed is minute compared to almost four decades of experience, increasing national incidence of ESRD and a vast population of 250 million people. Shortage of organ remains largely as the main obstacle , since Indonesia KTx program rely solely on living donors, mostly living related donors. Measures have been taken to ensure continuos improvement in donor welfare and post surgical quality of life.The introduction of laparoscopic donor nephrectomy was an important milestone in achieving this goal, thus making donation process appealing. Data presented clearly show a comparable outcome of KTx in Indonesia with other regional and international centers, despite a relatively low number of total cases performed. The longest surviving graft in Indonesia was 36 years. In conclusion, KTx is a feasible option of RRT in Indonesia,and should be adopted as the treatment of choise ,especially in the era of national health insurance.. KTx in Indonesia has undergone significant growth and is continuously growing.Medical and Surgical outcome parameters were comparable to other centres. In Indonesia,KTx is a “not-so-new”area of interest, waiting to be re-explored with an ultimate goal of providing the best available therapeutic option to the community. KTx remains a challenge as well as it is a fascinating opportunity.

Key word : kidney transplant, Indonesian experience.

80

SS 8.2 HYPERTENSION & KIDNEY (1)Treatment of The Failing Kidney Graft Neil Sheerin (UK)

It is increasingly recognized that Chronic Kidney Disease is a major Health problem, affecting up to 16% of the population in some countries. CKD is associated with an increase in morbidity and mortality and the risk of developing End Stage Renal Disease. The impact of ESRD on patients is huge, and the treatment, with either dialysis or transplantation, represents a major challenge to healthcare providers. In the UK the treatment of ESRD consumes approximately 2% of the healthcare budget. Treatments to prevent the progression of CKD to ESRD are limited, in part due to our limited understanding of disease pathophysiology and the problems associated with designing clinical trials in chronic conditions.

In this talk I will discuss the clinical aspects of CKD, our current understanding of its pathophysiology and how we can translate this into treatments that will slow disease progression and prevent development of ESRD.

81

SS 8.3 HYPERTENSION & KIDNEY (1)Infection in Kidney Transplantation Lestariningsih (Indonesia)

Infections are a common cause of morbidity and mortality after transplantation, and infections rank second as the cause of death in patients with allograft function (1). The rate of first infections in the initial 3 years after kidney transplantation is 45.0 per 100 patient-years of follow-up, as estimated using Medicare claims data collected by the U.S. Renal Data System (2). With pretransplant screening of donor and recipient, vaccination, and post-transplant surveillance and prophylaxis, the impact of infections may be reduced. This article is an overview of the more common infections in kidney transplants recipients and will review strategies for prevention and treatment of these infections. Post-transplant infections may follow a predictable pattern with regard to timing after transplant(3). The traditional paradigm has noted that early infections (within the first month) are more likely to be due to nosocomially acquired pathogens, surgical issues, and some donor-derived infections. Opportunistic pathogens occur later, often during the subsequent 5 months, reflecting the greater impact of immunosuppressive therapies. Late infections may be secondary to opportunistic pathogens or conventional ones; opportunistic pathogens are more frequently seen in patients who require greater immunosuppression or who have specific environmental exposures. It is important to note that although this time line of infections is a helpful starting point, the pattern and timing of infections may be significantly altered by the choice of immunosuppressive agents that may affect the net state of immunosuppression at different time points, as well as.

Timeline of common infections in transplant recipients. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HBV, hepatitis B virus; HCV, hepatitis C virus; HSV, herpes simplex virus; LCMV, lymphocytic choriomeningitis; MRSA, methicillin-resistant Staphylococcus aureus; PCP, Pneumocystis jiroveci pneumonia; PML, progressive multifocal leukoencephalopathy; PTLD, post-transplant lymphoproliferative disorder; VRE, vancomycin-resistant enterococci; VZV, varicella-zoster virus. Reprinted from reference 3, with permission.

Opportunistic infections: as a result of the growing population of immunosuppressed patients with prolonged survival, an increased incidence and spectrum of opportunistic infections is observed.(4,5) Guidelines for the diagnosis and treatment of infection in transplant recipients have been developed.(6)

References

1. Karuthu S and Blumberg EA. Common Infections in Kidney Transplant RecipientsClin J Am Soc Nephrol 2012, 7: 2058–2070

2. The AST Infectious Disease Community of Practice, Amercian Society of

82

Transplantation, Infectious Disease Guidelines for Transplantation. American Journal of Transplantation 2009; 9 (Suppl 3): S64–S70

3. Fishman JA. Infection in Solid-Organ Transplant Recipients. N Engl J Med 2007;357:2601-14

4. Fischer SA, Avery RK; AST Infectious Disease Community of Practice: Screening of donor and recipient prior to solid organ transplantation. Am J Transplant 2009,9: S7–S18

5. Grim SA and Clark NM . Management of Infectious Complications in Solid-Organ Transplant Recipients. Clinical pharmacology & Therapeutics 2011, vol 90 no 2

6. Chandecar A. Infection in kidney transplantation. Up To Date 2016

83

SS 9.1 ALLERGY & IMMUNOLOGYManagement of Anaphylaxis in Drug Allergy Heru Sundaru (Indonesia)

Division of Allergy & Clinical ImmunologyDepartment of Internal MedicineFaculty of Medicine UI / Cipto Mangunkusumo General Hospital, Jakarta

ABSTRACT.

Anaphylaxis is a severe, life threatening, generalized or systemic hypersensitivity reaction. Although the incidence rate is not high but it is also not rare and it is increasing. Many cases are underreported due to underdiagnosis. Therefore, recognition of early signs and symptoms are important to treat patients appropriately. Diagnosis of anaphylaxis is primarily based on clinical history of exposure to a potential triggering agent or event, time elapsed between exposure and symptoms, and evolution of symptoms and signs over minutes or hours. The target organ involved included the skin in 85% - 90% of episode, respiratory in 60% of episode, gastrointestinal tract in 25-35% of episode, cardiovascular in 20-30% of episode and CNS in 10-15% of episode. For practical purpose World Allergy Organizations introduced three criterias, of which anaphylaxis is highly likely when any of the following criterias fulfilled. There are several steps in treating anaphylaxis patients, such as assessment of vital organs, injection of epinephrine, establish intravenous access, give oxygen and appropriate position. Understanding the potential triggers, mechanisms and patient-specific risk factor are important keys to perform appropriate risk assessment. Medication triggers such as antibiotic, NSAID, analgesic, biologic agents, and contrast media have been reported as elicitors drugs. Elderly has increased risk of fatality if he/she has severe asthma as well as chronic obstructive pulmonary disease and other respiratory diseases, cardio vascular diseases, and use of concurrent medication such as β adrenergic blockers. The use of concurrent medication such as β adrenergic blockers and angiotensin converting enzym inhibitors for treating cardiovascular disease makes anaphylaxis more difficult to treat. For future prevention, avoidance of elicitor drugs is critically important. If it is not possible to subtitute with alternative drug, doctor expert in allergy should supervise desensitization. Since anaphylaxis is unpredictable, can be occured in anyone, anywhere and anytime, emergency preparedness is very important especially how to recognize early symptoms and signs of anaphylaxis, giving injection of epinephrine, emergency action plan, medical identification. Therefore, anaphylaxis education is important for health care personels, patients, family and friends of patients.

84

SS 9.2 ALLERGY & IMMUNOLOGYAsthma and Allergic Rhinitis: United Airway Disease

Iris Rengganis (Indonesia)Division of Allergy-Clinical ImmunologyDepartment of Internal Medicine, Faculty of Medicine, University of Indonesia

Allergic rhinitis is an important risk factor for developing asthma and is also an important cause of uncontrol of asthma. Links between upper- and lower- airway diseases exist through inflammatory mediators. Asthma and rhinitis are frequently associated with atopy with preferential sensitization to airborne allergens. Asthma and rhinitis appear to be interrelated at the epidemiologic level and at the pathophysiologic level. The concept of one airway disease had a noticeable impact on the management including their treatment and prophylaxis. People who have both asthma and allergic rhinitis should use both a preventer nasal spray and an asthma preventer inhaler regularly.

85

INDUSTRY SYMPOSIUM 1.1 (NOVO NORDISK)GLP-1 RA from The Concept to Clinical Experience

Sidartawan Soegondo (Indonesia)

86

INDUSTRY SYMPOSIUM 1.2 (NOVO NORDISK)Results of Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes Wolfgang Schmidt (Germany)

87

INDUSTRY SYMPOSIUM 2.1 (MUNDIPHARMA)The Role of Antiseptic & Antibiotic in Prevention of the Spreading of MDRO Khie Chen (Indonesia)

88

INDUSTRY SYMPOSIUM 2.2 (MUNDIPHARMA)The Role of Povidone Iodine Antisepsis Emerging and Re-Emerging Infectious Disease Maren Eggers (Germany)

During an infectious disease outbreak, preventive measures to mitigate the spread of infection include the use of effective virucidal hand hygiene products. Clinical studies against the specific pathogen is time-consuming, may be difficult to perform due to ethical considerations and may not be in time to meet the outbreak response. In such viral outbreaks, in-vitro testing offers a quick and effective solution. In Europe, EN 14476:2013/A1:2014 test method is a well-established standard used to evaluate virucidal efficacy for antiseptics. The Modified Vaccinia virus Ankara (MVA) was introduced as test virus model for enveloped virus in 2014. A range of povidone-iodine products including BETADINE Skin Cleanser, BETADINE Antiseptic Solution and BETADINE Gargle were tested against Ebola virus, MERS-COV, SARS-COV and Influenza viruses and had surpassed a minimum of log 4 reduction (99.99 % kill rate) as stipulated EN14476 standard for virucidal effectiveness. This confirms excellent virucidal efficacy of PVPI against enveloped viruses. These results are helpful for the implementation of appropriate guidance and mitigation infection control measures to exposed people in outbreaks.

89

INDUSTRY SYMPOSIUM 2.3 (MUNDIPHARMA)Improving Oral Mucositis Management for Patients with Cancer Jeeve Kanagalingam (Singapore)

Oral mucositis is inflammation of the mucous membranes of the oral cavity and oropharynx. This is a common consequence of cancer treatment – occurring in 40% of patient treated with chemotherapy and virtually all patients treated with chemoradiation for head and neck cancers. It results in severe pain, inability to eat, weight loss and increased susceptibility to infections, including life-threatening septicaemia. There is a consequent increase in hospitalization and medical resource utilization. Often there is treatment interruption, treatment dose reduction which may affect cure rates. In this lecture, A/Professor Jeeve Kanagalingam will discuss on the possible strategies including the use of povidone iodine mouthwash and its clinical benefits to manage oral mucositis, an undermanaged condition faced by many cancer patients.

90

INDUSTRY SYMPOSIUM 3.1 (ROCHE)Understanding The Role of IL6 in RA: Comparison of Tocilizumab with other Biologic Ernest Choy (UK)

Professor Ernest Choy, Head of Rheumatology and Translational Research, Insti-tute of Infection and Immunity, Cardiff University

Over the two decades, five classes of biologic agents have been licensed for the treatment of rheumatoid arthritis (RA): tumour necrosis factor alpha (TNF) inhibitors, interleukin (IL)-1 inhibitor, depleter of B cells, T cell co-stimulation blocker and IL-6 inhibitor. These treatments are effective but expensive. Optimizing treatment and predicting response to treatment are important to patients and healthcare providers to maximise health economic value and minimise the risk of side effects. Currently, there are many research programmes trying to develop biomarkers that can predict response to biologic treatment. However, it will be some time before these become clinically available. In the interim, experimental studies, clinical trials and importantly real world pragmatic studies have provided important information to help with making clinical decision.

Amongst biologic agents licensed for the treatment of RA, Tocilizumab, a humanised anti-IL-6 receptor monoclonal antibody is the only inhibitor of IL-6. It is often given with Methotrexate but is licensed as monotherapy if methotrexate is not tolerated or contraindicated. IL-6 differs from other cytokines such as TNF and IL-1 in that it has hormone like activities and a key driver of systemic inflammation in RA that leads to the acute phase response, anaemia of chronic diseases, thrombocytopenia and osteoporosis. IL-6 also differs from TNF in that it has a major role in the adaptive immune response through effects on T and B cells. Recent studies using system biology approach have shown that methotrexate, Adalimumab (ADA) and Tocilizumab (TCZ) have distinct immunologic phenotypic profiles consistent with their mode of action1. Interestingly methotrexate has a significant effect on inhibiting B cell function which is reflected in its ability to reduce immunogenicity of therapeutic monoclonal antibodies. Interestingly, methotrexate in combination with ADA inhibited more signaling end-points as compared to individual agent on its own. In contrast, minimal differences between methotrexate plus TCZ when compared to TCZ alone2. These date are consistent with clinical experience that the magnitude of benefit when methotrexate is combined with TCZ3 is less than those observed with methotrexate and TNF inhibitors4,5

References:1. Tan SL et al ACR 2013. 2. O’Mahony A et al. EULAR 2014 Abs no THU0526. 3. Dougados et al. Ann Rheum Dis 2013;72:43-50. 4. Breedveld FC, et al. Arthritis Rheum 2006; 54:26–37. 5. Klareskog L et al. Lancet 2004; 363(9410): 675–681

91

INDUSTRY SYMPOSIUM 3.2 (ROCHE)Real World Evidence of Tocilizumab on Global RA Patients Handono Kalim (Indonesia)

Rheumato-Immunology Division, Department of Internal Medicine Faculty of Medi-cine , Brawijaya University, Malang, Indonesia

Following the successful cloning of the IL-6 gene, IL-6-related research has rapidly progressed. The researches clarify the almost complete IL-6-mediated signaling system provide us the clue for the functional pleiotropy and redundancy of the cytokine. The pathological role of IL-6 in various inflammatory diseases has been elucidated , resulted in the development of the humanized anti- IL-6R monoclonal antibody, targeting the IL-6 receptor (IL-6R) a protein in its soluble and membrane-bound forms , tocilizumab ( Fig. 1 ).

Fig 1. A schematic of the mechanism of action of tocilizumab.

Clinical trials of tocilizumab started in the late 1990s, resulted in the adoption of tocilizumab as a first-line biologic for the treatment of Rheumatoid Arthritis ( RA) and is currently being used in more than 130 countries. An extensive clinical studies has demonstrated tocilizumab efficacy in DMARD-naive RA patients, DMARD-inadequate response patients ( Yazici et al., 2012), and TNF-inadequate response patients . At a dose of 8 mg/kg in combination with conventional DMARDs such as MTX, tocilizumab led to ACR20 responses of approximately 60% at 24 weeks ( Smolen et al., 2008). Onset of action was rapid, with falls in mean tender and swollen joint counts observed after 4 weeks (Burmester et al., 2011). The efficacy response rates are maintained in long-term follow-up studies of up to 5 years (Nishimoto et al., 2009; Genovese et al., 2013). In addition to clinical efficacy, several studies have demonstrated that tocilizumab able to reduce radiographic progression of RA ( Nishimoto et al., 2007), even in the presence of persistent synovitis or high disease activity ( Smolen et al., 2012).

In contrast to the other biologic agents licensed for the treatment of RA, tocilizumab appears effective as monotherapy, with only small additional benefit attained from combination with MTX ( Weinblatt et al., 2013). The result of studies with anti-TNF therapy consistently shown significant improvement in efficacy when these agents are used in combination with MTX and fail to demonstrate superiority of anti-TNF agents over DMARDs when used as monotherapy (Breedveld et al., 2006). Recently this different was confirmed by the ADACTA study, a head-to-head comparison of tocilizumab versus adalimumab monotherapy that demonstrated superiority of tocilizumab monotherapy for ACR50 , EULAR response , and DAS28 remission rates (Gabay et al., 2013). Several studies also demonstrated the ability of tocilizumab monotherapy to reduce radiographic progression (Nishimoto et al., 2007; Dougados et al., 2013). It should be noted that current treatment guidelines for RA recommend use of TNF inhibitors with MTX or other

92

DMARDs.

A study showed that a significant numbers of patients remain in remission after tocilizumab treatment cessation. The DREAM (Drug Free Remission/Low Disease Activity after Cessation of Tocilizumab [Actemra] Monotherapy) study followed participants from phase III RCTs of tocilizumab monotherapy who were in clinical remission or low disease activity state at cessation of study treatment (Nishimoto et al., 2014a). One year after tocilizumab cessation, the proportions of patients in LDA, DAS28-ESR remission, or ACR/EULAR remission were 13.3, 9, and 7.5%, respectively. A follow-up study, RESTORE (Retreatment Efficacy and Safety of Tocilizumab in Patients with Rheumatoid Arthritis in Recurrence), demonstrated that retreating these patients with tocilizumab (as monotherapy or combined with DMARDs) led to 89% achieving DAS28-ESR remission and 43.9% achieving ACR/EULAR remission criteria (Nishimoto et al., 2014b).

The success of tocilizumab has accelerated the development of other IL-6 inhibitors. It is expected that during the next decade IL-6 inhibitors will be widely used for the treatment of various as-yet-intractable diseases, and that their application is certain to overcome the refractory nature of such diseases ( Kang et al,2015).

Conclusion

The result of clinical trials of tocilizumab started in the late 1990s showed that tocilizumab has a good profile as a first-line biologic for the treatment of RA and is currently being used in more than 130 countries. Onset of action was rapid, with falls in mean tender and swollen joint counts observed after 4 weeks with the efficacy response rates are maintained in long-term follow-up studies of up to 5 years. In addition to clinical efficacy, several studies have demonstrated that tocilizumab is able to reduce radiographic progression of RA .

References

Breedveld FC, Weisman MH, Kavanaugh AF, et al. (2006) The PREMIER study: A multicenter, randomized, double-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment. Arthritis Rheum 54:26–37.

Burmester GR, Feist E, Kellner H, Braun J, et al (2011) Effectiveness and safety of the interleukin 6-receptor antagonist tocilizumab after 4 and 24 weeks in patients with active rheumatoid arthritis: the first phase IIIb real-life study (TAMARA). Ann Rheum Dis 70:755–759

Dougados M, Kissel K, Sheeran T, et al. (2013) Adding tocilizumab or switching to tocilizumab monotherapy in methotrexate inadequate responders: 24-week symptomatic and structural results of a 2-year randomised controlled strategy trial in rheumatoid

93

arthritis (ACT-RAY). Ann Rheum Dis 72:43–50.

Gabay C, Emery P, van Vollenhoven R, Dikranian A, et al.; ADACTA Study Investigators (2013a) Tocilizumab monotherapy versus adalimumab monotherapy for treatment of rheumatoid arthritis (ADACTA): a randomised, double-blind, controlled phase 4 trial. Lancet 381:1541–1550.

Genovese MC, Rubbert-Roth A, Smolen JS, et al (2013) Longterm safety and efficacy of tocilizumab in patients with rheumatoid arthritis: a cumulative analysis of up to 4.6 years of exposure. J Rheumatol 40:768–780.

Kang S, Tanaka T, Kishimoto T et al. ( 2015) Therapeutic uses of anti-interleukin-6 receptor antibody. Immunology, 27 : 21–29

Nishimoto N, Hashimoto J, Miyasaka N, et al (2007) Study of active controlled monotherapy used for rheumatoid arthritis, an IL-6 inhibitor (SAMURAI): evidence of clinical and radiographic benefit from an x ray reader-blinded randomised controlled trial of tocilizumab. Ann Rheum Dis 66:1162–1167

Nishimoto N, Miyasaka N, Yamamoto K, et al (2009) Long-term safety and efficacy of tocilizumab, an anti-IL-6 receptor monoclonal antibody, in monotherapy, in patients with rheumatoid arthritis (the STREAM study): evidence of safety and efficacy in a 5-year extension study. Ann Rheum Dis 68:1580–1584

Nishimoto N, Amano K, Hirabayashi Y, Horiuchi T, et al. (2014a) Drug free REmission/low disease activity after cessation of tocilizumab (Actemra) Monotherapy (DREAM) study. Mod Rheumatol 24:17–25.

Nishimoto N, Amano K, Hirabayashi Y, Horiuchi T, et al. (2014b) Retreatment efficacy and safety of tocilizumab in patients with rheumatoid arthritis in recurrence (RESTORE) study. Mod Rheumatol 24:26–32

Smolen JS, Beaulieu A, Rubbert-Roth A, et al ; OPTION Investigators (2008) Effect of interleukin-6 receptor inhibition with tocilizumab in patients with rheumatoid arthritis (OPTION study): a double-blind, placebo-controlled, randomised trial. Lancet 371:987–997

Weinblatt ME, Kremer J, Cush J, et al (2013) Tocilizumab as monotherapy or in combination with nonbiologic disease-modifying antirheumatic drugs: twenty-four-week results of an open-label, clinical practice study. Arthritis Care Res (Hoboken) 65:362–371

Yazici Y, Curtis JR, Ince A, Baraf H, et al (2012) Efficacy of tocilizumab in patients with moderate to severe active rheumatoid arthritis and a previous inadequate response to disease-modifying antirheumatic drugs: the ROSE study. Ann Rheum Dis 71:198–205.

94

INDUSTRY SYMPOSIUM 3.3 (ROCHE)Maximizing the Experience of Tocilizumab on Indonesian RA Patients Harry Isbagio (Indonesia)

Div.of Rheumatology, Depart.of Internal Medicine, University of Indonesia/Cipto Mangunkusumo General Hospital Jakarta Indonesia

RA is a chronic destructive inflammatory disease that has both articular and systemic symptoms. Interleukin-6 (IL-6) plays a pivotal role in RA pathogenesis, and has been implicated in the development of systemic symptoms and local inflammation, pannus formation and bone resorption leading to joint damage. Tocilizumab (TCZ), a humanised monoclonal antibody that binds to IL-6 receptor-α and inhibits IL-6–mediated pro-inflammatory signalling, has demonstrated efficacy and safety in the treatment of patients with RA.

Picture INA Study, a Phase IIIb, interventional, local, multicenter, open-label, non-comparative study was conducted from March 2011 – July 2012 to evaluate the efficacy and safety of tocilizumab (TCZ) in combination with methotrexate (MTX) in 39 patients RA Indonesian patients who were inadequate response to non-biologic DMARDs.

This study showed high remisison rate as measured by DAS28 ESR score (DAS28 ESR <2.6) increase overtime from week 4 to 4 week 24. The hs-CRP level was normalized after first infusion and stable until the end of this study on week 24. Serious adverse event occurred only in small propotion (less than 5 %)

95

SPONSORED SYMPO 1 (MENARINI)The Role of Vasodilatory Betablockers in Hypertension Ketut Suwitra (Indonesia)

96

SPONSORED SYMPO 2 (MENARINI)New Insight into the Role of Betablockers for Heart Failure Idrus Alwi (Indonesia)

97

SPONSORED SYMPO 3 (MENARINI)Betablockers in the Elderly: The Rationale for the SENIORS Study and Its Main Result Teguh Santoso Sukamto (Indonesia)

98

SS 10.1 CARDIOVASCULAR (2)Current Guideline of Acute Coronary SyndromeSally Aman Nasution (Indonesia)

99

SS 10.2 CARDIOVASCULAR (2)The Role of Antiplatelet in the Management of Acute Coronary Syndrome Hanafi B Trisnohadi (Indonesia)

100

SS 10.3 CARDIOVASCULAR (2)The Role of Anticoagulant in the Management of Acute Coronary Syndrome Abdul Majid (Indonesia)

101

SS 11.1 ENDOCRINE (2)New Approach in the Management of Diabetic Retinopathy (The Role of Anti-VEGF) Gitalisa Andayani (Indonesia)

1. Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia – Kirana Eye Center, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

2. Jakarta Eye Center, Jakarta, Indonesia

Diabetic retinopathy (DR) is a microvascular complication of diabetes and the most important cause of visual impairment in diabetic patients. DR is a leading cause of blindness in working age adults. The main management of DR is controlling blood sugar levels (HbA1c less than 7%), blood pressure and lipid levels, and DR screening through timely eye examination with dilated pupils. Routine eye examinations could determine which patients would need referral to ophthalmologists for prompt treatment. Decreased vision in DR is usually caused by the the presence of macular edema, vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma. Vision-threatening DR requires various treatment modalites. Diabetic macular edema (DME) is the most common cause of visual loss in patients with DR. Earlier trials, mainly the Early Treatment for Diabetic Retinopathy Study (ETDRS), revealed that laser photocoagulation for DME can reduce the incidence and progression of visual loss. However, it is further proven that laser treatment may not restore visual loss due to DME. Intravitreal Anti-Vascular Endothelial Growth Factor (Anti-VEGF) is the latest treatment modality, which is now considered as the first line treatment for DME. Numerous trials have shown the improvent of vision and reduced thickness of the retina, in patients with DME treated with Anti-VEGF injections. One of the more recent landmark trials, the Diabetic Retinopathy Clinical Research network (DRCR.net) has demonstrated that anti VEGF therapies, including Ranibizumab, combined with prompt or deferred focal/grid laser achieved superior visual acuity and reduced macular thickness as shown with optical coherence tomography (OCT), compared with laser treatment alone. Furthermore, the Protocol T by DRCR.net, showed that all available AntiVEGF drugs (ranibizumab, bevacizumab and aflibercept), can improve vision, with aflibercept giving the highest gain in visual acuity.

102

SS 11.2 ENDOCRINE (2)Renal Concerns in Diabetes: Hypertension and Nephropathy Pranawa (Indonesia)

103

SS 11.3 ENDOCRINE (2)An Approach to Diabetic Polyneuropathy Adri Kok (South Africa)

The patients living with both Type 1 and Type 2 Diabetes mellitus can develop various complications of the nervous system over time, especially if they are not controlled adequately with strict glycaemic control. Of these, the diabetic polyneuropathy is the most challenging to manage. All these complications of the microvascular system should be avoided and this is possible through strict control of glucose levels, aiming for HbA1c levels of 7% ideally. There are individualized targets for patients of different ages and with various co-morbidities. In T1DM HbA1c levels of 6,5% or less is possible but must be achieved without the risk of hypoglycaemia.

Once diabetic polyneuropathy has developed, it becomes necessary to treat the severe pain and neuropathic symptoms that these patients may present with. It is a debilitating and severe complications and may lead to significant morbidity. The condition, presentation and physiology will be discussed, treatment options and complications as well as management.

104

SS 12.1 HEMATOLOGY & ONCOLOGY (2)Refractory Bleeding Andi Fachruddin Benyamin (Indonesia)

Abstract

Division of Hematology-MedicaZl Oncology, Department of Internal Medicine Faculty of Medicine - Hasanuddin University Hospital

Hasanuddin University Makassar, South Sulawesi, Indonesia

Refractory bleeding can result from increased fragility of vessels, platelet deficiency or dysfunction, derangement of coagulation, and combinations of these. Understanding the role of normal hemostasis is important to understand the mechanism of the specific bleeding disorder. It should be recalled that the normal hemostatic response involves the blood vessel wall, the platelets, and the clotting cascade. Tests used to evaluate different aspects of hemostasis are bleeding time, platelet counts, prothrombine time (PT), partial thromboplastin time (PTT). More specialized tests are available to measure the levels of specific clotting factors, fibrinogen, fibrin split products, the presence of circulating anticoagulants, and platelet function. With this overview, we can turn to the various categories of bleeding disorders.

Bleeding disorders caused by vessel wall abnormalities sometimes called nonthrombocytopenic purpuras, are relatively common but do not usually cause serious bleeding problems. Most often, they induce small hemorrhages (petechiae and purpura) in the skin or mucous membranes. Bleeding in these conditions is rarely life threatening with the exception of some cases of hereditary telangiectasia. Recognition of the presenting symptoms should prompt further studies to establish a specific diagnosis.

Reduction in platelet number constitutes an important cause of generalized bleeding.

Platelet play an important role in hemostasis as they form temporary plugs that quickly stop bleeding and promote key reactions in the clotting cascade. Spontaneous bleeding associated with thrombocytopenia most often involves small vessels. The common sites of such hemorrhage are the skin and the mucous membranes of the gastrointestinal and genitourinary tracts. Intracranial bleeding is a threat to any patient with a markedly depressed platelet count. Qualitative defects of platelet function can be congenital or acquired. Congenital disorders of platelet function can be classified into three groups on the basis of the specific functional abnormality that are defects of adhesion, defects of aggregation, and disorders of platelet secretion (release reaction). Among the acquired defects of platelet function, two are clinically significant. The first is ingestion of aspirin and other nonsteroidal anti-inflammatory drugs, which significantly prolongs the bleeding time. The second condition is uremia which exemplifying an acquired defect in platelet function. Although the pathogenesis of bleeding in uremia is complex and not fully

105

understood, several abnormalities of platelet function are

found

A deficiency of every clotting factor has been reported to be the cause of a bleeding disorder, with the exception of factor XII deficiency, which does not cause bleeding. The bleeding in factor deficiencies differs from platelet deficiencies in that spontaneous petechiae or purpura are uncommon. Rather, the bleeding is manifested by large post-traumatic ecchymoses or hematomas, or prolonged bleeding after a laceration or any form of surgical procedure. Bleeding into the gastrointestinal and urinary tracts, and particularly into weight- bearing joints, is common.

Acquired disorders are usually characterized by multiple clotting abnormalities. Vitamin K deficiency results in impaired synthesis of factors II, VII, IX, and X and protein C. Since the liver makes virtually all the clotting factors, severe parenchymal liver disease can be associated with a hemorrhagic diathesis. Disseminated intravascular coagulation (DIC) produces a deficiency of multiple coagulation factors.

Hereditary deficiencies have been identified for each of the clotting factors. Deficiencies of factor VIII (hemophilia A) and of factor IX (hemophilia B) are transmitted as sex- linked recessive disorders. Most others follow autosomal patterns of transmission. These hereditary disorders typically involve a single clotting factor.

Keyword : refractory bleeding, hemostasis, coagulation

106

SS 12.2 HEMATOLOGY & ONCOLOGY (2)Diagnosis and treatment of DIC Hideo Wada (Japan)

Department of Laboratory Medicine, Mie University School of Medicine,Mie, Japan

Abstract

Disseminated intravascular coagulation (DIC) is a syndrome characterized by systemic bleeding or activation of blood coagulation that generates intravascular fibrin leading to thrombosis of small-and medium-sized vessels and eventually organ dysfunction. DIC is subclassified as either overt or non-overt DIC. The Scientific and Standardization Committee (SSC)/International Society of Thrombosis and Haemostasis (ISTH) and Japanese Association for Acute Medicine (JAA) published diagnostic criteria for DIC based on the results several recent clinical trials. These diagnostic criteria constitute a modified version of the criteria of the Japanese Ministry of Health, Labour and Welfare (JMHLW). The JAA diagnostic criteria have been shown to demonstrate excellent sensitivity, but low specificity, for mortality. Meanwhile, the ISTH overt-DIC diagnostic criteria display high specificity, but low sensitivity, for DIC. There are no significant differences in the ability to predict a poor outcome between the three sets of diagnostic criteria. Our retrospective study demonstrated that providing early diagnosis and treatment for DIC is important. Therefore, we recommend the use of hemostatic molecular markers in order to successfully make an early and rapid diagnosis.

Three guidelines for the treatment of DIC have been published in the literature by the British Committee for Standards in Haematology, the Japanese Society of Thrombosis and Hemostasis and the Italian Society for Thrombosis and Haemostasis. Although broadly similar, there are variations in the recommendations. Therefore, the ISTH/ SSC harmonized the three guidelines for DIC and published the guidance for the diagnosis and treatment of DIC based on the harmonization of the recommendations from three guidelines. The recommendations will be introduced.

107

SS 13.1 GERIATRIC (2)Frailty in Indonesia Elderly: Result of INA in the Fragile Study

Siti Setiati1, Tirza Z Tamin2, Purwita Wijaya Laksmi1, Rahmi Istanti1, Sri Sunarti3, Novira Widajanti4, IGP Suka Aryana5, Lazuardhi Dwipa6

1Geriatric Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia2Department of Medical Rehabilitation, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia3Geriatric Division, Department of Internal Medicine, Faculty of Medicine Universitas Brawijaya, Syaiful Anwar General Hospital, Malang, Indonesia4Geriatric Division, Department of Internal Medicine, Faculty of Medicine Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia5Geriatric Division, Department of Internal Medicine, Faculty of Medicine Universitas Udayana, Sanglah General Hospital, Bali, Indonesia6Geriatric Division, Department of Internal Medicine, Faculty of Medicine Universitas Padjajaran, Hasan Sadikin General Hospital, Bandung, Indonesia

Corresponding email: [email protected]

Frailty is defined as a multidimensional syndrome of the loss of physiological reserves, multi system dysregulation, and limited capacity to maintain homeostasis that gives rise to vulnerability to response the internal and external stressors. There is no gold standard yet to define frailty syndrome. However, Fried has proposed a well known frailty criteria consists of: unintentional weight loss, low energy, low physical activity, slow walking speed, and low grip strength. Frailty divided into three stages which are: fit/robust, pre frail, and frail. The stages are a dynamic process meaning that subject can move from fit/robust into pre frail or frail, and vice versa. It is important to diagnose and screen frailty as early as possible for the benefits of doctors, patients, families, and the country itself. Due to the lack of data about frailty in Indonesia, we conduct a longitudinal study called INA-FRAGILE (Indonesian Frailty, Aging, and Quality of Life). There are some facts found from this study, as follows: prevalence of frail and pre frail subjects in Indonesia is higher than other countries; the proportion of improving and worsening frailty stage is lower in Indonesia compared to USA; hand grip strength and comorbidity are prognostic factors that could influence the worsening of frailty stage in Indonesia; the most frequent adverse outcomes of frailty in Indonesia is hospitalization; proportion of falls in pre frail subjects is similar in Indonesia compared to Brazil while proportion of hospitalization is higher; age, nutritional, and functional status are some of the risk factors that could influence the occurrence of frailty in Indonesia; the cut off point for hand grip strength in Indonesian subjects is lower than Chinese subjects; and compared with one systematic review by Rijk, et al. the result of our study is similar regarding the hand grip strength as a protective factor for frailty related outcomes, when it is higher. We hope that the result of this study

108

could bring more ideas for another research regarding all aspects about frailty, thus a more optimal diagnosis and treatment about this burden-causing syndrome could be conducted, not just in Indonesia but in all of the countries in the world.

109

SS 13.2 GERIATRIC (2)Diagnostic Tools for Frailty in the Elderly Philip Poi (Malaysia)

The concept of frailty amongst the many medical issues we face daily is becoming more relevant as Asia ages. Physical frailty as described by Fried is recognized as a harbinger of disability. The causes of frailty amongst older people are multi-factorial requiring a multidisciplinary team to identify and manage optimally. There are many diagnostic tools for frailty but many are not adopted. Screening for both physical and mental frailty should be the first step any nation can take to reduce disability and the burden of care. Some tools that have been successfully been used will be discussed in this presentation. As in many other diagnostic tools for various illnesses, the most effective diagnostic or screening tool is often country specific.

110

SS 13.3 GERIATRIC (2)Update on the Management of Frailty: Focus on the Role of Metformin Purwita Wijaya Laksmi (Indonesia)*Geriatric Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia/ Cipto Mangunkusumo Hospital

The world aging population increases in accordance with global life expectancy, many age-related health problems ensue. Pathologic aging process may lead the elderly to become frail and incxrease the risk of disability, hospitalization, institutionalization, poor health-related quality of life and mortality. This geriatric syndrome is commonly viewed as the clinical syndrome (phenotype) or as deficits accumulation. These two concepts classify the elderly as normal (fit/ robust), pre-frail, and frail. Frail elderly has a tendency of having poor endurance, lack of energy, along with declining body weight, muscle strength, gait speed, and physical activity. Sarcopenia (low of muscle mass and function) is hypothesized by Fried, et al as the major component of physical frailty which lead to those clinical manifestations. Insulin resistance, inflammation, hyperglycemia/ diabetes mellitus, low vitamin D concentration, low protein intake, polypharmacy, and depression also contribute to the development of frailty syndrome. Thus, frailty syndrome is a dynamic process that may potentially reversible by managing those modifiable contributing factors. Metformin, which has been known for its ability to improve insulin resistance, may have potential role in managing frailty syndrome through its activation on adenosine monophosphate-activated protein kinase (AMPK), while inhibiting inflammatory mediator and mammalian target of rapamycin (mTOR). Metformin was also found to delay aging process and prolong life span in animal studies. In vitro study showed that low concentration of metformin increased mRNA myostatin expression, while higher concentration decreased the expression. Myostatin may relate to sarcopenia since it stimulates muscle protein degradation and its expression also found to be increased in insulin resistance state as well as obesity. Case control study done by Sumantri, et al showed significant difference of frailty status between metformin and non-metformin treated type 2 DM patients, emphasizing the protective effect of metformin against frailty syndrome. As a result, this evidence may trigger critical thinking and future research about other pleiotropic effects of metformin in aging and frailty syndrome beyond its capacity as an oral anti-diabetic agent.

111

SS 14.1 HEPATOLOGY (2)Update of Hepatic Encephalopathy C. Rinaldi A. Lesmana (Indonesia)Department of Internal Medicine, Hepatobiliary Division Cipto Mangunkusumo Hospital, University of IndonesiaJakarta, INDONESIA

Hepatic encephalopathy (HE) is still one of the most challenging complications in liver cirrhosis. This condition were classified to minimal (MHE) and overt HE. However, it is also related to three types of condition, acute liver failure (ALF), portosystemic bypass, and cirrhosis or portal hypertension. HE will influence daily activity and quality of life. Most of liver cirrhosis patients with MHE will fall into overt HE condition. Several theories have been proposed in HE pathogenesis such as disorder of astrocyte function, neurotoxic substances, and the gene expression in the brain. One of the famous hypotheses is ammonia production. It is produced in gastrointestinal tract and detoxified by the liver. When there is a decrease of hepatocyte function, and portosystemic shunting, will lead to hyperammonemia.

Management of HE includes diet, cathartic agent, antibiotic, and LOLA. In the past, low protein diet has become a hallmark of HE management. Recently, the evidence showed there is no need for protein restriction in HE management since it will lead to protein-energy malnutrition (PEM). Cathartic agent such as Lactulose is still become number one evidence in HE management. It helps to inhibit ammoniagenic coliform bacteria. Antibiotic (recently such as Rifaximin) is needed to decrease the ammoniagenic coliform bacteria. Intravenous LOLA is also effective to decrease ammonia level based on trials in most European countries. It stimulates the urea cycle and helps to reduce ammonia level. However, LOLA is only recommended when it is used via injection due to lack of evidence for oral preparation for LOLA. It means that LOLA injection is given in liver cirrhosis patients with overt HE. Preventing HE could be achieved by lactulosa, Rifaximin, and probiotics.

At the end, the goal of successful treatment will be depend on the liver condition and the etiology of chronic liver disease. Liver transplantation should be considered in advanced liver cirrhosis patients where complications are difficult to manage.

112

SS 14.2 HEPATOLOGY (2)Bacterial Infections in Liver Cirrhosis Irsan Hasan (Indonesia)Division of Hepatobilary, Department of Internal MedicineFaculty of Medicine Universitas Indonesia / CiptomangunkusumoHospital

Patients with liver cirrhosis are more prone to be infected than healthy individuals, with prevalence of 25-47%.1,2 Infection in liver cirrhosis occurs as interaction of several factors, comprised of alteration in gut microbiota, gut barrier dysfunction, bacterial translocation, and immune deficiency.2 Little data is currently available for infection in Indonesian population, but study from one tertiary hospital in Jakarta prevailed prevalence of 37,4%, with pneumonia and urinary tract infection as the most dominant infections (19,6% and 12,1%), whereas bacteremia, skin or soft tissue infection, and SBP only held a little proportion (4,7%, 1,9%, and 0,9%).3

Establishing the diagnosis in this group of patients is very challenging. Detailed physical examination has to be accompanied by a careful look of possible source of infection in order to determine the infection status.4 Fever and leukocytosis as one of the typical clinical signs of bacterial infection are only found in less than half patients. As much as 10-30% patients with decompensated cirrhosis have systemic inflammatory response (SIRS) even though they are currently free from infection.5 Sudden deterioration of liver or renal function, proggressivity of ascites or hepatic encephalopathy, low protein finding on ascitic fluid, or variceal bleeding are atypical but even more suggestive of bacterial infection.6 In this case, supporting tests including chest X-ray, ascitic fluid analysis, urine sediment or culture, and sputum examination have a high diagnostic value. 4

Recent studies display the potency for procalcitonin (PCT). Data from Indonesia is provided by Mesanti et al. The mean PCT level was 0,065±0,022 ng/ml for uninfected compensated cirrhotic patients; 0,312±0,208 ng/ml for uninfected decompensated cirrhotic patients; 3,547±1,827 ng/ml for infected decompensated ones. The study also stated that PCT level with cut-off value of 2,79 ng/mL can be used to distinguish between uninfected and infected patients with decompensated cirrhosis.7

Accurate diagnosis followed by adequate treatment is obligatory in order to reduce the risk of mortality in these group of patients. The management workup principle follows the type of infection, and the choice of antimicrobial agents depends on the origin of infection, either community acquired or nosocomial.2

References:1. Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, Stadlbauer V, et al.

Bacterial infections in cirrhosis: A position statement based on the EASL Special Conference 2013. J Hepatol. 2014;60: 1310-24.

113

2. Strauss E. The impact of bacterial infections on survival of patients with decompen-sated cirrhosis. Ann Hepatol. 2014; 13: 7-19.

3. Clinical presentations and outcome of bacterial infection in liver cirrhotic patients. Lesmana LA, Lesmana CRA, Cahyadinata L, Angga B, Pakasi LS. Meeting abstract at APASL Conference. Brisbane, Australia. 12-15 Mar. 2014.

4. Fernandez J, Arroyo V. Bacterial infections in cirrhosis: a growing problem with signif-icant implications. Clin Liv Dis. 2013; 2(3): 102-5.

5. Fagiuoli S, Colli A, Bruno R, Burra P, Craxi A, Gaeta GB, et al. Management of in-fections in cirrhotic patients: report of a consensus conference. Dig Liver Dis. 2013; 30: 1-9.

6. Bruns T, Zimmermann HW, Stallmach A. Risk factors and outcome of bacterial infec-tions in cirrhosis. World J Gastroenterol. 2014; 20: 2542-54.

7. Mesanti O, Gani RA, Simadibrata M, Suhendro. Perbedaan kadar prokalsitonin pada pasien sirosis hati yang tidak terinfeksi bakteri dan sirosis hati yang terinfeksi bak-teri [tesis]. Jakarta: Program Subspesialisasi Konsultan Gastroenterohepatologi Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia; 2016.

114

SS 14.3 HEPATOLOGY (2)Current Treatment of Portal Hypertension Shiv K. Sarin (India)

Prof. Shiv K Sarin, M. D., D.M., D.Sc, F.N.A.Senior Professor, Department of HepatologyInstitute of Liver and Biliary Sciences (ILBS)New Delhi, [email protected]

Patients with cirrhosis and portal hypertension develop over a period of time complications primarily due to high portal pressure, such as esophageal or gastric variceal bleeding, ascites, spontaneous bacterial peritonitis, coagulopathy, bacterial infections; or due to involvement of other organs such brain (hepatic encephalopathy), kidney (hepatorenal syndrome, HRS), lung (hepatopulmonary or portopulmonary syndrome) adrenals (hepatoadrenal syndrome), etc.

In the recent past, our understanding of pathogenesis of PHT has increased immensely, from a fixed to a dynamic process with the major cellular players being liver sinusoidal endothelial cells, hepatic stellate cells (HSC), myofibroblasts and core mediators as NO, ET, CO, PGF2,Thromboxane A2, AT-II, etc. Senescence and modulation of these cells, could help regression of PHT. The role of hepatic venous pressure gradient (HVPG, calculated as the difference between the wedged and free hepatic vein pressure) has emerged as a major determinant and a gradient >10 mmHg as the best predictor of clinically significant portal hypertension (CSPH) and development of varices and decompensation and is recommended to be used to stratify patients with compensated cirrhosis in clinical trials.

Variceal hemorrhage occurs in 25-40% patients with cirrhosis, with mortality still around 15%–20%.A combination of endoscopicvariceal ligation, and vasoactive agent is the first-linetreatment to achieve hemostasis. The APASL recommendation is to have a ‘Door to Needle Time’ of <30min of hospitalization and ‘Door to Scope Time ‘ <6 hours. Active bleeding at the time of endoscopy, hypotension,HVPG > 20 mm Hg and Child’s C status are risk factors for failureof control of bleeding and early and emergency TIPS is recommended for them. Those with high MELD or occluded portal vein could be benifitted with Denis Ella SEMS. The role of non-invasive tools as fibroscan is still not clear. In a recent study we found a significant correlation of fibroscan and HVPG (r=0.25, p-0.00) with a cut-off of 20.9kPa LSM (AUROC 0.77, sensitivity 72.1%, specificity 71.4%) to be predictive of clinically significant portal hypertension (HVPG≥10).

Gastric varices are present in about 20% of patients with portal hypertension with a reported incidence of bleeding of about 25% in 2 years, with a higher bleeding incidence

115

for IGV1 and GOV2. High risk GV are >20mm, Child class (C>B>A), and endoscopic presence of variceal red spots. Use of N-butyl-cyanoacrylate glue or TIPS is recommended for control of acute GV bleed and for secondary prophylaxis.

Treatment of patients with small varices with non-selective beta-blockers appears to reduce progression of varices and thereby reducing bleeding risk.

Patients without varices and those with small varices may behave differently.

Future trialsneed to stratify patients into 2 sub-groups – no varices and small varices.

Significant advances have taken place in the diagnosis and management of patients with variceal bleeding, the commonest complication of portal hypertension (PHT) and cirrhosis of the liver. Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks and is defined as presence of hematemesis within last 24hr of presentation, and / or ongoing melena, with last melenic stool within last 24hr. According to the APASL consensus, the AVB further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive therapy- Terlipressin, somatostatin or octreotide, should be given immediately (<30min of hospitalization, ‘Door to Needle Time’) combined with endoscopic variceal ligation (‘Door to Scope Time ‘<6 hrs) as first line therapy. Rebleeding (48 hr of t0 and after a period of 24 hr of hemodynamic stability) is further subclassified as very early rebleeding (48 h and 120 h from t0), early rebleeding (6day and 42 d from t0) and late rebleeding (after 42 d from t0.) for uniformity of clinical trials. Emphasis is put to evaluate the role of associated comorbid conditions and poor predictors of non-response to combination therapy.

Role of Hepatic vein pressure gradient (HVPG) in AVB is crucial. HVPG is an independent risk factor predicting control of variceal bleeding, success of primary therapy and need for alternate therapies. Patients not responding to the combination therapy should undergo early emergency TIPS specially if the HVPG is >20 mmHg, even in patients with advanced liver disease. Antibiotic prophylaxis is recommended and search for acute ischemic hepatic injury should be done. After an index esophageal variceal bleed, patients should be beta blocked and undergo endoscopic band ligation until the varices are eradicated. Carvediolol hasbeen recently considered superior to propranolol for higher reduction of HVPG. Variceal band ligation results in lower risk of first variceal bleed compared with beta-blockers,though there is no survival advantage over beta-blockers.

Treatment of patients with small varices with non-selective beta-blockers appears to reduce progression of varices and thereby reducing bleeding risk. Carvediloldelays progression of small varices to large varices. In early cirrhosis, a reduction of 8-10 mm Hg is considered adequate to delay progression of varices.

Patients without varices but high HVPG (>10 mmHg) need to be studied further for their

116

natural history and growth of varices

Gastric varices are present in about 20% of patients with portal hypertension with a reported incidence of bleeding of about 25% in 2 years, with a higher bleeding incidence for IGV1 and GOV2. High risk varices are >10mm, Child class (C>B>A), and endoscopic presence of variceal red spots. Use of N-butyl-cyanoacrylate glue or TIPS is recommended for control of acute GV bleed and for secondary prophylaxis. Alternative options like percutaneous transhepatic obliteration of varices and balloon retrograde obliteration of varices (BRTO) and self expanding metal stents are also gaining popularity. Liver transplant remains the definitive therapy in patients who have Child’s C liver disease.

117

SS 15.1 RHEUMATOLOGY (2)What’s New in Pathophysiology and Diagnosis of Gout? Elsa Van Duuren (South Africa)

Dr Elsa van DuurenBMedSci, MBChB, MSc (Sports Medicine), MMed ( MedPhys)Rheumatologist / Rumatoloog

Suite 209 Jakaranda Hospital Tel: 012 343 0428 / 343 1223Middelberg Street, Cell: 082 492 5993 Muckleneuk, Pretoria Fax: 012 343 1223

P.O. Box 2429, Brooklyn Square, 0075 PR 0172790

______________________________________________________________________

What’s New in Pathophysiology and Diagnosis of Gout?

Gout is one of the earliest rheumatic diseases to have been described, but remains an ongoing problem. The incidence of gout is increasing and it has become the most common inflammatory arthritis in men in several countries around the world. In contrast to many forms of inflammatory arthritis, it can be treated very successfully, but it is often still poorly managed.

It is the formation, deposition and reaction to monosodium urate (MSU) crystals, which form when the serum urate concentration is elevated, that causes the disease. Our understanding of these processes has improved and can help to better treat it.

Along with a better understanding of the pathogenesis of gout, has been the development of newer imaging modalities. These can be used to help with the diagnosis of atypical clinical presentations and assessing the severity of the disease in patients with asymptomatic hyperuricaemia, to help make decisions on treatment.

118

SS 15.2 RHEUMATOLOGY (2)Gout Problem in Chronic Kidney Disease Bagus Putu Putra Suryana (Indonesia)

Rheumatology Division, Internal Medicine DepartmentUniversity of Brawijaya – Saiful Anwar General HospitalMalang, Indonesia

Gout and chronic kidney disease (CKD) have bidirectional relationship. Hyperuricemia and gouty arthritis are common concomitant conditions in patients with CKD. CKD is known as the third most common independent risk factor for gout after obesity and hypertension. Increased serum uric acid levels in CKD due to decreased renal excretion will trigger gouty attack and other uric acid related problems. Conversely, gout and hyperuricemia may independently impair kidney function result in CKD. Genetic factor GLUT9 polymorphism has been reported strongly associated with hyperuricemia in general population with normal renal function, and holds as strong predictive power for CKD progression. The other problems are treatment of gout in CKD patients are also limited by renal functions and the medication should also consider renal side-effects that may worsen renal functions.

An observation from 123 patients with CKD in year 2016 at Saiful Anwar General Hospital Malang (Presented as free paper in WCIM Bali 2016) consist of 49.6% male with age 51.5+12.5 years, and 22 patients (17.9%) have gout problem. Hypertension (45.5%) is the most frequent cause of CKD, and followed by diabetes (24.4%), renal stone (10.6%), NSAIDs nephropathy (6.5%), uric acid nephropathy (2.4%) and others (10.6%). Most of patients (97.6%) have severe CKD (stage IV and V) requiring regular dialysis including 89.4% with hemodialysis and 3.3% with peritoneal dialysis. Serum uric acid (SUA) level mean are 8.39+1.93 mg/dL and 78% of patients are hyperuricemia (SUA>7.0 mg/dL). Only 43.1% of patients take allopurinol routinely with average dose 100 mg every other day to 100 mg/day. Joint pattern involved including knee (64%), ankle (27%), metatarso-phalangeal (MTP) joint I (18%), wrist (9%), and hand joints (9%). Tophy was not clinically found among those patients. Medication frequently prescribed for gouty attack in CKD patients are combined acetaminophen with codein or tramadol (40.7%) and colchicine (0.8%). Duration of dialysis is statistically significant and positively correlated with number of joints involved (p=0.026 ; r=+0.201), but not statistically significant with number of attack per year (p=0.063 ; r=+0.168). We conclude that gout and hyperuricemia is more frequent in CKD patients, and SUA target 6 mg/dL is rarely achieved that may associate with poor compliance to allopurinol therapy.

119

Most guidelines emphasize both non-pharmacologic and pharmacologic approaches for managing gout and lowering SUA with a goal of SUA less than 6 mg/dL. Colchicine or oral corticosteroids are frequently prescribed for acute attack in CKD pateints, but NSAIDs are relatively contraindicated. The two first-line options for urate lowering therapy are the xanthine oxidase inhibitors, febuxostat and allopurinol. Febuxostat does not require renal dose adjusment in mild to moderate CKD, suggest that febuxostat can be prescribed more safely and efficiently than allopurinol in CKD patients. Low dose colchicine can be used to prevent acute flare in CKD patients, but NSAIDs are contraindicated.

120

SS 15.3 RHEUMATOLOGY (2)Problems of Daily Gout Treatment in Indonesia Faridin HP (Indonesia) Division of Rheumatology, Department of Internal Medicine, Hasanuddin University

Gout results from an inflammatory response caused by hyperuricemia and the resulting deposition of monosodium urate monohydrate crystals in the articular cartilage and synovial membrane. In USA, 2.6 million in 2005, projected to increase to 3.6 million in 2025. Indonesia is the fourth largest country in the world whose inhabitants suffer from gout, 35 % of gout in men under the age of 34 years and the incidence Minahasa highest population amounted to 29.2 %. The high incidence of gout in Indonesia due to many factors , in addition to gender , age , genetic and environmental factors there are also some factors supporting where in this paper, we divide into three factors that doctors, patients and therapy . Problems of management Gout in Indonesia can not be separated from the knowledge of doctors about the diagnosis of gout and when to start of therapy, patients in the discipline of ULT (Urate Lowering Therapy) consumption and low-purine diet , as well as the problem of availability ULT in Indonesia.

Keywords. Gout, Problems of management, diagnosis, therapy

121

SS 16.1 Tropical and Infectious Diseases (2) - The Spread of Artemisinin Resistance

Erni Juwita Nelwan (Indonesia)

122

SS 16.2 Tropical and Infectious Diseases (2)Primaquine: Should we Deployed it with or without G6PD Testing? Kevin Baird (Indonesia)

Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia

Plasmodium vivax causes one half of cases of the at least several million cases of acute malaria in Indonesia each year. Despite the dogma of benign consequences with this infection we were all taught, firm evidence now proves vivax malaria routinely kills patients, especially those receiving delayed for improper therapy. Treatment of vivax malaria requires two classes of therapies: blood schizontocidal against the acute attack, and hypnozoitocidal against latent liver stages causing multiple clinical attacks over the next year or more. Strains of P. vivax exhibit varying relapse behaviors, and Indonesian strains (especially in eastern Indonesia) are among the most aggressive (relapse quickly and repeatedly at short intervals is the rule). The only available hypnozoitocidal therapy, primaquine, causes an acute hemolytic anemia in patients deficient in glucose-phosphate-dehydrogenase

(G6PD), a very common inherited blood disorder affecting about 8% of people living in malaria endemic countries. G6PD deficiency occurs as many distinct variants of

variable degrees of enzymatic dysfunction and sensitivity to hemolysis and Indonesians (like much of the rest of Asia-Pacific) tend to have some of the most severely deficient variants. Providers who cannot test of G6PD deficiency face a dilemma with a diagnosis of P. vivax malaria – treat the patient with primaquine and

risk serious harm caused by the drug, or withhold treatment with primaquine and risk serious harm caused by the parasite. This lecture considers this dilemma and options for solving it by new point-of-care G6PD deficiency testing technologies. No

patient in Indonesia should receive primaquine without G6PD testing or close

clinical monitoring – it is too dangerous. However, providers also must understand that withholding primaquine therapy invites very high risk of multiple debilitating attacks, each one capable of causing serious illness and onward transmission.

123

SS 16.3 Tropical and Infectious Diseases (2)The Management of Severe Malaria in Limited Resource Area. Paulus Novian Harijanto (Indonesia)

Severe malaria (SM) is a medical emergency with high mortality rate. Malaria is a common disease in low resources areas in tropical countries. The mortality of severe malaria varies from 10 % to 50% depending on the health care facilities, the numbers of organ failure, the early detection and the prompt and accurate treatment. Since the use of artemisinin derivatives for malaria treatment, the incidence and mortality of malaria have been decreasing globally, including in low resources areas. In Indonesia, since the use of artemisinin in 2004, the annual parasite incidence (API) decreased from 1.75 (2011) to 0.85 (2015), with only 23 % of provinces have API > 0.85. The facts are severe malaria cases and their mortality decrease. Many obstacles might occur in the management of malaria cases in low resources settings. The most important thing is early detection of malaria infection and prompt treatment. The majority of malaria cases found in the limited resources facilities, and only a few cases reach the tertiary hospital. Survival and recovery of severe malaria patients need a great effort in management. Early diagnosis by clinical finding is difficult; the giemsa-stained microscopic examination is still the gold standard. Where microscopic examination is not available, the RDT (rapid diagnostic test) should be used. Treatment with artesunate parentally should be started without delay. If not available, artemether intramuscular or even quinine injection can be used initially or even ACT full dose as EDT ( emergency drug treatment).

Aassessment of organ failure should be done early. The most common complications are jaundice, cerebral manifestation ( change of behavior ) and renal failure. Study among 366 cases in Minahasa, North Sulawesi showed that jaundice were found in 59.3% of severe malara cases, while cerebral malaria 21.22% and renal failure 20.65%. In the quinine era, hypoglycaemia occured in 17.5% (22 cases among 126 cases of SM). Hypoglycaemia may occur in 3 hours after quinine infusion. The management of SM should avoid hypoglycaemia, not use lactate infusion, treat with furosemide if there is lung edema, use of anti-convulsion when necessary. In limited resources where ventilator, dialysis are not available, the most important things are do not give treatments that can cause the conditions worse such as giving too much fluid, using lactate infusion, using quinine instead of artesunate.

The last effort should be directed to refer patients as soon as possible to the nearest facilities where severe malaria can be treated properly. The “comm-info” is necessary in the country that is endemic for malaria, as “acute emergency evacuation service” should be ready all the time to rescue patients and bring them to the nearest and the safest hospital that is able to treat malaria accurately.

Key words : severe malaria, artesunate, emergency treatment

124

SS 17.1 The Powerful 24 Hours of Blood Pressure Reduction with Single Pill Combination Idrus Alwi (Indonesia)

125

SS 17.2Primary Stroke Prevention in Atrial Fibrillation Optimizing The Use of NOAC in Clinical Practice Teguh Santoso Sukamto (Indonesia)

126

SS 18.1 PULMONOLOGY (1)Current Diagnosis of COPD and Asthma and ACOS Cleopas Martin Rumende (Indonesia)

127

SS 18.2 PULMONOLOGY (1)Optimalization Benefit of ICS in COPD Management Arto Yuwono Soeroto (Indonesia)

Division of Respirology and Critical Care – Internal Medicine DepartmentFaculty of Medicine Universitas Padjadjaran – Hasan Sadikin General HospitalBandung Indonesia

Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory disease of the airway. In current management COPD, inhaled corticosteroids (ICS) are used as anti inflammatory medication to improve lung function, health status, for decreasing the risk of acute exacerbations and also for decreasing the rate of disease progression.

Combination of ICS with a long acting beta agonist (LABA) produce greater improvements in these outcomes than the LABA alone and may also impact on decreasing mortality.

At the other side, the use of medication in COPD management that contain ICS has a potential side effects, especially when ICS given as monotherapy. LABACS combination increased the risk of pneumonia. Other drug of choice for frequent exacerbation COPD patients (group C and D) is Long acting anti muscarinic drugs (LAMA) which is also as effective as LABA/ICS in preventing exacerbations. Choice between these drugs rise a question which patients is best suitable for each drugs

Several consideration should kept in mind when giving LABACS combination to COPD patients.

Patients with bronchiectasis may experience more pneumonia if treated with ICS. Those with evidence of old tuberculosis that was not treated effectively are also at risk of reactivation.

The WISDOM study try to identify response of ICS withdrawal in if clinically stable severe COPD patients who received triple therapy LABA/LAMA/ICS therapy for at least 4 months. There was no significant difference between the dual bronchodilator arm and triple therapy in the rate of moderate or severe exacerbations. None of the pre specified risk factors including smoking status, lung function

or prior exacerbation history identified a group needing ICS therapy in these stable patients.

The INSTEAD study also demonstrated that patients with moderate COPD with no recent exacerbation history could change from ICS/LABA to Indacaterol, a LABA monotherapy without any clinical deterioration.

128

The blood eosinophil count has been proposed as a stratifying variable for ICS response. Data in studies of acute exacerbations suggested that treatment failure was less likely when the blood eosinophils exceeded 2% of the total white blood cell count. Compared to vilanterol alone fluticasone furoate/vilanterol combination reduced exacerbations significantly only inpatients with an eosinophil count above 2% . The ISOLDE study suggested that ICS slowed the rate of lung function decline over 3 years in those with an initial blood eosinophil count above 2%. Similar findings were seen with beclomethasone. Few other studies also support this findings although some other studies careful review shows inconsistency of response when using the 2 % threshold for eosinophils. This rise idea that may be higher value of blood eosinophil to be more reliable way to apply this approach clinically.

There is also evidence that in COPD patients older than 65 years treatment with a LABA/ICS prevents hospitalisation and reduces mortality compared to LABA monotherapy when there is a prior history of asthma

In summary ICS use in the form of LABACS but not as monotherapy can have positive effects in COPD. This is in accordance with GOLD guidance, that one of the goal of COPD treatment is to reduce exacerbations meanwhile other effective therapies can do this without some hazards that develop from sustained long term ICS treatment. History of asthma remains one of the simplest and most useful ways of identifying COPD patients where treatment with an inhaled corticosteroid as well as long acting inhaled bronchodilators will be clinically helpful. Some data from recent studies shows that stratification according to blood eosinophil count can identify a subset of patients more likely to respond to ICS therapy although this finding needs confirmation with broader clinical trials.

129

SS 18.3 PULMONOLOGY (1)Managing Airway Problem and Systemic Inflammation of COPD Zen Ahmad (Indonesia)

130

Wednesday, 24 August 2016

KEYNOTE LECTURE 4.1Implementation of Quality Standards in Internal Medicine L. Harry Van Hulsteijn (Netherlands)

Quality is defined by delivering high-quality care, which meets the most actual state of science. Therefore it is a dynamic concept. Quality of care has seven flavours: safety, effectiveness, delivered in due time, efficiency, patient centred, equal access and transparency: doctors should be accountable to patients and society. This is no hype or modernism, it is a Hippocratic principle. That’s why quality knows a strong intrinsic motivation. “Good is never good enough if it could be better”.

A crucial part of quality is an optimal relationship between the patient and the doctor. Medical knowledge combined with optimal communication results in complete trust. Trust should be the basis of the treatment. At that very moment science turns into an art. Our great example is the famous internist Sir William Osler, one of the founding fathers of Johns Hopkins. He wrote an essay called “Aequanimitas”, translated by: “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril”. That’s quality!

Another essential part of quality is safety. Safety is another Hippocratic principle; primum non nocere: first of all do no harm. If you think safety is expensive, try an accident! Safer care leads to better quality and is less expensive: less complications, IC admissions, re-interventions, etcetera. Therefore, in each hospital, the slogan should be: “You should work safe, otherwise you’d better not work here”.

In this presentation, implementation of various examples of quality standards are shown, concerning four domains: evaluation of patient care, functioning of Internal Medicine department, patient perspective and professional development. Next, examples are shown of measures to control costs (a worldwide problem) in Internal Medicine: another aspect of quality. Finally, a third Hippocratic principle is discussed: salus aegroti suprema lex i.e. salvation of the sick is the highest law.

Dr. Harry van Hulsteijn, MD, PhD, FACP

131

KEYNOTE LECTURE 4.2Leadership in the Event of Catastrophe; Experiences from Haiti and other EarthquakesRolf A.Streuli (Switzerland)

M.D. MACP, FRCP, University of Zurich, Switzerland

Catastrophes are characterized by the following: Confused situation; lacking information; contradictory information; interrupted connections; rumors; contradictory orders; unclear responsibilities. Involved victims and helpers have to fight against irrational behavior because of fear; fear to fail; overtiredness; overwhelming impressions; climatic, visual, and olfactory burden.

Two historic examples describe successful and failed leadership in case of catastrophe. The first example is Sir Ernest Shackleton, whose ship Endurance was stuck in the ice of Antarctic for more than one year in 1916. He succeeded in holding together his crew, fighting boredom and exhaustion, and keeping order in a dangerous and chaotic environment. The negative example is Captain Edward J.Smith, who commanded the Titanic, who collided with an iceberg in 1912. He was lacking any leadership, he did not check the correct execution of his orders, and he remained in a state of shock on his bridge. The most important principles of leadership are the following: Do not wait for orders; take your own initiative; do not rely on electronic means of communication; carefully observe your collaborators; early diagnose overexertion and stress in your collaborators; motivate your collaborators; send back home people, who seriously damage the morale of your team.

132

KEYNOTE LECTURE 5.1HIV in Asia Pasific: From Problem to Policy to Action Samsuridjal Djauzi (Indonesia)

Asia and the Pacific have made significant progress in controlling HIV epidemic. In 2015, around 5.1 million people living with HIV (PLHIV) live in 12 countries: China, Cambodia, India, Indonesia, Malaysia, Myanmar, Nepal, Pakistan, Papua New Guinea and Timor Leste. However, the number of new infections has dramatically reduced since 2001 by 26% with 300,000 new infections in the given year. Treatment coverage has steadily increased over the last five years, whereas recent figures showed 41% adults are on antiretroviral treatment (ART). Some countries, like Thailand, Cambodia, Malaysia has made significant progress in accessing Prevention of Mother to Child Transmission (PMTCT) treatment. AIDS related death amongst children hasalso declined from 18,000 cases (2004) to 15,000 cases (2009). Nevertheless, PMTCT treatment coverage in the region remains low, 19%. It is much lower than other regions, including sub Saharan Africa (59%) and the global average of 62%.

HIV prevalence among People Who Inject Drugs (PWID) declined, but varies greatly in the region. Evidences clearly highlight the link between using clean needles and injecting equipment and low HIV prevalence. Drug retention centers remain a common feature, but their effectiveness to the HIV response is greatly debated. Rising HIV prevalence amongst men who have sex with men (MSM) is particularly high in urban areas in the region; it’s described as a matter of urgency by UNAIDS.

HIV epidemic in Asia and the Pacific is complicated; with great variation of complication in each country. However, some commonalities that highlight area of critical concern namely (i) low coverage of HIV treatment and (ii) rising HIV epidemic amongst MSM population. The great challenge of HIV control in Asia Pacific will be ensuring that funding for the response is sustained. Domestic funding for national response responses has increasedacross the region. Countries including China and Thailand are leading the way;their national funding is 88% and 85% respectively. Hopefully, more countries could increase their domestic spending on HIV;a call for collaboration between countries to achieve fast tract targets by 2020: 90-90-90HIV treatment target, only 88.000 new infections and zero discrimination.

133

KEYNOTE LECTURE 5.2I.M in Charge: Bringing out the Internist in Subspecialist Sandra V. Navarra (Philippines)

Modern medicine has come to focus on technology , sub-specialization and “defensive” medical practice – veering away from why we are physicians in the first place ie for THE PATIENT.

The various clinical settings for practice of General Internal Medicine include: Ambulatory care, the complex patient, chronically ill, continuity of care. In actual practice, there is extensive overlap between general internist and subspecialist. For example, hypertension and dyslipidemia are treated by internists, cardiologists, endocrinologists, nephrologists, and rheumatologists.

Effective health care particularly in the chronic care setting requires patient-centered care, patient education and shared decision-making. In complicated situations, the Internist must take on the role of Gatekeeper or “captain of the ship”, rendering coordinated care. This approach has been shown to result in better overall outcomes including quality of life and dignity even in dying.

134

SS 19.1 CARDIOVASCULAR (3)Diagnostic Approach for Stable Coronary Artery Disease Ika Prasetya Wijaya (Indonesia)Cardiology Division, Internal Medicine Departement, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

The European Society of Cardiology (ESC) guidelines on the management of Stable Coronary Artery Disease (SCAD) published in 2013 and ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease give practical recommendations for diagnostics and therapy. The approach depends on the clinical picture and symptoms of the patient, the severity and extent of ischemia, the degree and location of coronary stenosis, additional cardiac findings and finally on non-cardiac comorbidities. All patient with suspected SCAD must undergo basic testing, includes standard laboratory, biochemical testing, ECG, resting echocardiography, and chest X-ray for selected patient. Physician should consider also consider patient’s quality of life, and possibility cause of chest pain other than coronary artery disease. Pretest probability (PTP) for the presence of coronary disease also plays an important role in diagnostic SCAD patient. If PTP >85%, diagnosis of SCAD can be established and physician can proceed to risk stratification. In patients with severe angina at a low level of exercise and those with a clinical constellation indicating a high event risk, proceeding directly to invasive coroner angiography is a reasonable option.

Keywords: stable coronary artery disease, diagnosis, coronary artery disease

135

SS 19.2 CARDIOVASCULAR (3Update Management in Stable Coronary Artery Disease Mariano Lopez (Philippines)

MD,FPCP, FPCC, FSCP, FACC

24 August 2016 (Wednesday) 9:20am- 9:40am3rd World Congress of Internal Medicine 2016Bali Nusa Dua Convention Center(BNDCC), Bali, Indonesia

Chronic stable coronary artery disease (SCAD) is the milder form in the spectrum of atherosclerotic coronary artery disease; the high risk counterpart in the other end of the spectrum, being the acute/ unstable coronary syndromes. Though SCAD shares similar pathogenetic mechanisms with the high risk unstable coronary syndromes (ACS, NSTEMI, STEMI, etc), treatment strategies are not entirely similar, mainly in the use of coronary revascularization as the primary approach to therapy. For SCAD, the primary management approach is combination medical therapy consisting of antiplatelet, anti-ischemic and lipid- lowering drugs. These drugs have been shown in earlier clinical trials either to relieve ischemia and symptoms, to reduce and to stabilize the atheroma plaques and prevent plaque rupture, and/or to prevent cardiac complications. Revascularization for SCAD is only considered on those with high risk features or severe symptoms that are not controlled with medical therapy.

Though evidence based studies have not shown superiority of the early invasive therapy in the early 2000s, the advances in coronary revascularization, utilizing drug- eluting stents and more effective antithrombotic drugs, led many physicians to subject their patients with SCAD to early coronary angiogram then revascularization, if warranted. Early invasive therapy is now being favoured, despite no clear evidence of its benefit over the early conservative approach.

The COURAGE Trial (2007) compared the early invasive versus the early conservative therapy in a wide range of SCAD patients (mild to severe ischemia). Randomized patients were given the best of medical therapy, termed as optimal medical therapy (OMT), alone (early conservative therapy) or OMT plus coronary angiogram/ PCI (early invasive therapy) as initial therapy. Results showed that PCI did not reduce the risk of death, MI, or other major cardiovascular events when added to optimal medical therapy. Better angina relief was shown though with PCI. The BARI 2 (2009) randomizing diabetic patients with SCAD (a higher risk SCAD group) also showed no superiority of OMT plus PCI over OMT alone. The FAME 2 trial (2012) compared FFR- guided PCI plus OMT versus OMT alone

136

on SCAD patients. FFR-guided PCI improves patient outcome as compared with medical therapy alone. This improvement is driven by a dramatic decrease in the need for urgent revascularization for ACS. Death from any cause and myocardial infarction were similar between FFR- guided PCI plus OMT versus OMT alone.

Since controversy still exists on the role of early invasive therapy on patients with SCAD with moderate to severe ischemia, the ongoing ISCHEMIA Trial will recruit 8,000 patients, with randomization before cardiac catherization to OMT plus PCI versus OMT alone. Results will be available by May 2019.

mblopez05June16

137

SS 19.3 CARDIOVASCULAR (3)The Role of Imaging in Stable Coronary Artery Disease Sally Aman Nasution (Indonesia)

138

SS 20.1 ENDOCRINE (3)Comprehensive Approach of Thyroid Nodules Chia Su Ynn (Singapore)

Thyroid nodules are very common but only a small percentage are cancerous. The evaluation of a thyroid nodule begins with taking a history, in particular looking out for high risk factors including a family history of thyroid cancer and possible features of certain syndromes like Gardner’s or Cowden’s. A baseline TSH should be done as higher TSH levels have been found to be associated with a higher incidence of thyroid cancer. A high resolution ultrasound of the thyroid is crucial to evaluate features of the nodule. High risk features for malignancy including being hypoechoic, having microcalcifications, increased internal vascularity, irregular margins and being taller than wide. The American Thyroid Association (ATA), in its most recent guidelines, has recently published a useful pictorial representation of the risk of cancer in a nodule based on ultrasound features. This also helps the clinician decide on whether a fine needle aspiration (FNA) is required. Further management is then dependent on the results of the FNA. Benign nodules can be managed with observation using serial ultrasounds at 12-24 month intervals, alcohol ablation in selective cases and radioactive iodine in the case of toxic adenomas. Clearly malignant nodules should be excised. Indeterminate nodules remain a management challenge with potential molecular markers in various stages of development.

139

SS 20.2 ENDOCRINE (3)The Concept of Vitamin D Sufficiency and Insufficiency in Graves DiseaseZafar Ahmed Latif (Bangladesh)

Professor of EndocrinologyBangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders.

Graves’ disease (GD) is an autoimmune disorder of the thyroid gland resulting from dysregulation of the immune system against this important Endocrine gland. The disease is characterized by Hyperthyroidism and presence of circulation auto antibody which stimulates the Thyroid Hormone Receptor(TSHR). The auto antibody is also responsible for goiter and other extra-thyroidal manifestation like ophthalmic, dermatological and others. Vitamin D deficiency is reported to link with variety of autoimmune diseases. However the relation between thyroid autoimmunity of Graves’ disease and Vitamin D deficiency is still not very clear. But in some studies, it is found that there is strong correlation between thyroid autoimmunity and vitamin D – 1,25-(OH) deficiency in newly diagnosed GD. It is found < 15 pmol/L. In one studies it is found <12.5. According to definition of insufficient or deficient most of the Author agreed to describe insufficiency when it is < 30 and deficient when < 20 pmol/L. Vitamin D Receptor gene polymorphism is also associated with increased risk of Graves’ disease and higher volume of goiter. In other studies it is found that, the increased thyroid antibody titer is associated with Vitamin D deficiency. Some other studies showed that, treatment with Vitamin D in GD there is significant early improvement of the diseases. Meta-analysis shows low Vitamin D is also associated with higher risk of development of GD. Moreover, hyperthyroidism leading to osteoporosis in GD is also associated with low Vitamin D level and improves by treatment with Vitamin D. However, whether Vitamin D deficiency or insufficiency favor’s the onset of GD or supplementation of Vitamin D has any beneficial effect, needs further research.

140

SS 20.3 ENDOCRINE (3)Interventional Treatment of Benign Thyroid Nodules Dante Saksono Harbuwono (Indonesia)

141

SS 21.1 HEMATOLOGY & ONCOLOGY (3) Epidemiology of Thalassemia in South East Asia. Suthat Fucharoen (Thailand)

Pranee WinichagoonThalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Salaya Campus, Nakornpathom, Thailand

Alpha, beta-thalassemia and some common abnormal hemoglobin such as Hb E is common in Asia. The complex gene-gene interaction leads to many thalassemic diseases including homozygous beta-thalassemia, beta-thalassemia/Hb E and Hb Bart’s hydrops fetalis. Total management of thalassemia is by offer the best treatment to improve the patients’ quality of life and to preve nt the birth of new cases with severe thalassemia.

The treatment for thalassemia is regular blood transfusion to maintain adequate hemoglobin levels in severely anemic cases. Iron chelation is needed in iron overload patients secondary to multiple blood transfusions and increased iron absorption. In the past most patients in SE Asia could not afford for regular transfusion and chelation. Until recent years, with improvement of the economy, health care system and advance in biomedical sciences including novel iron chelation make it become possible to offer iron chelation to thalassemia patients in SE Asia. Moreover, many SE Asian countries such as Singapore, Malaysia, Thailand are running the thalassemia screening and prevention program. With the comprehensive approaches the number of thalassemia in some SE Asian countries is reducing with better quality of life in living patients.

In conclusion thalassemia is still causing a public health burden for many countries in SE Asia and need proper program for the prevention of the disease by each local government.

142

SS 21.2 HEMATOLOGY & ONCOLOGY (3)Adult with Transfusion Dependant Thalassemia: How to Provide a Safe and Adequate Blood Transfusion Djumhana Atmakusuma (Indonesia)

143

SS 21.2 HEMATOLOGY & ONCOLOGY (3)Iron Toxicity as Complication of Transfusion Dependant Thalassemia & Non Transfusion Dependant Thalassemia Wanchai Wanachiwanawin (Thailand)Division of Hematology, Department of MedicineFaculty of Medicine Siriraj HospitalMahidol University, Bangkok, THAILAND

Thalassemias and abnormal hemoglobin structural variants are the most prevalent inherited single-gene disorders worldwide. Thalassemias are endemic in Southeast Asia, Indian subcontinent, the Middle East and the Mediterranean basin. Co-inheritances of thalassemia alleles or thalassemia alleles together with structural hemoglobin variants lead to various α- or β-thalassemia syndromes in accordance to the defective synthesis of the α- or β-globin. Pathophysiology of thalassemia diseases is related to the imbalance of globin synthesis with the excess of normally produced globin chain, leading to hemolysis and various degree of ineffective erythropoiesis with resultant anemia. Following clinical consequences include expansion of hematopoiesis both intramedullary and extramedullary, splenomegaly, and iron overload with toxicity to various organs especially heart, liver and endocrine glands.

Transfusion requirement has recently been used to discern various thalassemia phenotypes and their severities. Transfusion dependency is recognized as a clinical feature of severe thalassemia diseases such as β-thalassemia major, severe Hb E/β-thalassemia. While non-transfusion dependent thalassemia (NTDT) denotes β-thalassemia intermedia, Hb E/β-thalassemia (mild and moderate forms) and Hb H disease. Patients with NTDT may require occasional or more frequent blood transfusions in certain situations, for example during or following infections when anemia worsens. Increased body iron to the degree of overload is inevitably encountered in transfusion dependent thalassemia (TDT) and steadily occurs in NTDT. Non-transferrin bound iron or labile plasma iron, in the setting of iron overload, causes organ toxicity through oxidative damage at the cellular levels. Cardiac abnormalities and liver impairments are major complications of iron overload resulting in significant morbidity and mortality in thalassemia patients. Chelation remains the only effective treatment of iron overload in thalassemias. This presentation will discuss different characteristic features of iron overload between TDT and NTDT. Optimal chelation therapy and assessment of iron burden will also be covered.

144

SS 22.1 GASTROENTEROLOGY (1)Update of Diagnosis and Treatment for H Pylori Infection I Dewa Nyoman Wibawa (Indonesia)

145

SS 22.2 GASTROENTEROLOGY (1)Risk Factor and Prevalence of H Pylori Infection in Indonesia Ari Fahrial Syam (Indonesia)

Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia

Corresponding author: [email protected]

Indonesia is a developing country located in Southeast Asia that is an archipelago with a multi-ethnic society (more than 1,000 ethnic and sub-ethnic groups). The age-standardized incidence of gastric cancer in Indonesia has been reported to be 2.8/100,000, which is low compared with that recorded among other Asian countries (available from the International Agency for Research on Cancer; GLOBOCAN2012, http://globocan.iarc.fr/). Indonesia, with its different ethnicities, cultures, life-styles and religions, presents an appropriate model to examine the effects of migration and co-evolution on the bacteria-host interactions involved in the H. pylori infection

Our last publication in PLoS One reported a prevalence of H. pylori infection of 22.1% (59/267). Papuan, Batak and Buginese ethnics had higher risk for H. pylori infection than Javanese, Dayak and Chinese ethnics (OR = 30.57, 6.31, 4.95; OR = 28.39, 5.81, 4.61 and OR = 23.23, 4.76, 3.77, respectively, P <0.05). In this study, we also got that the source of drinking water such as well or river water was associated with increased risk of infection.

In Asia countries, we have a low prevalence of H. pylori infection. We attempted to identify the risk factors for H. pylori infection, but found inconsistencies according to location.

Another our study has evaluated the risk factors for H. pylori in Indonesia. We found that the incidence of H. pylori infection in patients with poor sanitation was higher compared with patients who had a good sanitation status. The lower the sanitation status, the higher the risk of H. pylori infection (OR, 2.5; 95% CI, 1.01–6.19; P = 0.044). The use of public toilets can increase the spread of infection because of individuals’ lack of hygienic behaviour, while the use of well water sources, especially shallow wells, increases the risk of transmission of H. pylori. We reported that the incidence of H. pylori infection in areas with a low clean water index was higher than that observed in areas with a high clean water index. The lower the index, the greater the risk of H. pylori infection (OR, 1.524; 95% CI, 0.57–4.04; P = 0.396). We also reported that 13.5% of their sample had a high crowding index, although the association between H. pylori infection and crowding did not achieve statistical significance (OR, 1.2; 95% CI, 0.37–4.49).

Keyword: H pylori infection- Low prevalence - ethnicity

146

SS 22.3 GASTROENTEROLOGY (1)Gastrointestinal Complication of H Pylori Infection Yoshio Yamaoka (Japan)

Helicobacter pylori infection is linked to various gastroduodenal diseases; however, only approximately 20% of infected individuals develop severe diseases. Despite the high prevalence of H. pylori infection in Africa and South Asia, the incidence of gastric cancer in these areas is much lower than in other countries. Such geographic differences in the pathology are believed to be able to be explained, at least in part, by the presence of different types of H. pylori virulence factors, especially the CagA types; East Asian type CagA is more virulent than Western type CagA. However, recent our analyses of strains in Mongolia, the 2nd worst incidence of gastric cancer in the world showed that most of the Mongolian H. pylori possessed Western type CagA. Therefore, geographic differences in the incidence of gastric cancer might not be able to be explained by the current concept. H. pylori contains approximately 1,600 genes and, to date, it is likely that only a fraction of the potential virulence genes have been identified (e.g., VacA, OipA, BabA in addition to CagA). Genome-wide analyses using whole-genome sequencing technology, in particular, next-generation sequencers, which can read DNA sequences in less time and at lower costs than Sanger sequencing, enabled us to efficiently investigate the novel virulence factors of H. pylori related to gastric cancer pathogenesis as well as to search the novel virulence factors of H. pylori. Finally, in 2016, Japanese society for Helicobacter Research (JSHR) released new guidelines for H. pylori management JSHR proposed that the cure of H. pylori infection should be presupposed to prevent gastric cancer from active gastritis universally developed in the infected subjects. Another important advance in this guideline is that we can use “vonoprazan”, a novel potassium-competitive acid blocker, as a component of Helicobacter pylori eradication therapy. Vonoprazan is effective as part of first-line triple therapy and as part of second-line triple therapy in H. pylori-positive patients with a history of gastric or duodenal ulcer. In this review, I explain the current knowledges of H. pylori virulence from our experiences in molecular epidemiological surveys in Asian countries as well as current consensus of H. pylori managements in Japan.

147

SS 23.1 HEPATOLOGY (3)Screening and Diagnosis of HCC Rino Alvani Gani (Indonesia)Hepatobiliary Division, Department of Internal MedicineFaculty of Medicine Universitas Indonesia / Ciptomangunkusumo Hospital

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and an important cause of cancer-related death worldwide.1 The detection of HCC at an early stage improves survival and allows the use of potentially curative treatments.2,3 For this reason, the detection of early disease by surveillance and the use of accurate diagnostic methods are essential to the management of HCC.

HCC surveillance should be put into practice because all of the criteria for effective surveillance testing are met. The American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL) recommends that patients who have cirrhosis and some patients who have chronic liver disease without cirrhosis undergo surveillance for HCC with ultrasonography (USG) every 6 months.4,5 Surveillance with CT is just as good as surveillance with USG but is less cost-effective. Asia Pacific Association for the Study of the Liver (APASL) recommends USG and AFP level examination every 6 months for cirrhotic patient with HBV or HCV infection.6

Quadruple phase, contrast-enhanced CT or MRI is the test of choice for the diagnosis of HCC. The hallmark of HCC is the presence of arterial enhancement, followed by washout of the tumour in the portal-venous and/or delayed phase.7 An algorithmic approach is used to guide recall strategies for patients with abnormal test results. The diagnostic algorithm from APASL used tumor vascularity instead of tumor size for further evaluation.6 According to AASLD and EASL, serum biomarker has no role in diagnosis of HCC. But APASL used AFP and DCP for diagnosis of HCC. Recently, some new biomarker such as PIVKA, glypican, osteopontin and AAG were being developed to assist in diagnosis of HCC.

1. GLOBOCAN International Agency for Research on Cancer (IARC) 2012 Available at: http://globocan.iarc.fr/old/FactSheets/cancers/liver-new.asp.

2. El-Serag HB. Hepatocellular carcinoma. N Engl J Med. 2011;365(12):1118-1127.3. El-Serag HB, Davila JA. Surveillance for hepatocellular carcinoma: in whom and

how? Ther Adv Gastroenterol. 2011;4(1):5-10.4. Bruix J, Sherman M; American Association for the Study of Liver Diseases. Man-

agement of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020-1022.

5. Bruix J, Sherman M; American Association for the Study of Liver Diseases. Man-agement of hepatocellular carcinoma. Hepatology. 2005;42(5):1208-1236.

6. Omata M, Lesmana LA, Tateishi R, et al. Asian Pacific Association for the Study of

148

the Liver consensus recommendations on hepatocellular carcinoma. Hepatol Int. 2010;4(2):439-474. 62.

7. European Association for the Study of the Liver; European Organisation for Re-search and Treatment of Cancer. EASL-EORTC clinical practice guidelines: man-agement of hepatocellular carcinoma. J Hepatol. 2012;56(4):908-943.

149

SS 23.2 HEPATOLOGY (3)Non- Operative Management Masathosi Kudo (Japan)

150

SS 23.3 HEPATOLOGY (3)Operative Management: Resection vs. Transplantation Stephen K.Y Chang (Singapore)

Operative management offers certain advantages which can be served by both resection and transplantation. In addition, transplantation has the added advantage of possible cure from cirrhosis and the underlying liver disease. The disease free and overall survival is generally higher after transplant compared to resection. However, problems with graft availability and surgical expertise hampers widespread use of transplant as a curative strategy for HCC. Resection remains a good alternative with equivalent survival in certain group of patients. However, in patients with advanced cirrhosis and bilateral centri-lobular disease, liver transplant remains only viable option. Moreover, in advance disease, though liver transplant may not offer long term survival, it may be the only treatment option to prolong survival; while traditional selection criteria are used for better deceased donor graft allocation, it may not be ethically right to refuse a donor for LDLT to a relative even when disease is advanced to prolong his survival. Cost has always been a consideration when considering resection or transplantation but with increasing number of centres offering transplantation worldwide, liver transplantation may be more affordable now.

151

SS 24.1 RHEUMATOLOGY (3)B Cell Role in Pathophysiology of SLE Joewono Soeroso (Indonesia)

THE ROLE OF B CELL IN THE PATHOPHYSIOLOGY OF SLEJoewono SoerosoDivision of Rheumatology-Department of Internal MedicineMedical Faculty Airlangga Univesrsity - Dr Soetomo HospitalSurabaya-Indonesia

INTRODUCTION

Systemic lupus erythematosus (SLE) is a complex autoimmune disease, predominantly affecting young women. Five-year survival in patients with SLE has improved from 50% in the 1950s to over 90%. However, the mortality remains higher ¬compared with the general population. B cells have important roles in SLE, which involve numerous different cells and molecules at different stages. B-cells are intolerance with abundant and different production of autoantibodies indicate the B cells improper signaling against (auto) antigen. Some B-cell surface molecules, are alternative targets for both inhibition of B cells and induction of cell death. Inhibition of co-stimulation against co-stimulatory signals, monoclonal antibodies against the cytokines. Recently, the role epigenetics such as micro RNAs (miRNAs) which regulate B-cell development, differentiation, apoptosis and function may be flawed in SLE, however, the regulatory mechanisms of miRNAs remains uncharacterized. Knowing the B cell pathophysiology in SLE will give perspectives about the new treatments for SLE.

152

SS 24.2 RHEUMATOLOGY (3)What’s new in the treatment of SLE Kong Kok Ooi (Singapore)

Systemic Lupus Erythematosus (SLE) Kok Kong Ooi

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with substantial clinical heterogeneity. Current treatments for SLE are effective at reducing morbidity and mortality but fail to provide a cure, and they frequently have adverse effects. Traditional treatments include NSAIDs and antimalarial agents, which are the first-line therapies for mild SLE. In addition, glucocorticoids and cytotoxic or immunosuppressive agents—such as azathioprine, mycophenolate mofetil, cyclophosphamide, cyclosporine and methotrexate —are used for SLE with organ involvement. Advances in understanding the immunopathogenesis of SLE have led to the development of targeted immunotherapies. Given the numerous immune-based abnormalities associated with SLE, the potential therapeutic targets for biologic agents and the candidate biologic approaches are also numerous. These approaches include: biologic agents that promote B-cell depletion, B-cell inactivation, or the generation of regulatory B cells; biologic agents that induce T-cell tolerance, block T-cell activation and differentiation, or alter T-cell trafficking; biologic agents that target the B-cell activating factor (BAFF) axis, type I interferons, IL-6 and its receptor, or TNF; and the adoptive transfer of ex vivo-generated regulatory T cells. Owing to the great heterogeneity inherent to SLE, no single approach should be expected to be effective in all patients. As our understanding of the pathogenic mechanisms of SLE continues to expand, additional therapeutic targets and approaches will undoubtedly be identified and should be fully exploited.

153

SS 24.3 RHEUMATOLOGY (3)Clinical Challenges in Lupus Sandra V. Navarra (Philippines)

Systemic lupus erythematosus (SLE) is an autoimmune disease which can involve several organ systems with approximately 75% of patients having abnormalities in one or more vital organs such as the kidneys, heart, lungs and brain - thus making Lupus a prototype Internal Medicine disease. Clinical challenges in lupus of concern to the internist ranges from acute life threatening situations such as systemic infection and seizures to chronic potentially disabling conditions like nephritis and interstitial lung disease. Moreover, the clinician is also faced with the usual dilemma of whether the patient’s presentation is due to active SLE or due to medications especially glucocorticoids eg hypertension, diabetes. Unlike many other diseases, the presentation and treatment of SLE is extremely variable, with an unpredictable clinical course in most cases, requiring a highly INDIVIDUALIZED and HOLISTIC management approach. Team approach by dedicated clinicians is essential in complicated situations.

154

SS 25.1 Tropical and Infectious Diseases (3)MDR, XDR, PDR Gram-Negative Bacterial Infections: Clinical Impact Suharto (Indonesia)

155

SS 25.2 Tropical and Infectious Diseases (3)Drug Development and Antibiotic Pipeline Combating Antimicrobial Resistance Po Ren Hsueh (Taiwan)

156

SS 25.3 Tropical and Infectious Diseases (3)Optimizing PK/PD to Improve Clinical Response Usman Hadi (Indonesia)

Department of Internal Medicine

Airlangga University School of Medicine - Dr. Soetomo Hospital Surabaya

Knowledge of PK / PD antibiotics is essential so that antibiotics can be used optimally to improve clinical respons, and prevent the emergence of bacteria resistant to antibiotics (AMR). Pharmacokinetics (PK) related to the time course of antibiotic concentrations and its metabolite in the body. Some PK parameters are clearance of antibiotic, volume of distribution, half-life, bioavailability, and protein binding.

Pharmakodimamic relates to what happens after the antibiotic in the body, then how the antibiotic effect against microorganisms that cause infections and how the relationship between those concentration and the antimicrobial effect. By using combination information or parameter of PK/PD and minimum inhibitory concentration (MIC) is expected to optimize the use of antibiotics and improve outcomes. These parameters are as follows: Peak / MIC ratio, the T> MIC, 24-h AUC / MIC ratio, and microbiological kill curves. After administration of antibiotics the bacterial count may decline, when levels of the portion of the drug not bound to protein exceed the minimum bactericidal concentration (MBC) as a result of drug effects and host defenses. Using these PK/PD parameters antibiotics can be divided into 3 categories: 1. Concentration-dependent killing and prolonged persistent effects, 2. Time-dependent killing and minimal persistent effects, and 3. Time-dependent killing and moderate to prolonged persistent effect. This paper discuss the PK / PD of antibiotics in order to more optimal antibiotic therapy to improve clinical respon and prevent antimicrobial resistance.

Keywords: Pharmacokinetics; Pharmacodynamics; Antibiotics.

157

SS 26.1 New Understanding in Residual Vascular DiseaseWhat is the Relationship between Triglyceride and Atherosclerotic Vascular Disease? Idrus Alwi (Indonesia)

158

SS 26.2 New Understanding in Residual Vascular DiseaseManaging Bleeding Risk in Thrombotic Diseases Karmel L Tambunan (Indonesia)

159

SS 26.3 New Understanding in Residual Vascular DiseaseNew Paradigm in Hypertension Management with Dual Approach Role of Eprosartan Teguh Santoso Sukamto (Indonesia)

160

SS 27.1 HYPERTENSION / KIDNEY (2)How to Retard The Progression of Renal Disease Paweena Susantitaphong (Thailand)

Chronic kidney disease (CKD) is one of the most extremely important non-communicable diseases that have significant morbidity and mortality consequences. Identify factors associated with CKD progression to inform prognosis should be done. These factors include cause of CKD, level of GFR, level of albuminuria, age, sex, race/ethnicity, elevated BP, hyperglycemia, dyslipidemia, smoking, obesity, history of cardiovascular disease, and ongoing exposure to nephrotoxic agents. Therefore, all risk factors should be corrected or maintained to retard the progression of kidney disease by using life style modification and medications. The Kidney Disease Improving Global Outcomes guidelines recommend that individuals with CKD receive expert dietary advice and information in the context of an education program, tailored to severity of CKD and the need to intervene on salt, phosphate, potassium, and protein intake where indicated. Avoiding high protein intake (>1.3 g/kg/day) in adults with CKD because it is associated with high risk of progression. CKD patients should be encouraged to undertake physical activity compatible with cardiovascular health and tolerance (aiming for at least 30 minutes 5 times per week), achieve a healthy weight (BMI 20 to 25, according to country specific demographics), and stop smoking. Adults with CKD should seek medical or pharmacist advice before using over-the-counter medicines or nutritional protein supplements. Not using herbal remedies in people with CKD should be advised. Balance the risk of acute impairment in kidney function due to contrast agent use against the diagnostic value and therapeutic implications of the investigation.

161

SS 27.2 HYPERTENSION / KIDNEY (2)Role of Complement in Progression of Renal Disease Neil Sheerin (UK)

The complement system is part of the innate immune system and has a key role in protection from infection and coordination of the adaptive immune system. Under physiological conditions its activity is carefully regulated by a series of membrane bound and fluid phase control proteins. However, despite these control mechanisms, it is recognised that inappropriate or excessive complement activation can lead to tissue injury and cause disease. In nephrology we have used immunochemical staining of renal biopsies for complement proteins to classify disease for over 50 years. In some of these diseases complement is an important mediator of renal disease and complement therapeutics are now in clinical use.

There is evidence that complement activation contributes to CKD disease progression. I will present the evidence from pre-clinical and clinical studies that support this hypothesis and discuss how complement therapeutics could be applied to patients with CKD.

162

SS 27.3 HYPERTENSION / KIDNEY (2)When to Start Renal Replacement Therapy Ketut Suwitra (Indonesia)

163

INDUSTRY SYMPOSIUM 4.1Diabetes Therapy Today and in the FutureRoy Panusunan Sibarani (Indonesia)

Endocrine Center, Sahid Sahirman Memorial Hospital, Jakarta, Indonesia

People with type 2 diabetes have increased throughout the world. The International Diabetes Federation estimates that by 2025, 333 million people will have this disease (1). Asia is emerging as the epicentrum of this epidemic (2). It contained some of the most populous countries in the world and has undergone pronounced demographic, epidemic, and socioeconomic change in recent decades. This issue will affect to the need of finding the way to prevent diabetes or the treatment to minimalize the complications. UK Prospective Diabetes Study confirmed that intensive glycemic control was associated with significan tly decreased rate of microvascular and neuropathic complications in type 2 diabetes patients (3), and also long-term follow-up of UKPDS showed enduring effects of early glycemic control on most microvascular complications.

Today, there is a number of excellent therapy to lower blood glucose and improve diabetes control. After insulin was found in 1922 and got modified in 1936 (3), the development of the sulfonylurea drugs is the serendipitous result of investigations of the antibiotic properties of modified sulfonamides. The so-called first generation of sulfonylureas developed in the early 1950s has been followed in recent years by a “second generation ” of far more potent compounds, and the third generation as well (4).

Sulfonylureas are widely used in the treatment of diabetes type 2. These medications inhibit the ATP-driven potassium channels in pancreatic ß cells, pushing calcium to enter ß cells, inducing them to release insulin in a process known as depolarization (5). The safety of sulfonylureas has been questioned. In the UKPDS, the outcome of sulfonylureas was similar to that of insulin whereas insulin or sulfonylurea treatment resulted to be inferior to metformin in overweight patients (6). Hypoglycemia, which is a frequent side effect of treatment with sulfonylureas, has been associated with adverse cardiovascular outcomes (7).

Metformin has been used to control hyperglycemia in patients with type 2 diabetes for more than 50 years and it is currently recommended as the first-line drug treatment along with lifestyle modification. The most widely accepted model of the anti-hyperglycemic action of metformin is that suppression of hepatic gluconeogenesis occurs principally as a

consequence of mitochondrial inhibition. AMPK, which is activated in response to mitochondrial inhibitors, including metformin, has been proposed to be an important effector of metformin (8). Previous findings to indicate that metformin can be regarded as an enhancer of GLP-1 secretion and possibly as a GLP-1 sensitizer, beyond its known biological functions (9).

164

Thiazolidinediones (TZD), which are agonists of the peroxisome-proliferator-activated receptor γ (PPARγ), are one of the new classes of anti-diabetes drugs. Early studies suggested that TZD were no more effective in lowering glycemia than were older oral medications. The result of such studies, together with the side effects of the TZD (which include, fluid retention, and the risk of congestive heart failure), contributed to the decision not to include them in the first-line treatment of diabetes. In addition, the cost of brand-name TZD is higher than that of generic metformin (10). The need of more oral agents for treatment of diabetes increased because insulin associated with more hypoglycemia and insulin still “refused” by many patients as it made weight gain (11). The unmet need of type 2 diabetes treatment promotes rapid development of incretin-based therapy. The physiological role of glucagon- like-peptide-1 7-36 amide (GLP-1 7-36) in man was investigated. GLP 1 7-36-like immuno- reactivity was found in the human bowel; its circulating level rose after oral glucose and after a test breakfast (12). GLP-1 stimulates insulin secretion, suppresses glucagon secretion, delays GI tract motility and decreases appetite (13).

Cardiovascular disease is a more common cause of death than microvascular complication in population with diabetes. There is evidence for a cardiovascular benefit of intensive glycemic control after long-term follow up of study cohort treated early in the course of type 1 and type 2 diabetes. In the DCCT, there was a trend toward lower risk of CVD events with intensive control (14). In type 2 diabetes, there is evidence that more intensive treatment of glycaemia in newly diagnosed patient may reduce long-term CVD rates, but severe hypoglycemia induces CVD events and it also may dilute the potential benefits of intensive glucose control. The future of diabetes therapy will constantly consider this cardiovascular safety. Novel therapies for type 2 diabetes abovementioned include GLP-1 agonist, DPP-IV inhibitors, bile acid sequestrant , which proven efficacy in reducing elevated low-density lipoprotein cholesterol in patients with primary hyperlipidemia and improved glycemic control in adults with type 2 diabetes (15), Bromocryptine, which is not associated with an increase of cardiovascular events, is an oral dopamine receptor agonist but its use still limited (16), and sodium glucose cotransporter-2 (SGLT2) inhibitor, a novel treatment for diabetes which is recently approved and available worldwide. Inhibition of renal tubular glucose reabsorption leading to a reduction in blood glucose concentration through enhanced urinary glucose excretion (17).

Diabetes is a perennial area of research in endocrinology and scientists are now on the precipice of a new era of treatment options. Continuous subcutaneous insulin infusion (CSII) more commonly known as insulin pump therapy was first in the marketplace in the

1980s. As the route of insulin with optimal utilization most closely mimics the physiological action of pancreas, this modality was used widely now. The use of insulin pump therapy has been expanded by the population of diabetes type 2. The evidence for CSII in type 2 diabetes remains limited (18). In the other side, the field of regenerative medicine is rapidly evolving, paving the way for novel therapeutic interventions through cellular therapies

165

and tissue engineering approaches that are reshaping the biomedical field. Mesenchymal stem cells (MSCs) offer new opportunities in the treatment of diabetes, but they also raise many scientific question that need to be addressed, particularly those related to safety and efficacy. These issues have obvious implications for the clinical application of MSC and other innovative cellular therapies (19).

Conclusively, according to the new guidelines, on bariatric surgery for type 2 diabetes, metabolic surgery should be recommended to treat type 2 diabetes in patients with Class III obesity (BMI greater than or equal to 40 kg/m2), as well as in those with Class II obesity (BMI between 35 and 39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and medical therapy. It should also be considered for patients with type 2 diabetes who have a BMI between 30 and 34.9 kg/m2 if hyperglycemia is inadequately controlled. The Consensus Statement also recognizes that BMI thresholds in Asian patients, who develop type 2 at lower BMI than other populations, should be lowered 2.5 kg/m2 for each of these categories (20).

References

1. Sicree R, Shaw J, Zimmet PZ. The global burden of diabetes. In: Gan D,ed. Diabetes Atlas, 2nd ed.

Brussels: International Diabetes Federation, 2003:15-712. Kun-Ho Yoon,Jin-Hee Lee, Jae Hyoung Cho, Yoon-Hee Choi, Seung-Hyun Ko, Paul

Zimmet, Ho-YoungSon. Epidemic obesity and type 2 diabetes in Asia. Lancet 2006; 368:1681-16883. David M. Nathan. The Type 2 Diabetes Epidemic Prevention and Treatment. Clinical

Endocrinology2016. Harvard Medical School. April 2016:2974. Feinglos MN, Lebovitz HE. Sulfonylurea treatment of insulin-independent

diabetes mellitus.Metabolism 1980 May;29(5):488-945. Aschcroft FM, Gribble FM. ATP-sensitive and K+ channels and insulin secretion:

their role in health and disease. Diabetologia 1999;42:903-9196. M. Monami, S.Genovese, E Mannucci. Cardiovascular safety of sulfonylureas:

a meta-analysis of randomized clinical trials. Diabetes, Obesity and Metabolism 2013;15:938-953

7. Atoshi Goto, Onyebuchi Arah, Maki Goto, Yasuo Terauchi, Mitsuhiko Noda. Severe hypoglycemia and

cardiovascular disease: systematic review and meta-analysis with bias analysis. BMJ 2013; 347: f4533

8. Graham Rena, Ewan R. Pearson, Kei Sakamoto. Molecular mechanism of action of metformin : old or new insight? Diabetologia 2013;56:1898-1906

9. YM Cho, TJ Kieffer. New aspects of an old drug: metformin as a glucagon-like peptide 1(GLP-1) enhancer and sensitizer. Diabetologia 2011;54:219-222

166

10. David M. Nathan. Thiazolidinediones for Initial Treatment of Type 2 Diabetes? N Engl J Med 2006;7:2477-2480

11. Wenhui Wei, Chunshen Pan, Lin Xie, Onur Baser. Real-world insulin treatment persistence among patients with type 2 diabetes: measures, predictors, and outcomes. Endocr Pract 2014;(20)1:52-61

12. B. Kreymann, MA Ghatei, G Williams, SR Bloom. Glucagon-like peptide-1 7-36: A

physiological incretin in man. Lancet 1987;5:1300-1304.13. Mentis N, Vardarli I, Kothe LD, Holst JJ, Deacon CF, Theodorakis M, Meier JJ, Nauck

MA. GIP does not potentiate the antidiabetic effects of GLP-1 in hyperglycemic patients with type 2 diabetes. Dianbetes 2011;60(4):1270-1276

14. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-1589

15. Luigi Brunetti, R Keith Campbell. Clinical Efficacy of Colesevelam in Type 2 Diabetes Mellitus. J of Pharm Pract 2011;24(4):417-425

16. Bromocriptine. Lexi-Comp Online. Hudson, Ohio: Lexi-Comp, Inc. http://www.lexi.com (subscription required). Accessed September 14, 2012

17. Abdul-Ghani MA, Norton I, DeFronzo RA. Role of sodium-glucose cotransporter 2 (SGLT2) inhibitors in the treatment of type 2 diabetes. Endocr Rev 2011;32:515-531

18. Raskin P, Bode BW, Marks JB, et al. Continuous subcutaneous insulin infusion and multiple daily

injection therapy are equally effective in type 2 diabetes: a randomized, parallel-group, 24-week study. Diabetes Care 2003;26(9):2598-603

19. Antonello Pilleggi. Messencymal Stem Cells for the Treatment of Diabetes. Diabetes 2012;61:1355 -1356

20. Francesco Rubino, David M.Nathan, Robert H Eckel, Philip R Schauer, K. George M.M. Alberti, Paul Z.

Zimmet, Stefano Del Prato, Linong Ji, Shaukat M. Sadikot, William H. Herman, Stephanie A, Amiel, Lee M. Kaplan, Gaspar Taroncher-Oldenburg and David E. Cummings on behalf of the Delegates of the 2nd Diabetes Surgery Summit. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes; A Joint Statement by International Diabetes Organizations. Diabetes Care 2016;39(6):861 -877

167

INDUSTRY SYMPOSIUM 4.2Improving Clinical Outcomes through New Generation Basal Insulin Wolfgang Schmidt (Germany)

168

SPONSORED SYMPO1.1Guidance in CV Risk Management: How to Deal with International Guidelines? Teguh Santoso Sukamto (Indonesia)

169

SPONSORED SYMPO1.2High Intensity Statins in DM & CKD: Guidelines, Evidence, Experence Soebagijo Adi Soelistijo (Indonesia)

Surabaya Diabetes and Nutrition CenterDr. Soetomo Hospital – Faculty of Medicine Airlangga UniversityIndonesia

Abstract

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for patients with type 2 diabetes (T2DM). The excess CVD risk in individuals with diabetes is due to several risk factors including both unmodifiable factors (genetics, gender, and age) and traditional risk factors such as hypertension, lipids, hyperglycemia and smoking. Most T2DM have a type of dyslipidemia that is related to insulin resistance. This profile is consist with decreased high-density lipoprotein (HDL), increased triglycerides, slightly increased low-density lipoprotein (LDL), and LDL particles that are smaller, more dense and more atherogenic.

Although LDL-cholesterol is not usually markedly increased in such individuals, it has been established as the strong predictor of coronary heart disease risk in the general population, particularly in diabetics.

The benefit of lipid lowering for primary prevention of cardiovascular disease

Is based on evidence showing a significant 33% reduction in diabetes patients with no previous occlusive vascular disease in the Heart Protection Study. In secondary prevention, statins reduce the risk of death by about 30%. In Collaborative Atorvastatin Diabetes Study (CARDS), Atorvastatin 10 mg for 4,5 years provided a 37% risk reduction of major CV events (p=0.001) in diabetes population.

The 2015 American Diabetes Association Standard of Care have been revised

to recommend when to initiate and intensify statin therapy based on risk profile of T2DM patients. In all diabetes patients aged ≥40 years, without overt CVD or additional CVD risk factors, moderate intensity statin should be considered in addition to life style therapy. For all diabetes patients with overt CVD, high intensity statin should be added to life style therapy. For diabetes patients aged <40 years or >75 years with additional risk factors, consider using moderate or high intensity statins. For diabetes patients aged 40-75 years with overt CVD or with additional risk factors consider using high intensity statin. For adults with diabetes over 75 years of age, there are limited data regarding statin therapy. High-dose statins therapy should be individualized based on risk profile.

Statin use in patients with chronic kidney disease (CKD), including patients on dialysis,

170

is also increasing. Although fewer trials exist, statins have in fact been proven to decrease the cardiovascular event rates in patients with chronic kidney disease, and no substantial evidence of harm. In the CARDS-CKD post-hoc subgroup analysis, a modest beneficial effect of atorvastatin on eGFR was observed, particularly in those with albuminuria. Atorvastatin did not influence albuminuria incidence. Atorvastatin was effective at decreasing CVD in those with and without a moderately decreased eGFR. The Kidney Disease Improving Global Outcomes (KDIGO) 2013 guidelines suggest not starting statins in CKD patients receiving chronic dialysis but continuing statins if they are already being treated with statins

Keywords: Diabetes, CKD, CVD, Statin

171

SPONSORED SYMPO1.3Separating Facts from Myths: Safety Concern of High Intensity Statins Idrus Alwi (Indonesia)

172

SS 28.1 CARDIOVASCULAR (4)Atrial Fibrillation for Internist Lukman Hakim Makmun (Indonesia)

Div.of Cardiology Dept Int.Med.FMUI/RSCM

Atrial Fibrillation (AF) is a common heart rhytm disease, especially in the older age..AF is the potential risk for stroke, by building the thrombus and causes a high mortality risk. The causes of AF could be cardiac or non cardiac disease. The pathophysiology of AF based on Reentry Mechanism in small size namely Wavelet, minimally must be 5 wavelets existed. The reentry mechanism could be appear, if there is trigger, and this trigger could be come e.g. from Pulmonary vein. Clinically AF is divided into 4 classes: Paroxysmal, Persistent, Longstanding Persistent, and Permanent. Besides it, according to EHRA, based on symptoms, AF is also divided into 4 classes as well, i.e. from no symptoms to disabling symptoms. Because AF is a high risk factor for Stroke, AF must be treated to prevent this harmful disease. Firstly the underlying disease, if existed, must be treated, and AF self must be also treated. The drug to treat AF consists of 2 types: - to control the rhytm by AAD (Anti Arrhytmic Drugs) e.g Propafenon, Amiodarone, Sotalol, and - to control the rate by drugs that works on AV node e.g. verapamil, β blocker, diltiazem, digitalis. Asides from treating the rhytm, the thrombus building must also be prevented. The drugs that can be used, are: anti aggregation drugs i.e aspirin, clopidogrel, Vitamin K antagonist (VKA) e.g. warfarin and NOAC (Novel Oral Anti Coagulant). Based on the effectiveness, VIT K antagonist is superior to anti aggregation drug, but NOAC is more superior than VKA and more practicable. By using these drugs, the bleeding side effect must be also considered, therefore before deciding the drug, Cha2ds2- Vasc- and Hasbled score must be calculated.

Currently based on the pathomechanism of stroke, that the blod clots may come from LAA (Left Atrial Appendage), the new method nowadays is to close the LAA by device e.g. Watchman device. According to the trials, this new invasive method is not inferior than VKA warfarin in preventing the stroke incidence. The other mode to treat AF is Ablation on the points that could be as a focus of trigger that can cause reentry mechanism of AF . The ablation can be done on the PV (Pulmonary Vein), AV node or linear on the atrial tissue. According to class of AF, the effectiveness of therapeutical mode is different..

173

SS 28.2 CARDIOVASCULAR (4)Current Guideline in Atrial Fibrillation Taufik Indrajaya (Indonesia)

Medical Uversity of Sriwijaya

ABSTRACT

Atril Fibrillation (AF) is still a common clinical problem. AF occurs when structural and/ or electrophysiological abnormalities alter atrial tissue to promote abnormal impulse formation and/ or propagation. These abnormalities are caused by diverse pathophysiological mechanisms that are incompletely understood.

The Management of AF is complex and fraught with many uncertain and contious issue. Which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society (CCS) AF Guidelines Committee product anxtensive set of evidence based AF management guidelines in 2010 and they did updating in the areas of anticoagulation and rate/rhythm control in 2012. In Late 2013, they did another update regarding AF management guidelines detection of AF in patients, anticoagulation of AF patients with chronic kidney disease, detection of AF patients with stroke, investigation and management of subclinical AF, left atrial appendage closure in stroke prevention, emergency department management of AF, periprocedural anticoagulation management; and rate rhythm control including catheter ablation.

The 2014, the CS Guidelines update focused and deals with advances in oral antigoagulant (OAC) therapy and presents a new “CCS algorithm” that will allow clinicians to easily determine which AF patients will benefit from OAC therapy. The update also outlines the optimal approach to perioperative OAC management and updates rate and rhythm management in AF Including catheter ablation.

The madeical profession should play a central role in evaluating the evidence releated to drugs, devices, and procedures for the detection, management, and prevention of disease. This role can improve the quality of care, optimize patient outcomes, and favorably effect cost by focusing resources on the most effevtive strategies.

Keywords; AF, Stoke prevention, AOC, catheter ablations

174

SS 28.3 CARDIOVASCULAR (4)Stroke Prevention in Atrial Fibrillation Marulam M. Panggabean (Indonesia)

Division of Cardiology, Departement of MedicineFaculty of Medicine, University of Indonesia, Jakarta, IndonesiaCipto Mangunkusumo Hospital, Jakarta, Indonesia

Embolic stroke is the most common and catastrophic complication of Atrial Fibrillation(AF). Warfarin Oral Anti Coagulant (OAC) has been established as the most effective and the cheapest drug to prevent stroke in Atrial fibrillation of Valvular and Non-Valvular AF since 1950. Unpredictable responses, narrow therapeutic window, slow onset/offset of action, interaction with food and drugs lead to OAC requiring frequent monitoring of International Normalized Ratio (INR) to adjust OAC doses. Recently Novel Oral Anti Coagulant (NOAC) has been proven as an alternative and as effective as OAC in preventing Stroke in Non-Valvular AF. No study showed the benefit of NOAC in Valvular AF yet, NOAC should not be used in Valvular AF. Comparison betwen NOACs have not been perfomed by a head-to-head study. A convincing differentiation betwen NOACs has not been fully researched. Left Atrial Appendage (LAA) closure by Percutaneous Intervention or Surgical closure of LAA is another alternative for Prevention of Stroke in AF. But Percutaneous LAA Closure device can not negate the use of OAC because the device itself is a trigger for clotting formation and this has to be prevented by Antithrombotic or anticoagulant drugs. On the other hand, thrombus formation in AF can also form outside the LAA or in any place of the LA. That’s why the LAA closure device is only indicated if AF patient has a high risk of embolus formation and bleeding.

In conclusion : OAC is effective in prevention of stroke in patients with valvular and non-valvular AF but should be monitored for maintenance of INR between 2-3, while NOAC is as effective as

OAC in stroke prevention, decreased bleeding complication in Non-valvular AF without the need of INR monitoring. LAA device and surgical LAA closure is indicated in AF patients with high risk of stroke and bleeding.

175

SS 29.1 ENDOCRINE (4)Can GLP-1RA Be Used for Treatment of Obesity in non Diabetic Patients? Wolfgang Schmidt (Germany)

176

SS 29.2 ENDOCRINE (4)Clinical Update on Non-Alcoholic Fatty Liver Disease Aslam Amod (South Africa)

MB;ChB [Natal]; FCP [SA]; Cert Endocrinology and Metabolism

Life Chatsmed Garden Hospital, Durban; Dept. of Diabetes and Endocrinology, Nelson R Mandela School of Medicine, UKZN

Non-alcoholic fatty liver disease (NAFLD) was rare in the 1980’s when the first series of 20 patients was described. Currently, it is estimated that 20-45% of the adult population have some form of NAFLD, and it is the leading cause of chronic liver disease worldwide.

NAFLD is an all-encompassing description of liver disease associated with excess fat deposition in the hepatocytes, in the absence of excessive alcohol use or other causes (viral, autoimmune or iron overload). The spectrum of NAFLD from its mildest to its most severe form includes non-alcoholic fatty liver (NAFLD) usually without inflammation, non-alcoholic steatohepatitis (NASH), with or without fibrosis, and cirrhosis. Patients with cirrhosis are at increased risk of death and hepatocellular carcinoma.

Features of the metabolic syndrome are an independent risk factor for NAFLD

However routine screening for NAFLD in this population is not recommended. On the other hand, NAFLD is an independent risk factor for features of the metabolic syndrome as well as cardiovascular death. Screening for features of the metabolic syndrome is recommended for patients with NAFLD.

This presentation will discuss the clinical approach to the management of NAFLD. This includes an evaluation for other causes of fatty liver, metabolic syndrome assessment, optimisimg all treatments for components of the metabolic syndrome, and an evaluation for chronic liver disease. The role of liver biopsy in aiding management decisions will be discussed. Non-pharmacological and specific pharmacological therapies for NAFLD, in both patients with and without diabetes, will also be reviewed.

177

SS 29.3 ENDOCRINE (4)Gut Microbiota: New Approach for Obesity Treatment

Rina Agustina1,2 and Fiastuti Witjaksono1

1Department of Nutrition and Human Nutrition Research Cluster, Faculty of Medicine Universitas Indonesia; Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

2SEAMEO Regional Center for Food and Nutrition, Jakarta, IndonesiaRecent evidence suggests that dietary modulation of the gut microbial composition might be a novel approach in the prevention and treatment of obesity-related disorders. We reviewed studies explaining the link between diet-induced changes in gut microbiota and epigenetic alteration on the pathophysiology of obesity; and evidence on the beneficial properties of probiotic strains in reducing body weight and fat, which are currently still lacking. Several studies has shown that diet plays an important role in shaping gut micro-biota diversity. High fat and low fiber diets are found to be associated with dysbiosis of the intestinal microbiota composition and causes an undesirable ratio of Bacteriodetes and Firmicutes populations. In addition, indigenous gut microbiota produces folate, biotin and short chain fatty acids (SCFAs) like butyrate, propionate and acetate that regulate gene expression and influence epigenetic modifications and inflammation. SCFAs are known as important energy sources that regulate energy hemostasis via the role of G-protein coupled receptors and act as epigenetic regulators of gene expression through inhibition of histone deacetylase and histone-acetyl transferase, and therefore become important in the management of obesity. Furthermore, other potential strategies to beneficially alter the gut microbiota composition of an obese individual is by incorporating bacteria to express therapeutic factors and by the administration of exogenous beneficial microorganisms of probiotics. Several preclinical studies that used various bacterial strains, animal models and lengths of administration, have shown some anti-obesity properties of probiotics. Several randomized controlled trials (RCT) have shown the effects of probiotics in reducing the amount of weight gained in response to a high-fat diet. However, these effects may vary depending both on the bacterial strain and on the host. A recent meta-analysis showed no significant effect of probiotics on body weight and body mass index. However, definitive conclusions are difficult to draw due to limited number of RCT, small sample size, low methodological quality of the studies, and the lack of longer-term follow up. In conclusion, gut microbiota, through the role of probiotic strains and their SCFA metabolites, have potential capacity to restore gut dysbiosis, and essential in the preven-tion and treatment of obesity. More rigorously designed RCTs are needed to prove the beneficial effects of probiotic strains on the management of obesity in the future.

178

SS 30.1 HEMATOLOGY & ONCOLOGY (4)Pain Through the Patients Lens: Cancer Pain is as Real as the cancer itself Aru W. Sudoyo (Indonesia)

179

SS 30.1 HEMATOLOGY & ONCOLOGY (4)A Perspective on Cancer Pain Management Guideline Asrul Harsal (Indonesia)Division of Hematology - Medical Oncology ,Department of Internal medicine, Faculty of Medicine University of Indonesia , Dharmais Cancer Hospital, Jakarta, Indonesia

Cancer pain is a big problem in advanced stage of cancer, more than 70 % of them complaint about pain. Many patient come to the health system in advanced stage, besides for the treatment of cancer, they also seek for supportive treatment, such as cancer pain management, nutrition, infections and others.

Many doctors are not familiar with management of cancer pain especially with opioid, and unfortunately most of those have prescribed opioid are still “under-treatment” and their patients still experiencing pain until they died. It can be considered inhumane, because good management of cancer pain is part of human right.

There are four kinds of pain, i.e. somatic, visceral, neuropathic, and idiopathic pain. Cancer pain is the combination of all.

Management of cancer pain consists of “Assessment and reassessment”, ”Treatment” and “Evaluation”.

Assessment.

Assessment is a very important part and also the first management of cancer pain. It starts with anamnesis from patient and family, physical examinations, imaging tools like X-ray, ultrasonography, CT-scan, MRI or PET-CT. We use scoring system such as Visual Analog Score (VAS) to determine the stage of cancer pain. The conclusion of assessment includes mild stage (VAS 1 – 4), moderate (VAS 5 – 6) and severe pain (VAS 7 – 10).

Treatment.

The treatment is tailored based on assessment. Almost 90% of cancer pain can be treated by medication and only about 10% must be treated using other modalities, such as radiotherapy, blockage-anesthesia and others. Medication for mild cancer pain includes paracetamol, mefenamic acid, or other NSAIDs. Sometime we also need adjuvant treatments such as bisphosphonates, gabapentin and amitriptyline. If the response is inadequate, we may consider using moderate cancer pain regiments.

Moderate cancer pain (VAS 5 – 6) treatment starts with codeine or tramadol and adjuvant treatments, according to ESMO (European Society of Medical Oncology) guideline.

Medication for severe cancer pain (VAS 7 – 10) or those have no response with previous treatment can be started with morphine infusion and titration. Pain is reassessed every 15 minutes, and intravenous bolus morphine injection can be given until pain subsides.

180

At Dharmais Hospital, reassessment is done every 120 minutes. If the pain has been controlled with fixed dose morphine infusion, we can convert it to oral morphine for convenience. The equivalent dose for converting morphine infusion to morphine oral is 1 : 3 respectively.

Evaluation

If the cancer can be cured or treated, the dose of morphine can be gradually reduced according to the reassessment and even stopping the opioid is possible. If the cancer is untreatable and the patient only get supportive treatment, the dose of opioid might increase with time and must be continued for life.

Opioid is a strong pain killer, very effective and relatively safe for severe cancer pain management. It has no ceiling dose, though naloxone should always be prepared as antidote if needed. Common side effects are nausea, constipation, and sleepy, while bradypnea is serious side effect. Always give patient laxative together with opioids.

The target of treatment is free of pain, and it can be reached by thorough assessment and reassessment.

Conclusion

Cancer pain is a big problem, especially in advanced stage of cancer. Good assessment and reassessment will make it easier to control the pain, thus increasing patient’s quality of life.

181

SS 30.2 HEMATOLOGY & ONCOLOGY (4)Oxycodone : New Formulation of Time - Tested Molecule to Optimize Cancer Pain Management Christopher Gharibo (USA)

182

SS 31.3 GASTROENTEROLOGY (2)Management of Variceal Bleeding Hernomo Ontoseno Kusumobroto (Indonesia)

Surabaya Gastroentero HepatologyCenterAirlanggaUniversity School of MedicineSutomoHospital, Surabaya

Acute variceal bleeding (AVB) is a medical emergency associated with a mortality that, in spite of recent progress, is still in the order of 20% at 6 weeks. Variceal bleeding constitutes 70% of all upper gastrointestinal bleeding episodes in patients with portal hypertension, and they result from esophageal varices (EVs), gastric varices (GVs), or ectopic varices. Remaining 30% is due to other causes, like portal hypertensive vasculopathies, Mallory Weiss lesions and ulcers.

AVB needs a clear definition, especially in terms of time frame to differentiate it from recent bleeding and rebleeding. This is especially important because treatment modalities and prognosis may differ in each of these situations.

Patients who have UGIB must be promptly and accurately clinically assessed, to provide a rational basis for key early decisions on their medical management. The medical history, physical examination, and initial laboratory values are important in assessing resuscitation requirements, triage, endoscopy timing, consultation requirements, and prognostication. Although a complete medical history is obtained, it should be focused on the gastrointestinal tract, other highly relevant history, and significant comorbid conditions. In a patient in hypovolemic shock or otherwisein extremis, the medical history is initially obtained rapidly in summaryform because of the need for emergency resuscitation, but a complete historyis obtained after patient stabilization.

In selected patients, the placement of a nasogastric tube can be considered because the findings may have prognostic value. The presence of blood in nasogastric aspirate confirms an upper GI source. Although some data do not support the placement of a nasogastric tube, the detection of red blood with an in-and-out nasogastric tube has been shown to predict poor outcome and the need for emergency endoscopy. In RUGBE, the presence of bright blood in the aspirate was an independent predictorof rebleeding. Although the consensus panel felt thatdiagnostic nasogastric aspiration is redundant, if very earlyendoscopy is to be performed orogastric or nasogastric lavagemay be helpful to clear the stomach of blood and clotsbefore endoscopy.

Patient resuscitation includes fluid administration, blood transfusion, cardiorespiratory support, and treatment of significant comorbid diseases, such as sepsis or coronary artery disease. In patients who have severe hemodynamic or pulmonary instability, EGD should be delayed until the patient is adequately resuscitated and stabilized. Patients

183

are assessed for hypovolemia and shock to determine requirementsfor fluid infusion and transfusion of packed erythrocytes, and are assessedfor comorbid diseases, especially cardiovascular disease. Intravenous accessis secured at two or more sites using 18-gauge or larger catheters. Patientswho have active bleeding receive at least 500 mL of saline, or another crystalloid solution, during the first 30 minutes to maintain the blood pressure, while several units of packed erythrocytes are typed and crossed. Fluid infusions increased if the blood pressure fails to increase or declines.

Early endoscopy should be performed in patients with major bleeding. Endoscopic therapy increases control of bleeding and decreases the risks of rebleeding and mortality. Ligation (EVL) is the recommended form of endoscopic therapy for acute esophageal variceal bleeding, although sclerotherapy may be used in the acute setting if ligation is technically difficult.

In suspected variceal bleeding, vasoactive drugs should be started as soon as possible, before endoscopy. Vasoactive drugs (terlipressin, somatostatin, octreotide, vapreotide) should be used in combination with endoscopic therapy and continued for up to 5 days. Approximately 20% of patients with variceal bleeding will suffer from an infection, when they are hospitalized. Invasive procedures will further increase the risk of bacterial infections. Meta-analysis of clinical trials comparing antibiotics with placebo demonstrates that antibiotic prophylaxis improves survival with 9% (p < 0.004). Quinolones or intravenous cephalosporins should be preferred.Antibiotic prophylaxis is an integral part of therapy for patients with cirrhosis presenting with upper gastrointestinal bleeding and should be instituted from admission.

Secondary prophylaxis should start as soon as possible from day 6 of the index variceal episode. The start time of secondary prophylaxis should be documented. Combination of beta-blockers and band ligation is the preferred therapy as it results in lower re-bleeding compared to either therapy alone.

Keywords : Variceal Bleeding, Vasoactive drugs, Endoscopic hemostasis

184

SS 31.4 GASTROENTEROLOGY (2)Marcellus Simadibrata MD PhD FACG FASGE FINASIMDepartment of Medical Education FMUI, Division Gastroenterology Department Internal Medicine FMUI / Dr. Cipto Mangunkusumo Hospital

Upper non-variceal GI tract bleeding is increasing in Indonesia and the world. The frequent etiology of upper non-variceal GI tract bleeding are NSAID, anti platelet agent, Helicobacter pylori infection etc, The comprehensive treatment of upper non-variceal GI tract bleeding need the multidisiplin management and treatment such as internal medicine, surgery, radio-intervention expert, laboratory, anesthesiology etc. Upper GI tract bleeding is defined as bleeding with the source from upper gastrointestinal tract, from esophagus to duodenum/jejunum above the ligamentum Treitz.

The diagnosis is made upon history taking, physical examination and supporting examination including endoscopy. We have to ask the patient and the family about the history of upper GI bleeding(hematemesis melena) now and before, was there coffee ground vomiting(hematemesis)/melena , history of NSAID or antiplatelet , and history of Liver diseases, DM, Cardiovascular disease, CVD, chronic renal failure, arthritis.

The management of Upper non-variceal gastrointestinal tract bleeding divided into : early management and advanced management. The early management of Upper Non-variceal GI tract include early evaluation and resuscitation. The early management of uppr no-varicesl GI tract include Multidisiplin approach, Stratification of pts with low or high risk rebleeding using Blatchford and Rockal, Inserting the nasogastric tube, Nasogastric or orogastric lavage and giving Proton pump inhibitor intravenously .

Key words: Diagnosis, Management, Upper non-variceal Gastrointestinal Tract, Bleeding

185

SS 31.5 GASTROENTEROLOGY (2)Diagnostic Aprroach of Obscured GI Bleeding Murdani Abdullah (Indonesia)Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Uni-versitas Indonesia, Cipto Mangunkusumo General Hospital

Patients with obscured gastrointestinal bleeding may present as asymptomatic disease, and patients could come to clinical practice with anemia but without any presenting symptoms before. Obscured gastrointestinal bleeding may present with overt or occult bleeding, but the source was unidentified on upper endoscopy or colonoscopy. The term of obscured gastrointestinal bleeding recently known as small bowel bleeding. Because of the development of small bowel investigation, the source of bleeding in small bowel could be identified whereas obscured gastrointestinal bleeding could be categorized as suspected small bowel bleeding. It is estimated that 75% of obscured gastrointestinal bleeding, the source is in the small bowel. However, more than 50% patients with initial esophagogastroduodenoscopy and colonoscopy identified the source of bleeding, only approximately 5-10% patients are classified as small bowel bleeding. Etiology of small bowel bleeding are likely to be inflammatory bowel disease, Meckel’s diverticulum, neoplasm, vascular lesion ulceration, or Dieulafoy’s lesion. Other rare cause of small bowel bleeding including small bowel varices, amyoloidosis, Peutz-Jeghers syndrome, sarcoma Kaposi, etc. Diagnostic modality of small bowel bleeding inclusing capsule endoscopy, push enteroscopy, intraoperative enteroscopy, angiography, or radiographic evaluation. Video capsule endoscopy have higher diagnostic yield compared to push enteroscopy (61,7% vs 55%, respectively) and VCE appeared as the first-line procedure for small bowel investigation. However, VCE only have diagnostic value and did not have therapeutic function whereas push enteroscopy may have therapeutic intervention. In the setting, wherein both VCE and deep enteroscopy are available, VCE should be the initial procedure because it is noninvasive; could provide an equivalent degree of diagnostic information as does deep enteroscopy, and at the same time provides guidance as to the direction that deep enteroscopy should be performed should it be needed.

186

SS 32.1 PSYCHOSOMATIC (1)Psychosomatic Depression in Chronic Kidney Disease: What’s should Internist Know? Hamzah Shatri (Indonesia)

Division of Psychosomatic & Palliative, Department of Internal Medicine,Ciptomangunkusumo National Hospital / Faculty of Medicine, University of Indonesia.

Depression as a psychosomatic disorder is one of the most common disorders in the daily practice. Psychosomatic depression often experienced as a stigma in community and may lead misdiagnosis. Difficulty diagnosis may be due to limited communication between doctors and patients and also overlapping symptoms in organic diseases or chronic diseases, such as depression in patients with chronic kidney disease.

Chronic kidney disease (CKD ) is important one of chronic disease that is increasing in frequency and cause psychosomatic disorders, mostly depression.. The frequency of CKD arises year by year in the world. According the course of illness, the CKD patients will experience chronic renal failure (CRF), and become to terminal stage that require renal replacement therapy to survive longer.

Renal replacement therapy like dialysis or transplantation help patient with end stage renal diseases (ESRD ) survive and one side, but may lead psychosomatic on the side of the. those ESRD patients will experience an imbalance or psychological disorder, psycho social and financial problems , which are require attention and adjustment to life and living. By the time the CKD patients already knew that they had more severe kidney disease, and must be treated by renal replacement therapy. Some patients became surprised, and experience the psychological shock, panic, deny, anger, anxiety, fear, helplessness, hopelessness, feelings and thoughts disturbed and experiencing various forms of emotional disturbance which can be developed into a psychosomatic disorder and its consequences.

The one important of psychosomatic problems, in patients with CKD, is depression. Several studies have shown that 20%-50% of late CKD patients experiencing moderate or severe depression requiring treatment . Psychosomatic research indicates that depression in patients suffering from kidney disease, accelerate the occurrence of renal failure, may worsen the prognosis, increased morbidity and mortality,and also increase treatment costs and also reduce the quality of life of patients

In General, the hypothesis of etiology widely accepted associated with depression is reduced or imbalance of neurotransmitters in the brain, primarily associated with the lymbic system. Depression can also occur due to a disturbance in the neurons receptor associated with neurotransmitter in the synaptic cleft, or reduced G protein that functions as a post receptor transduction. Some of the factors associated with increasing

187

the incidence of depression are psychosocial factors, environmental factors ,somatic stressors, age, hormonal, and some medications include beta blockers, clonidine, digoxin, steroids etc. Risc factors os depression in patients with CKD are also associated with uremia, anemia, malnutrition, infection and inflammation As well as other disorders are common in patients with CKD, medical procedures, financial problems, dialysis, loss of time and job problems, reduced social activities cause CKD patients become more depressed.

Diagnosis of depression should be done early by anamnesis systematically and details include the history of the patient’s illness past and present. The diagnosis of depression becomes more difficult because overlapping the symptoms of depression and CKD. If the medical condition of CKD has improved but not reduced patient complaints, depressed mood and fatigue, resistance or refusal of treatment, lack of adherence to treatment schedules may indicate depression.. It is recommended to screen depression patients with CKD using of the Beck Depression Inventory (BDI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Patient Health Questionnaire-9, when scores indicate a history of depression followed by a deep interview to ensure their depression syndrome.

CKD patients should perform psychosomatic examination early in order to avoid interference either depression or other psychological disorders. If done well, the difficulty of psychological and social constraints when the patient entered the terminal stage can be minimized.

Management of depression in acute conditions of CKD , should be focuse to the medical treatment according to medical conditions and clinical problems should be defined. The comprehenships standard treatment of CKD, underlaying diseases, and comorbidity, with concern to drug interactions and avoid medications that can cause or worsen depression. Simultaneously to the treatment on mental or psychic and somatic disorders, if necessary, as well as controlling the psychosocial stressors may add successful management.

Eliminating the symptoms such as dyspneu, tightness and chest pain immediately may reduce psychosomatic problems and depression. Anxiolytics can be administered together with treating the symptoms and medical conditions, when needed and there are no contra-indications. Mostly cases benzodiazepines agent were relatively safe and help patients. After the acute phase is resolved, screened the symptoms of depression soon and prioritize supportive psychotherapy before using anti-depressants. Psychotherapy (Talking Cure), especially supportive psychotherapy can be done such as ventilation, education, guidance and counseling, suggestions, spiritual religion therapy.

In patients undergoing haemodialysis group therapy is recommended.

Antidepressant may be necessary for patient with severe depression, beside intensive or special psychotherapy such as cognitive behavioral therapy. Using new

188

generation antidepressants such as selective serotonin reuptake inhibitors (SSRIs) as first choices in patients with CKD, ESRD, haemodialysis patients which also suffering of cardiovascular disorders, because it is safer than other antidepressants so we can avoid triggering arrhythmias and hypertension.

Study the use of antidepressants in CKD is limited, but some clinical studies show good results on the use of drugs such as desipramine, fluoxetine, and fluvoxamine, sertraline in patient’s haemodialysis. In peritoneal dialysis patients nefazodone, sertraline, citalopram, paroxetine and bupropion may improve the symptoms of depression. Combination with psychotherapy for 8 weeks provides a more meaningful and improves the quality of life of patients.

Internist should know, about psychosomatic depression in CKD are include early detection of depression, stressor associated depression, and management of psychosomatic depression to make better quality of life.

189

SS 32.2 PSYCHOSOMATIC (1)Comorbid Anxiety Disorders with Coronary Heart Disease: Should Immediately be Treated? E. Mudjaddid (Indonesia)

190

SS 32.3 PSYCHOSOMATIC (1)Treatment of Depression in Diabetes Patients: An Update Agus Siswanto (Indonesia)

An Update on the Treatment of Depression in Diabetic Patients:

Introducing “Latihan Pasrah Diri (LPD)”

Agus Siswanto, Arief Kurniawan Siregar

Psychosomatic Division Department of Internal Medicine

Medical Faculty of Gadjah Mada University

Abstract

Depression and diabetes has been an emerging problem worldwide. Co - occurrence of depression and diabetes further complicates the problem. Approximately 10% of diabetes patients have major depression, and recent studies have demonstrated that people with diabetes have a two fold increased odds of depression compared to individuals without. Meanwhile, adults with depression have a 37% increased risk of developing type 2 diabetes. These findings suggest a bidirectional relationship between depression and diabetes, where the outcomes of both conditions are worsened by the other. Although psychological and psychopharmacological interventions are effective in treating depressive symptoms in people with diabetes, they have inconsistent effects on glycemic control. Complementary alternative medicine (CAM) alone or in combination with standard medical treatment, targeting both depression and diabetes, appears to be promising. Latihan Pasrah Diri (LPD) has been recognized as a type of relaxation technique under CAM that variably showed its efficacy in treating depression among diabetic patients. Combined with standard therapy, LPD is expected to show its beneficial effects. However, other recent and ongoing research are about to reveal the best treatment option.

Keywords: depression, diabetes, treatment, complementary alternative medicine, latihan pasrah diri

191

SS 33.1 Tropical and Infectious Diseases (4)Risk Factors for the Development of Invasive Fungal Infections Suhendro (Indonesia)

192

SS 33.2 Tropical and Infectious Diseases (4)Invasive Candidiasis: How Can We Appropriately Use the Available Diagnostic Tools? Erni Juwita Nelwan (Indonesia)

193

SS 33.3 Tropical and Infectious Diseases (4)Antifungal Stewardship in Invasive Candidiasis Budi Riyanto (Indonesia)

The case of Invasive Fungal Infection among the patient in hospitalization are high. The frequencies very high especially in solid organ tumors. The data from 15 centers involved in a prospective cohort study of invasive fungal infections in solid transplant recipients indicate that mortality at 12 months is approximately 40% for aspergillosis, 34% for candidiasis and 27% for cryptococcosis.

These infections may cause burden not only to health but also economic burden. The pharmacy cost for the patients in the hospital very high. The patients also facing to cost and toxicities of antifungal therapy. The other issues coming up are the increasing of the resistance to antifungal. The high mortality/morbidity associated with invasive fungal infections, including adverse impact on curative chemotherapy, combined with suboptimal diagnostic tools, has driven the overuse of anti-fungal drugs. De-escalation of empiric therapy is one of the most challenging aspects of Antifungal Fungal Stewardship to implementation.

Practice guidelines adapted to the local context are the cornerstone of Anti-Fungal Stewardship. Local epidemiology of the each hospital informs the choice of anti-fungal agents for the prevention and management of Invasive Fungal Diseases, underscoring the need for surveillance. Adherence of the doctors to use minimum standards of the consensus and prescribing ensures that clinical outcomes are optimized and drug toxicities minimized, and the coordination between health care quality manager and the doctor very important to have the high target of the patient safety.

There a few data about prevalence of invasive candidiasis in Indonesia. The study reports in Indonesian journal usually about cutaneous fungal infection. Like the others developing countries, the problems are: Diagnostic, lack of experience use the anti-fungal, lack of epidemiological data and the high cost of anti-fungal. We have six parenteral injections antifungal, with two among them are local product.

The tools for succes to realize the antifungal stewardship at least needs four elements : Multidisciplinary team, periodic feedback to physician regarding programs benefits and focused goals. Use the local data and always looking back the guidelines are very important.

194

SS 34.1 HYPERTENSION / KIDNEY (3)Treatment of Hypertension in CKD Patient Paweena Susantitaphong (Thailand)

Hypertension is a global public health problem that contributes to the burden of kidney disease, disability and premature mortality. The use of automated office measurements and out of office measures, including ambulatory blood pressure monitoring and home readings, improves measurement accuracy and better predicts the risk of cardiovascular events. The Kidney Disease Improving Global Outcomes guidelines for the management of blood pressure in patients with CKD recommends prescribing an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor type 1 blocker (ARB) as the primary antihypertensive drug for patients with CKD regardless of proteinuria unless there is a contraindication. Combined RAAS blockade is currently not recommended because there is insufficient evidence to prevent progression of CKD. The target of blood pressure control in both diabetic and non-diabetic adults with CKD and urine albumin excretion <30 mg/ 24 hours are office BP ≤ 140 mm Hg systolic or ≤ 90 mm Hg diastolic and office BP ≤ 130 mm Hg systolic or ≤ 80 mm Hg diastolic in adult CKD patients with urine albumin ≥ 30 mg/ 24 hours . Lowering salt intake to <90 mmol (<2 g) per day of sodium (corresponding to 5 g of sodium chloride) in adults, unless contraindicated is also recommended in this guideline. Newer treatment approaches that use devices to reduce blood pressure seem to be reasonably safe from some clinical studies of CKD patients, but have yet to demonstrate greater efficacy than control procedures. Therefore, these procedures have not yet entered the mainstream of hypertension care in CKD. Further studies are required to clarify the most treatment regimens.

195

SS 34.2 HYPERTENSION / KIDNEY (3)Treatment of Hypertension in Diabetic patient Zulkhair Ali (Indonesia)

Div. Nephrology & Hypertension, Dept of MedicineMoh. Hoesin Hospital, Sriwijaya Medical Faculty, Palembang, Indonesia

Hypertension and diabetes are becoming increasingly common. More than 75% of adults with diabetes have blood pressure (BP) levels >130⁄80 mmHg or are using antihypertensive medication. In the natural history of type 1 diabetes, development of an elevated BP is a major predictor of nephropathy and future declines in kidney function. In contrast, hypertension is already evident in most patients with type 2 diabetes at the time of diagnosis. Untreated or poorly controlled hypertension can significantly accelerate the development and progression of both the micro and macrovascular complications of diabetes. Aggressive BP control improves patient outcomes and reduces health care costs. Unfortunately, nearly two-thirds of people with diabetes do not have BP readings within the target range.

The pathogenesis of hypertension associated with diabetes mellitus (DM) involves an interplay of hereditary and acquired mechanisms. High BP tend to occur together because they share certain physiological traits. Many metabolic and hemodynamic features of diabetes mellitus contribute to the etiology of hypertension. Several potential mechanisms are the development of renal disease, obesity, atherosclerosis, extracellular volume expansion, the contribution of renin-angiotensin-aldosterone system, altered sensitivity to catecholamines or angiotensin II, and Insulin resistance and/or hyperinsulinemia. Other factors may have a role, including abnormalities of atrial natriuretic peptide, blood viscosity and red blood cell deformability.

Given the number of guidelines regarding the management of hypertension in patients with diabetes mellitus with and without coexisting renal dysfunction, it is not surprising that there remain differences between them as to what the BP threshold to initiate pharmacologic antihypertensive therapy should be, and, once started, the goal BP to achieve. ADA in Standards of Medical Care in Diabetes 2015, recommended the goal of BP in diabetic patients is < 140/90 mmHg. Lower BP targets such as < 130/80 mmHg, may be appropriate for certain individuals, such as younger patients, if they can be achieved without undue treatment burden. Patients with BP >120/80 mmHg should be advised on lifestyle changes to reduce BP. Patients with confirmed office-based BP higher than 140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve BP goals. Pharmacological therapy for patients with diabetes and hypertension should comprise a regimen that includes either an ACE inhibitor or an angiotensin receptor blocker (ARB). If one class is not tolerated, the other should be substituted. Multiple-drug therapy (including a thiazide

196

diuretic and ACE inhibitor/ARB, at maximal doses) is generally required to achieve blood pressure targets. Considering recommendations from any guideline, it is important to remember that the management of hypertension in diabetic patients should be tailored to the individual patient.

Key words: Hypertension; Diabetes Mellitus; ACEI-ARB

197

SS 34.3 HYPERTENSION / KIDNEY (3)Hypertension and Pregnancy Gde Raka Widiana (Indonesia)

Department of Internal Medicine School of Medicine Udayana UniversityBali, Indonesia

Abstract

Diagnosis of hypertension in woman should be based of correct blood pressure measurements using a mercury sphygmomanometer at sitting position with the arm at the level of the heart, appropriately sized cuff i.e., length 1.5 times the circumference of the arm should be used.

Hypertension in pregnancy is defined as an office (or in-hospital) systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, based on the average of at least 2 measurements, taken at least 15 minutes apart, using the same arm.

Hypertensive disorders of pregnancy is classified as pre-existing hypertension, gestational hypertension, preeclampsia, or “other hypertensive effects” on the basis of different diagnostic and therapeutic considerations. The presence or absence of preeclampsia must be ascertained, given its clear association with more adverse maternal and perinatal outcomes. Women with pre-existing hypertension, preeclampsia should be defined as resistant hypertension, new or worsening proteinuria, one or more adverse conditions, or one or more severe complications. Women with gestational hypertension, preeclampsia is defined as new-onset proteinuria, one or more adverse conditions, or one or more severe complications. Severe preeclampsia is defined as preeclampsia complicated by one or more severe complications.

Antihypertensive therapy for severe hypertension included lowering to < 160 mmHg systolic and < 110 mmHgdiastolic. Initial antihypertensive therapy in the hospital setting should be with nifedipine short-acting capsules, parenteral hydralazine, or parenteral labetalol. Alternative antihypertensive medications include a nitroglycerin infusion oral methyldopa, oral labetalol, oral clonidine, or postpartum oral captopril. Refractory hypertension may be treated with sodium nitroprusside. Nifedipine and magnesium sulphate can be used contemporaneously. Antihypertensive drug therapy may be used to keep systolic blood pressure at 130 to 155 mmHg and diastolic blood pressure at 80–105 mmHg. Non-severe hypertension (BP of 140–159/90–109 mmHg) with comorbid conditions, antihypertensive drug therapy should be used to keep systolic blood pressure at < 140 mmHg and diastolic blood pressure at < 90 mmHg. Initial therapy in pregnancy can be with one of a variety of antihypertensive agents as listed for women without co-morbidities. Captopril, enalapril, or quinapril may be used postpartum, even during breastfeeding.

Key words: - hypertension – pregnancy – classification – therapy – target blood pressure

198

Thursday, 25 August 2016 KEYNOTE LECTURE 6.1Anti Microbial Resistance - A Man Made Crisis Quazi Tarikul Islam (Bangladesh)

Prof. Quazi Tarikul IslamFCPS, FACP, FRCP(Glsg), FRCP (Edin)Professor of MedicnePopular Medical CollegeDhaka, [email protected]

Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to which it was previously sensitive, so that standard treatments become ineffective and infections persist and may spread to others. AMR is a consequence of the use, particularly the misuse, of antimicrobial medicines and develops when a microorganism mutates or acquires a resistance gene.

Antibiotics and similar drugs, together called antimicrobial agents, have been used for the last 70 years to treat patients who have infectious diseases. However, these drugs have been used so widely and for so long that the infectious organisms the antibiotics are designed to kill have adapted to them, making the drugs less effective. Infections caused by resistant microorganisms often fail to respond to conventional treatment, resulting in prolonged illness and greater risk of death. Inappropriate and irrational use of antimicrobial medicines provides favorable conditions for resistant microorganisms to emerge, spread and persist. Resistance to antimicrobials is a natural and inevitable biological phenomenon that can be amplified or accelerated by a variety of factors and practices that facilitate “selective pressure”. The microbes which adapt and survive carry genes for resistance which can be passed on to the next generation of microbes and also in some bacteria, across different species. The selection pressure is utmost when antimicrobials are used irrationally in health and veterinary sectors.

The emergence and spread of antimicrobial resistance are complex problems fuelled by the knowledge, expectations and interactions of prescribers and the patients, and regulatory environment. Easy access of antimicrobials in developing countries and myths amongst communities about their use exert an equally important influence on the emergence of resistance. Thus resistance is a biological, behavioral, technical, economic, regulatory and educational problem that requires a comprehensive response. It is a major public health issue. To combat this cross-cutting problem, WHO has developed a simple and easy-to-implement strategy.

199

Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness and greater risk of death. AMR reduces the effectiveness of treatment because patients remain infectious for longer, thus potentially spreading resistant microorganisms to others. When infections become resistant to first-line medicines, more expensive therapies must be used. The longer duration of illness and treatment, often in hospitals, increases health-care costs and the financial burden to families and societies. Without effective antimicrobials for care and prevention of infections, the success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised. The growth of global trade and travel allows resistant microorganisms to be spread rapidly to distant countries and continents.

The underlying factors that drive AMR are, inadequate national commitment to a comprehensive and coordinated response, ill-defined accountability and insufficient engagement of communities, weak or absent surveillance and monitoring systems; inadequate systems to ensure quality and uninterrupted supply of medicines, inappropriate and irrational use of medicines, including in animal husbandry, poor infection prevention and control practices and depleted arsenals of diagnostics, medicines and vaccines as well as insufficient research and development on new products.

The emergence of AMR is a complex problem driven by many interconnected factors; single, isolated interventions have little impact. A global and national multi-sectoral response is urgently needed to combat the growing threat of AMR.

WHO calls on all key stakeholders, including policy-makers and planners, the public and patients, practitioners and prescribers, pharmacists and dispensers, and the pharmaceutical industry, to act and take responsibility for combating antimicrobial .

We should raise our voice now and always against the development of AMR for our future generation.

200

KEYNOTE LECTURE 6.2Essentials in Internal Medicine Rodolfo Bado (Argentina)

Essentials in Internal MedicineDr. Rodolfo Bado

Abstract

During the last two decades world population have witnessed a substantial demographic growth, particularly in developing countries where 80% of chronic non communicable diseases are emerging.

The huge impact of hypertension, cardiovascular disease, chronic obstructive pulmonary disease, diabetes and cancer on an aging population is challenging the sustainability of health institutions and government health policies as well.

We, as doctors practicing internal medicine should foresee how to train the new generations of internists and emphasize our knowledge on chronic diseases.

Hypertension is a topic where we should target aggressive preventive measures, due to its prevalence and deleterious consequences on cerebral vascular disease, heart failure, end stage renal disease and peripheral vascular disease.

Obesity, Dyslipidemia and Type 2 Diabetes are metabolic conditions we should address from childhood, initiating preventive measures, counseling about eating behavior and exercise, and once established, appropriately initiate treatment according to available resources.

Due to the overlapping of these chronic conditions, polypharmacy, particularly in the elderly, is a growing risk of undesirable consequences. A comprehensive vademecum should be managed with profound knowledge to avoid deleterious drug interactions.

Antibiotic resistance and adult vaccination are two other topics we have to focus on to reduce possible complications in frail patients with chronic diseases.

201

KEYNOTE LECTURE 7.1Problem of Treating Tuberculosis over Years H.A.M. Nazmul Ahasan (Bangladesh)

Professor of Medicine, Popular Medical College

Tuberculosis is an old disease. It is as old as human civilization. There are approximately 259 strains of Mycobacterium. The whole genomes of 259 M. tuberculosis complex (MTBC) strains have been analyzed. It indicates that MTBC emerged about 70,000 years ago, accompanied with the migrations of anatomically modern humans out of Africa. Its expansion is often described as a consequence of increases in human population density, urbanization, industrialization and movement of people across the globe.

Tuberculosis has tremendous influence on human history, Medical science, art and literature. A single disease has enriched different discipline of Science. Collective contribution of numerous scientists and physicians has forwarded us where we stand now.

The discovery of the mycobacterium and antibiotics for treatment of Tuberculosis are turning points in the history of medical science. There are many pitfalls and problems in the management of Tuberculosis till today. Managing Tuberculosis in coexisting medical conditions and extra pulmonary tuberculosis are troublesome. Various adverse effects of anti tuberculosis drugs causes difficult situations. Tuberculosis has re-emerged as new threat on the new context of HIV infection. MDR and XDR tuberculosis are threatening public health conditions. Newer investigations have been evolved to detect Mycobacterium tuberculosis and its resistance to Rifampicin and isoniazid. New regimens have been formulated for MDR and XDR TB. No new Anti TB drug has been commissioned over more that 40 years, Though few are in the pipeline.

We must be updated with recent advancement. An estimated 43 million lives were saved through TB diagnosis and treatment between 2000 and 2014. WHO calls on countries and partners to “Unite to End Tuberculosis”. The call comes as we enter the era of the Sustainable Development Goals (SDGs). Ending tuberculosis (TB) by 2030 is a target of the SDGs and the goal of the WHO End TB Strategy.

202

KEYNOTE LECTURE 7.2Successful Aging William Hall (USA)

The world-wide increases in longevity and numbers of the elderly have resulted in increased use of medical services. Yet, the vast majority of adults age 65 years and older live healthy and productive lives. Less attention in the scientific community has been placed on the factors that result in their relative good health throughout life. However, we now recognize that key life-style characteristics seem to be associated with slower progression of physiologic change. A very robust literature has developed. These studies are generally referred to as “Successful Aging”. Key factors identified are better access to medical care throughout life, abundant physical exercise, and robust socialization. The combination of these factors may result not only functional improvement but also in cognition and social involvement. It is now possible to provide a “Prescription for Successful Aging” which can provide guidelines on diet, exercise, physical activity, and socialization which is cost-effective and highly beneficial.

203

SS 35.1 CARDIOVASCULAR (5) Diagnostic Approach for Peripheral Artery Disease Budi Yuli Setianto (Indonesia)

Division of Cardiology Department of Internal Medicine Faculty of Medicine Gadjah Mada University-Sardjito Hospital Yogyakarta

ABSTRACT

The term of peripheral artery disease (PAD) is used to include all vascular sites, including carotid, vertebral, upper extremity, mesenteric, renal, and lower extremity vessels. Diseases of the aorta are not covered. Although different disease processes may cause PAD, the main cause of PAD is atherosclerosis. Atherosclerosis in the peripheral arteries is a chronic, slowly developing condition causing narrowing of the arteries. Depending on the degree of narrowing at each vascular site, a range of severity of symptoms may occur, while many patients will remain asymptomatic throughout their life. Occasionally acute events occur, often associated with thrombosis and/or embolism and/or occlusion of a major artery. PAD often involves lower extremity artery disease (LEAD), but it can also involve upper extremity artery disease (UEAD). Interestingly, in the some cohort study, LEAD, compared with CAD and cerebrovascular disease, was much more strongly related to UEAD. Risk factors for PAD are similar to those important in the etiology of CAD and are the typical risk factors for atherosclerotic disease. These include the traditional risk factors: smoking, dyslipidemia, diabetes mellitus, and hypertension. The epidemiology of LEAD has been investigated in many countries, including several in Europe. In a recent study in a population aged 60–90 years, the prevalence of LEAD was 18% and that of intermittent claudication was 7%. Typically, one-third of all LEAD patients in the community are symptomatic. The prevalence of critical limb ischemia (CLI) is very much less i.e. 0.4% in those over 60 years of age. The estimated annual incidence of CLI ranges from 500 to 1000 new cases per 1 million populations, with a higher incidence among patients with diabetes. General diagnostic approach of PAD as follows 1). History, including family history of CVD, symptoms suggesting angina, any walking impairment, e.g. fatigue, aching, cramping, or pain with localization to the buttock, thigh, calf, or foot, particularly when symptoms are quickly relieved at rest, any pain at rest localized to the lower leg or foot and its association with the upright or recumbent positions, any poorly healing wounds of the extremities, upper extremity exertional pain, particularly if associated with dizziness or vertigo, any transient or permanent neurological symptom, history of hypertension or renal failure, post-prandial abdominal pain and diarrhea, particularly if related to eating and associated with weight loss, erectile dysfunction. 2). Physical examination, it must include at least: measurement of blood pressure in both arms and notation of inter-arm difference, auscultation and palpation of the cervical and supraclavicular, fossae areas, palpation of the pulses at the upper extremities, the hands must be carefully inspected, abdominal palpation and auscultation at different levels including the flanks, periumbilical

204

region, and the iliac regions, auscultation of the femoral arteries at the groin level, palpation of the femoral, popliteal, dorsalis pedis, and posterior tibial sites, the feet must be inspected, and the color, temperature, and integrity of the skin, and the presence of ulcerations recorded, additional findings suggestive of LEAD, including calf hair loss and skin changes, should be noted. 3). Laboratory assessment, the aim of the laboratory assessment is to detect major risk factors of CVD. 4). Ankle–brachial index (ABI) is a strong marker of CVD and is predictive of cardiovascular events and mortality. Low ABI values (<0.90) are predictive of atherosclerosis, such as CAD and carotid artery disease. A reduced ABI has been associated in several studies with an increased risk of cardiovascular morbidity and mortality. Also a very high ABI (>1.40) in relation to stiffened arteries is associated with increased mortality. Recently, the ABI has been shown to be a valid method of cardiovascular risk assessment in diverse ethnic groups, independent of traditional and novel risk factors, as well as other markers of atherosclerosis such as the coronary artery calcium score. ABI is recommended as an office measurement in selected populations considered at high risk of CVDs. When performed with a handheld Doppler device, the measurement remains inexpensive and minimally time consuming. Duplex ultrasound (DUS) is now widely available for the screening and diagnosis of vascular lesions. Initially, with continuous wave Doppler, severe stenosis were identified and quantified mainly by the peak systolic velocities. Nowadays, DUS includes B-mode echography, pulsed-wave Doppler, color Doppler, and power Doppler in order to detect and localize vascular lesions and quantify their extent and severity. New techniques, such as B-flow imaging or live 3D echography, as well as the use of ultrasound contrast agents, will further improve the performance of DUS. Angiography has now been replaced by other effective non-invasive diagnostic methods and is used almost exclusively during endovascular procedures. The use of computed tomography angiography (CTA) is not recommended for screening purposes due to the high doses of radiation used, potential contrast nephrotoxicity, and the lack of data demonstrating the effect of screening with CT. High-performance scanning is used during magnetic resonance angiography (MRA) with a high signal–noise ratio and rapid data acquisition at least a 1.0 Tesla system.

Keywords: peripheral artery disease; atherosclerosis; risk factors; diagnosis.

205

SS 35.2 CARDIOVASCULAR (5) Update Management in Peripheral Artery Disease Dono Antono (Indonesia)

Cardiology Division, Internal Medicine Departement, Faculty of Medicine Universitas Indonesia,

Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Atherosclerosis in the peripheral arteries is a chronic, slowly developing condition causing narrowing of the arteries. Risk factors for atherosclerosis such as cigarette smoking, diabetes, dyslipidemia, hypertension, and hyperhomocysteinemia increase the likelihood of developing Peripheral Artery Disease (PAD). Management patient with PAD should include lifestyle modification, pharmacological treatment, endovascular procedure, and surgery. Endovascular procedure on peripheral arterial disease have a good clinical success rate with lower complication than bypass surgery. The update of intervention therapy of PAD patients in Indonesia is not yet known. From data in Integrated Cardiac Care Cipto Mangunkusumo Hospital, the total of PTA from January 2007 until May 2016 are 429 cases, arteriography 1230 cases. The cases including acute limb ischemia, critical limb ischemia, ulcer in diabetic patients, aortic aneurysm including Thoracic Endovascular Aortic Repair (TEVAR) and Endovascular Aneurysm Repair (EVAR), cephalic vein stenosis, renal artery stenosis, and erectile dysfunction. Therefore, physicians perform more endovascular revascularization which PTA is the most widely used technique than bypass surgery. These findings indicate the update of the intervention therapy is about arteriography ad hoc PTA as the most common procedure for patient with PAD.

Keywords: peripheral artery disease, intervention therapy, percutaneous transluminal angioplasty

206

SS 35.3 CARDIOVASCULAR (5) Peripheral Artery Disease Treatment in Type 2 Diabetes Shaiful Azmi (Malaysia)

207

SS 36.1 ENDOCRINE (5)Beta cell and Stem Cell Therapy in Diabetes Angela Koh Fang Yung (Singapore)

Whole pancreas and islet transplantation are the currently available beta cell replacement procedures for the treatment of type 1 diabetes, with whole pancreas transplantation being increasingly performed in patients with type 2 diabetes.

Pancreases for both whole organ and islet transplantation are obtained from deceased donors, with additional processing required in the case of islet transplantation to isolate islets from the pancreas for transplantation.

Due to the limited number of specialized pancreas and islet transplantation centres and the limited availability of donor pancreases, in addition to the risks associated with both procedures (albeit less so with islet transplantation), pancreas and islet transplantation cannot and should not be offered to the majority of patients with diabetes. Furthermore, there are long term risks associated with immunosuppression.

Thus, individualized patient assessment should be carried out in specialized pancreas and/or islet transplantation centres with detailed discussions of risks vs. benefits so that the patient can make an informed decision.

In the future, alternate sites for islet transplantation are being explored, as there remain limitations to the current route of intraportal islet delivery.

Stem cells (embryonic stem cell or induced pluripotent stem cells) have the potential to be differentiated into beta cells, and can serve as an alternate source of beta cells for transplantation. This technology is in early stages of development currently.

208

SS 36.2 ENDOCRINE (5)The Genetic Medicine in Endocrinology and Metabolism. Tjin-Shing Jap (Taiwan)

Division of Endocrinology and Metabolism, Taipei-Veterans General Hospital, Taipei, Taiwan 112

Nowadays, the utility of molecular genetics in endocrine practice has improved tremendously as compared with what we did two decades ago. Diseases with multifactorial inheritance are not genetically determined, but may develop upon predisposition by a gene mutation along with other genetic and environmental factors. In other words, it may be classified as a complex disease which is more often studied in the field of molecular epidemiology and basic research, not in daily endocrine practice.

On the other hand, single gene inheritance, also referred to as a Mendelian inheritance is a straight forward in pathogenesis and can be utilized in daily endocrine practice because a change in one DNA base pair that results in the substitution of one amino acid for another in the protein made by a gene may cause a significant clinical consequence. About two decades ago, prior to the introduction of GWA studies, the primary investigation method of monogenic disease was through inheritance studies of genetic linkage in families.

The homozygous-trait hypercholesterolemia is due to mutation of the gene encoding LDL-receptor, which may cause severe xanthomatosis and early death by 30; Complete TBG deficiency may be misdiagnosed as a case of clinical hypothyroidism; Familial hypocalciuria hypercalcemia should be suspected in patient with subtle hyperparathyroidism and is due to a mutation of the gene encoding calcium sensing receptor. Therefore, early detection of the mutated gene in monogenic disease is warranted because surgical intervention may be avoided with a correct treatment regimen administered early in the course of the disease, or even may stop the medication or shift the treatment regimen, respectively.

In recent years, the advance of new technology such as next generation sequencing (NGS) enabled the researcher and clinician to perform whole genomic study or whole exome sequencing (WES) and other technique such as genome editing with lower price and less laborious.

In conclusion, refinement in sequencing techniques and bioinformatics will increase the detecting rate of mutations.

209

SS 36.3 ENDOCRINE (5)Beneficial Impact of Helminths on Adiposity and Insulin Resistance Dicky Levenus Tahapary (Indonesia)

Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.

Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands.

[email protected]

The prevalence of obesity and type 2 diabetes (DM2) is increasing, especially in developing countries in which rapid socioeconomic developments lead to over nutrition and sedentary lifestyle. These changes lead to increasing adiposity and insulin resistance IR), thus contributing to the development of DM2.

Although the pathophysiology of DM2 is complex, chronic low-grade inflammation is a key feature of DM2, suggesting a link between metabolic signalling and immune responses. Helminth infections, which are still endemic in many developing countries, with their immunomodulatory properties and the ability to skew immune responses toward anti-inflammatory type 2 immune response may decrease systemic inflammation and subsequently the development of IR.

Recent studies in animal models of obesity have shown that helminth infections could reduce adiposity and induce better insulin sensitivity. Furthermore, several population studies have reported lower adiposity, IR and DM2 risk among people with chronic helminth infections. However, all the population studies have been cross-sectional, therefore our group have performed a randomized controlled trial (Sugarspin project http://sugarspin.org/ ), which is a collaboration between Faculty of Medicine Universitas Indonesia (FKUI) and Leiden University Medical Centre (LUMC), with the aim to assess whether soil-transmitted helminth (STH) infections are associated with better whole-body insulin sensitivity and whether this beneficial effect is reversible by anthelmintic treatment. The results of this trial will be published soon and some major findings will be presented at WCIM 2016.

References

1. Tahapary DL, de Ruiter K, Martin I, van Lieshout L, Guigas B, Soewondo P, et al. Helminth infections and type 2 diabetes: a cluster-randomized placebo controlled

210

SUGARSPIN trial in Nangapanda, Flores, Indonesia. BMC Infect Dis. 2015;15:133.2. Wiria AE, Hamid F, Wammes LJ, Prasetyani MA, Dekkers OM, May L, et al. Infection

with Soil-Transmitted Helminths Is Associated with Increased Insulin Sensitivity. PLoS One. 2015;10(6):e0127746.

3. Wiria AE, Sartono E, Supali T, Yazdanbakhsh M. Helminth infections, type-2 immune response, and metabolic syndrome. PLoS Pathog. 2014;10(7):e1004140.

211

SS 37.1 HEMATOLOGY & ONCOLOGY (5)Oral Contraception as a Risk Factor for Thrombosis : A Systemic Review and Manage-ment Lugyanti Sukrisman (Indonesia)

212

SS 37.2 HEMATOLOGY & ONCOLOGY (5)Management of VTE in Pregnancy Catharina Suharti (Indonesia)

Division of Hematology-Medical Oncology, Department of Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia

Abstract

Pregnancy is hypercoagulable state. Venous thromboembolism (VTE) is the leading cause of maternal death in pregnancy, with many deaths associated with failure to obtain objective diagnoses and lack of adequate treatment. The relative risk of antenatal VTE is approximately 5-fold higher in pregnant women.

In non-pregnant patients diagnosis of VTE use a combination of validated structured clinical prediction rules with or without the use of D-dimer testing, followed by objective testing with CUS. In pregnant patients, neither structured prediction rules nor D-dimer have not been validated. Pregnant patients with clinical suspicion of deep vein thrombosis, ultrasonography is recommended, and should be repeated at least once over 7 days if the initial study is negative. The entire length of the venous system from the external iliac to the popliteal vein must be visualized and compression manoeuvres performed from the femoral to the popliteal vein. For the diagnosis of pulmonary embolism, either ventilation-perfusion scan or computed tomographic angiography can be used, with ventilation-perfusion scan is the preferred test. Neither D-dimer alone nor clinical prediction rules should be used to rule out venous thromboembolism in pregnant women without objective testing.

Low molecular weight heparin is the preferred pharmacologic agent over unfractionated heparin for the treatment of venous thromboembolism in pregnancy. The duration of therapy is recommended for a minimum 3 months, then, anticoagulation intensity can be decreased to intermediate or prophylactic dose for the remainder of the pregnancy and for at least 6 weeks postpartum. The use of oral Xa inhibitors and oral direct thrombin inhibitor is not recommended.

The use of graded compression stockings can be considered for relief of symptoms. Thrombolytic in pregnancy should only be considered in limb-threatening deep vein thrombosis or massive pulmonary embolism, while vena cava filters should only be used in pregnant women with acute pulmonary embolism or deep vein thrombosis and contraindications to anticoagulation.

Routine screening for all inherited thrombophilias in all women with a first episode of

213

venous thromboembolism diagnosed in pregnancy is not indicated. Testing for protein S, protein C, and antithrombin deficiencies is indicated following a venous thromboembolism in pregnancy if there is a family of these particular thrombophilias, or if thrombosis occurs in an unusual site. Antiphospholipid antibodies testing is indicated if the results would affect the duration of anticoagulation.

214

SS 37.3 HEMATOLOGY & ONCOLOGY (5)Thrombophilia as a Contributive Factor in Primary and Secondary Infertility: Clinical Experience with Anticoagulants Karmel L Tambunan (Indonesia)

Thrombophilia is a Contributive Factor in Infertility and IVF Embryo Transfer Failure : Precondition Treatment with Warfarin and Aspirin and Outcome Result

Karmel L Tambunan, Lugyanti Sukrisman, Aru W Sudoyo, Djumhana Atmakusuma, A Harryanto Reksodiputro, Willy

Background: About 30% infertility problem cause by Anti Phospholipid Syndrome (APS) acquired thrombophilia while the risk of miscarriage and infertility problem was 2,5 fold greater for FU Leiden mutation (unheredited thrombopilia) carrier than normal control. Thrombophilia has a significant role in In Vitro Fertilization (IVF) embryo transfer failure. It suggests that the mechanism of thrombophilia-associated implantation failure caused by impairment in the initial vascularization process of implantation occuring at the endomethrium site, which is necessary for a successful pregnancy Anticoagulant and aspirin might improve microcirculation and perfusion of endomethrium to produce adequate receptors in accepting the fertilized ovum or embryo. The aim of this study is to evaluate the efficacy of precondition therapy with anticoagulant and aspirin in patients with infertility and IVF embryo transfer failure.

Method: All patient referred or self referred to Hematology Thrombosis hemostasis and were evaluated for hemostasis. This Study was self controled. Patient divided in two groups, women with infertility without assisted reproductive technology (ART) and woman with infertility and IVF embryo transfer failure. All patient were tested for the presence acquired thrombophilia (ACA, LA, B2GP1) and inheredited thrombophilia (ATIII, Prot C, Prot S). Factor V Leiden, prothrombin mutation, methylene tetra-hydrofolat reductase (MTHFR) were not tested due to unavailable of these tests. All patient with thrombophilia were treated with 80 mg aspirin and warfarin to achieve INR of 1,5-2,5 for precondition. Warfarin switch to Unfractioned Heparin (UFH) or Low Molecular Weight Heparin (LMWH) immediately post conception and both agent were used to term delivery. Besides these therapy, patients were also treated with Folic acid, pyridoxine and Vitamin B2 (Neurobion)

Result: Total of 128 patients were included in this study, 50 patients with primary infertility and 78 patients with IVF embryo transfer failure. Of all primary infertility patients, thrombophilia was found positive in 38 patients (76%). Mean age was 33,6 years (28-43 years) and the mean duration of infertility was 63,2 months (12-168 months). 35 patients were preconditioned with warfarin and aspirin with mean duration of 10,23 months (1-69 months). The outcome were 13 (37.1%) natural pregnancies, 10 live births, 2 fetal loss, and 1 loss of follow up. Of all IVF embryo transfer failure patients, thrombophilia was found positive in 53 patients (67,9%). Mean age was 36,05 years (25-46 years), rate

215

of IVF failure was 2,3 times (1-5 times). 41 patients were preconditioned with warfarin and aspirin mean duration of 10,8 months (1-51 months). The outcome were 13 (31,7%) natural pregnancies, 5 live births, 4 fetal loss, and 4 ongoing pregnancies.

Conclusion: Thrombophilia has a role in infertility and IVF embryo implantation failure and precondition therapy with warfarin and aspirin seemed to be beneficial.

216

SS 38.1 PULMONOLOGY (2)Are All HCAP the Same? M. Harun Iskandar (Indonesia)

Pulmonology Division, Departement Internal Medicine

Medical Haculty Hasanuddin University Makassar

The number of individuals receiving treatment at facilities other than hospitals, including long-term–health care facilities, assisted-living environments, rehabilitation facilities, and dialysis centers. As with hospital environments, nonhospital settings present their own unique risks of pneumonia. Pneumonia in these facilities has been categorized as health care–associated pneumonia (HCAP), which covers pneumonias acquired in health care environments outside of the traditional hospital setting and excludes hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and CAP. Different studies have shown that, in comparison with community-acquired pneumonia (CAP) patients, HCAP patients are significantly older, have a higher number of comorbidities (cerebrovascular diseases, congestive heart failure, dementia, and diabetes mellitus) and show worse functional status before admission. It has also been observed that HCAP differs from CAP in terms of clinical presentation, risk factors, etiology, prognostics, and, likely, therapeutic approach. The clinical presentation of HCAP is often unusual because it is frequently conditioned by advanced age, multiple chronic comorbidities, and neurological disorders. Classic respiratory symptoms of pneumonia are often mild in HCAP, whereas extrapulmonary manifestations, including mental confusion and gastrointestinal disorders, are frequent. HCAP patients, commonly present a worse clinical presentation (hypoxemia, altered consciousness, fine score, multilobar infiltrates, etc.) than CAP, and a mortality rate close to that of hospital-acquired pneumonia.The recent definition of HCAP as a distinct subset of pneumonia was intended to identify those patients with an increased risk of infection caused by MDR pathogens. Identification of patients at risk for infection with MDR pathogens increases the likelihood of adequate empirical therapy while minimizing overuse of broad-spectrum antibiotics. Because initially inappropriate antibiotic therapy is associated with increased mortality and overuse of antibiotics leads to increased antibiotic resistance, this strategy is intended to improve short-term outcomes for individual patients and long-term outcomes for the general population. Patients with HCAP are a subset of patients who present to the hospital with pneumonia and are at greater risk of colonization and infection with MDR pathogens. Risk factors for infection with MDR pathogens identified in ATS/IDSA Guideline : antimicrobial therapy in preceding 90 days, Current hospitalization of at least 5 days, high frequency of antibiotic resistance in the community or in the specific hospital unit, presence of risk factors for HCAP, hospitalization for at least 2 days in the preceding 90 days, residence in a nursing home or extended-care facility, home infusion therapy, long-term dialysis

217

within 30 days, home wound care family member with infection involving MDR pathogen, immunosuppressive disease and/or therapy. If there were no risk factors for infection with MDR pathogens, patients with HCAP would be managed like patients with CAP, which would cover the usual CAP pathogens. If there were risk factors for infection with MDR pathogens, patients with HCAP would be managed with antibiotic coverage for MDR pathogens with an emphasis on de-escalation of the initial therapy based on the response of the patients and the availability of microbiological data.

Keyword : health care, pneumonia

218

SS 38.2 PULMONOLOGY (2)Bronchiectasis: New interest in an old disease John Kolbe (New Zealand)

Professor of Medicine, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland and Respiratory Physician, Respiratory Services, Auckland District Health Board, Auckland, New Zealand.

After several decades as a true “orphan disease”, bronchiectasis is now generating increased interest. Publications in this area have increased considerably in recent years and the evidence base for management of this disease is increasing rapidly. Modern treatments are directed at improving muco-ciliary clearance, reducing the microbial load in the airway and ameliorating the inflammatory response in the airways. They include the use of inhaled mannitol, inhaled antibiotics and the use of long term macrolide therapy. There are now two published severity indices for bronchiectasis which incorporate clinical, physiologic, microbiologic and radiologic parameters as well as validated, disease-specific quality of life instruments. There has recently been much greater interest in early disease (in childhood) particularly in indigenous populations. These, and other developments in the management of bronchiectasis, will be reviewed in this “update” presentation..

219

SS 38.3 PULMONOLOGY (2)Development and Prevention of Antibiotics Resistance Cleopas Martin Rumende (Indonesia)

Division of Respirology and Critical Care, Department of Internal Medicine,

Faculty of Medicine University of Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Bacteria can adapt and grow in response to the use of antibiotics through various mechanisms. It is a natural process accelerated by overuse and misuse of antibiotics. Surveillance worldwide reported high incidence of antibiotic resistance in bacteria causing infections both in hospitals and community. Efforts are being committed to ensure continuity of the ability to treat and prevent infectious diseases with effective and safe medicines. These require interventions in every sector, including policy makers, agricultural sector, patients, and health workers.

Physicians can prevent misuse of antibiotics by adapting good medical practice, following the available guidelines. In managing pneumonia, patients can be given initial empirical treatment. Upon identification of specific pathogen, antibiotics can be adjusted, while also considering the local antibiogram in each center. Measures of infection prevention should be adapted by all health workers, and all centers are advised to actively implement surveillance program.

220

SS 39.1 PSYCHOSOMATIC (2)Evidence-based Treatment of Anxiety in Patient with Cancer Arina Widya Murni (Indonesia)

Psychosomatic Sub Division Internal Medicine Department

Medical Faculty of Andalas University/M.Djamil Hospital Padang West Sumatera Indonesia

Cancer is still one of the major health problems in the world and significantly have related death. International Agency for Research on Cancer (IARC) in 2012 reported that there was 14,1 million cancer patient around the world and 8,2 million of them was died caused by major disease or complication of stroke or heart diseases (Wang T et al, 2015).

The treatment of cancer has been success and the survival rate of cancer patient has been rising over the past decade, but negative cancer experience and side effect of cancer treatment can affect psychological and emotional problems such as depression (10%-50%), PTSD (6% - 23%) and anxiety (0 – 32%), it can contribute significantly to sleep disturbance, loss of appetite, deterioration of quality of life and also increase the risk of recurrence and mortality of cancer, psychological distress also could impair patient immune response, it can contribute to worsening prognosis of cancer.

Treatment of patient cancer should aim not only expanding life span but also improving psychological well-being. Intervention pharmacologic such a kind of antidepressant Selective Serotonin Reuptake Inhibitor (SSRI), Selective Norepinephrine Reuptake Inhibitor (SNRI), the neuroleptic agent was needed.

Nowadays the healthcare professional and patients are interesting to using structured physical and behavioral intervention to relieve anxiety and depression in cancer patients after pharmacological treatment. The structured/behavioral intervention of interest include acupoints stimulation/acupuncture, yoga, high-intensity exercise program, hypnosis, relaxation techniques, Cognitive Behavioural Therapy and Intensive Mindfulness Stress Reduction.

Previous research reported that both pharmacological treatment and intervention nonpharmacological can reduce stress (anxiety) and improved quality of life of the patient with cancer.

Keywords: cancer, anxiety, pharmacological and nonpharmacological treatment.

221

SS 39.2 PSYCHOSOMATIC (2)Adequacy of Cancer Pain Therapy Using Pain Management Index in Hospitalized Cancer PatientsRudi Putranto (Indonesia)

HE Mudjaddid*, H Shatri**Division of Psychosomatic and Palliative Medicine , Department of Internal MedicineUniversity of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Introduction: Cancer is the burden of health in Indonesia. Pain is an important health care problem for patients with cancer . In cancer patients, pain is one of the most frequent and feared symptoms. Pain can interfere with all aspects of daily life and pain relief is an important component of patient quality of life. In Indonesia, opioid consumption rates are among the lowest in south east Asia. The pain management index is a score linking the severity of pain with the medication recommended to treat it.

The purpose of this study was to identify and describe the pattern the cancer pain and to measure the quality of treatment by estimation of inadequate pain management .

Methods : The study was conducted on patients who admitted in Internal Medicine wards at Cipto Mangunkusumo National Hospital, Jakarta Indonesia for different malignancies between January to November 2014. The following socio-demographic and medical variables were collected from all participating patients: age, gender, site of cancer, tumor stage and analgesic. We analyzed intensity of cancer pain with numerical patient-rated pain scores (numerical scores 0-10), pain type and analgesic treatment. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (numerical scores 1-3), moderate (numerical scores 4-7), or severe pain (numerical scores 8-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients had no pain medication, nonopioids, ‘‘weak’’ opioids, and ‘‘strong’’ opioids. The Pain Management Index (PMI) was developed as a simple and objective tool for evaluating the quality of analgesic prescriptions, and breakthrough pain was recognized as a separate entity. The PMI is a composite measure computed by subtracting a patient’s worst pain intensity from the rating of the most potent analgesic prescribed. The PMI is considered a conservative estimate, since it does not take into consideration the doses of the analgesics used or the schedule. The PMI is the single most often used outcome measure for quality of pain treatment. The pain management index (PMI) was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain treatment.

Results: The study found 200 subject were included and the complaint of pain found from 127 patients (63%). Patients were reporting 36,5% no pain, 55,5% mild pain, 8% moderate pain and none patients with severe pain. Depending on the primary tumor site,

222

patterns of cancer were 6% genital tumors, 12% were gastrointestinal cancers, 8% were breast cancer, 35% were head and neck cancer, 6.5% were bronchopulmonary cancer, 11.5% were follicular lymphoma and 21% were carcinoma without starting point. Most patients (39,5%) used weak opioid, fifteen patients (14%) used NSAID and three patient (2%) used strong opioid . A negative PMI reflected the under treatment of cancer pain was calculated for 16 patients (12,7). Patients with non and an advanced cancer (local cancer or no evidence of any recurrent cancer) were more likely to receive inadequate treatment (p = 0.003)

Discussion: The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization’s “analgesic ladder” approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain. Our study less negative PMI if compare with other study such as Mitera et al that found the PMI was 25,8%.

Limitation of PMI were we did not know how doses the analgesic and contribution of others confounding factors.

Conclusions

The quality of treatment of cancer pain need attention. The prevalence of inadequate cancer pain management was 12,7%. Weak opioid frequently used by physician.

Key worlds : cancer pain, pain management index (PMI)

Refferences: 1. Charles S. Cleeland, Rene Gonin, Alan K. Hatfield, John H. Edmonson, Ronald H. Blum, James A. Stewart, Kishan J. Pandya. Pain and Its Treatment in Outpatients with Metastatic Cancer. N Engl J Med 1994; 330:592-596

2. Marie-Josephine Seya, Susanne F. A. M. Gelders, Obianuju Uzoma Achara,Barbara Milani, and Willem Karel Scholten. A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country, Regional, and Global Levels. Journal of Pain & Palliative Care Pharmacotherapy. 2011;25:6–18.

3. Ramona Palalogos, Alexandru Mocanu, Loredana Balacescu, Ariana Nemes, Robert Rajcsanyi, Tobias Jozsef, Calin Cainap, Claudia Burz. The Assessment of Cancer Pain Treatment Using the Pain Management Index in Hospitalized Patients with Cancer. A Pilot Study. Journal of Radiotheraphy & Medical Oncology 2012 ; XVII / 2: 64-68.

4. Mitera G1, Zeiadin N, Kirou-Mauro A, DeAngelis C, Wong J, Sanjeevan T, Sinclair E, Danjoux C, Barnes E, Tsao M, Sahgal A, Chow E. Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index. J Pain Symptom Manage. 2010 Feb;39(2):259-67.

223

SS 39.3 PSYCHOSOMATIC (2)Role of Psychosomatic Medicine Related with Cancer Treatment Atsuko Koyama (Japan)

Department of Psychosomatic Medicine, Kindai University, Faculty of Medicine, JAPAN

Background: Total pain of cancer patients consists of a combination of four factors: physical, psychological, social distress, and spiritual pain. The Department of Psychosomatic Medicine, Kindai University Faculty of Medicine set up a new outpatient service for cancer patients and their family members in order to improve the quality of whole cancer care. The primary aim of this study is to clarify the role of psychosomatic medical doctors in cancer treatment and clinical practice, and the second aim is to clarify the characteristics of cancer distress types in order to elucidate the measures that should be taken.

Methods: The data of new patients who had visited the psycho-oncology outpatient service of Kindai University Hospital during the period of May 2013 to October 2015 were collected. Demographic factors and all assessed items were extracted from the patients’ medical charts retrospectively. Hospital Anxiety Depression Scale (HADS) was used for the assessment of psychological distress.

Results: The data of 101 cancer patients were analyzed and there were more female patients than male patients (female: male ratio = 71: 30). The most common psychiatric disorders were major depressive disorder, anxiety disorders and adjustment disorders. The reasons for consultation ranged from psychological support after receiving bad news, before/after surgery and chemotherapy to control delirium. Female cancer patients were more likely to suffer from psycho-social issues such as changes in appearance, family problems and sexuality issues than male patients, and male patients were more likely to have spiritual pain.

Conclusions: Psychosomatic medical doctors can play an important role in the field of cancer treatment through psycho-oncological activities. They contribute to improving the quality of whole cancer care, including physical, psychological, social and spiritual aspects, for both cancer patients and their family members.

224

SS 40.1 Tropical and Infectious Diseases (5)The Pre-travel Consultation to Tropical Countries: What should We Aware of? Erni Juwita Nelwan ( Indonesia)Division of Tropical and Infectious DiseaseDepartment of Internal Medicine Faculty of Medicine Universitas [email protected]

Travellers are a-specific population that poses higher risks of health problem due to sudden changes in environment or activities. Travel to tropical countries would increased risk of illness while returning home. In a geosentinel report 2000-2010, malaria, giardiasis, and dengue fever is the most common reported illness among traveller from 18 geosentinel surveys. It is clear that infectious diseases are of particular importance.

Pre-travel consultation is done in term of determine potential health hazards and could be used to educate traveller for anticipated risks and how to prevent, to give immunizations or vaccination for preventable diseases, prophylaxis medications, self-treatment, also to give counseling and messages regarding how to manage general health condition during travel particularly to tropical countries.

During pre-travel consultation several information need to be elaborated besides health background, data on itinerary of the trip: duration, travel purpose, activities. Potential risks should be determined and advice would be deliver in personalized manner. Such ubiquitous risks for food and water-borne infections, sexually transmitted disease, respiratory infections should be reminded. We could classify the destination place related to risk of illness as low risk, moderate risk or high risk. Each steps will resulted in different work up before leaving the home country. Preparation would be considered the (potential) disease outbreaks or current outbreaks too. During consultation, the patient perception and tolerance of risk should also be elaborated to have a agreeable decisions about activites and prophylactic measures that could be conducted.

225

SS 40.2 Tropical and Infectious Diseases (5)Travel Immunizations for Vaccine Preventable Diseases Iris Rengganis (Indonesia)

226

SS 40.3 Tropical and Infectious Diseases (5)Risk for Leptospirosis Infection in Adventurous Travel Activity Muhammad Hussein Gasem (Indonesia)

Leptospirosis is the most widespread zoonosis in the world and endemic in tropical countries. Leptospira sp, the causative agent, is excreted by urine of wild and domestic animals in the nature. Infection in human is caused by contamination with water, soil, or food containing urine from infected animals. This may happen by swallowing contaminated food or water or through skin contact, with mucosal surfaces such as the eyes or nose, or with broken skin. Risk factors for leptospirosis are vary, can be associated to environmental factors such as flooding, housing, sanitation, and host factors like personal hygiene, occupation, risky behavior, recreational or travel related activities.

Outbreaks of leptosirosis related to recreational activities have been increasingly reported in the last decade. In a multisport race, the athletes conducting activities that may facilitate exposure to environment-contaminated Leptospira such as jungle trekking, caving, canoeing, scuba-diving, mountain-biking and swimming. In this race, nearly half of athletes met the case definition of leptospirosis. Leptospirosis outbreaks were also reported following a triathlon competition and after an adventure race. In the latter, 23% of the participants fulfilled the criteria of suspect for leptospirosis after the race. Factors associated with increased risk of leptospirosis in the adventure race were swallowing water from river or swamp, and submerging in water.

Preventive measures for leptospirosis may be advisable for travelers before adventurous activities. Until now, effective human leptospirosis vaccine is not yet available. Self protection using goggles and wearing boot-shoes are suggested. Administration of doxycycline 200 mg oral/week for military training personnel in endemic areas and for people living in areas during or after flooding, has shown to be effective for clinical leptospirosis prophylaxis. Despite small number of subjects analyzed, taking doxycycline before or during the eco-challenge race was protective for leptospirosis. Whether doxycycline should be given for prophylaxis leptospirosis in adventurous activities, need to be proven in further study.

227

KEYNOTE LECTURE 8.1Emerging Therapies forDiabetes Mellitus Adri Kok (South Africa)

Type 2 Diabetes mellitus is a worldwide epidemic. As more people are diagnosed with this condition, it has become clear that many patients with the disease are not treated to adequate glycaemic levels to prevent long term complications. The ideal HbA1c level of 7% is a difficult target to achieve in many patients with existing therapies. There are also negative effects of existing therapies such as hypoglycaemia, weight gain, oedema, worsening heart failure and then, some therapies are less effective over time as beta cell failure worsens. This has necessitated the development of new classes of drugs with new target organs as well as improved insulin formulations.

This discussion will focus on several new classes of anti-diabetic treatments including the incretin mimetics, SGLT2 inhibitors, a brief mention of bromocriptine and new insulin formulations that will add to our treatment of the disease. The pathophysiology will be discussed, how these agents act with existing treatments and the significant advantages of the new therapies. Some of the cardiovascular outcome trials will be discussed, specifically the EMPA-REG and LEADER studies. New insulin formulations and their use in both T1DM and T2DM will be discussed. In conclusion the individualised approach to treating diabetes will be discussed as well as appropriate targets for glycaemic control.

228

KEYNOTE LECTURE 8.2Multidisciplinary Approach to Cancer: Role of the Internist - Aru W. Sudoyo (Indonesia)

229

Oral Presentation 1, Tuesday, 23 August 2016Moderator: William Hall (USA)Room: NDH 4Group: Animal Study

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 022 Fatih Tangı Turkey

Vitamin D Supplementation in High-Fat Diet Decreases Plasma Acylation Stimulating Protein and Complement C3 Levels in Rats

15.40 - 15.50 OP 034Fahimeh Mohammadghasemi

Iran

Balsamic Vinegar Ameliorates Liver Injury and Protects It Against Apoptosis in Rat Under High Fat Diet

15.50 - 16.00 OP 049 Indah Prasetya Putri Indonesia

Effect of Ethanoliic Extract of Sea Cucumber (Holothuria scabra) on the Blood Glucose Level Reduction of Alloxan Inducted Male White Rat (Rattus novergicus L)

16.00 - 16.10 OP 052 Eva Niamuzisilawati Indonesia

Effect of Ethanol Extract of Bee Propolis on The Expression ff NF-ΚB, Lymphocyte Count and The Degree of Intestinal Inflammation in The Rat Model of Sepsis

16.10 - 16.20 OP 061 Semra Ozdemir Turkey

The Effects of Aluminum Administration in Different Doses and Durations to Rats on Tissue Trace Element

16.20 - 16.30 OP 063 Andika Agus Budiarto Indonesia

Effectiveness Test of Ciplukan (Physalis Angulata) Extract as an Antimicrobial in Salmonela-Induced Wistar Rat

230

Oral Presentation 2, Tuesday, 23 August 2016Moderator: Adri Kok (South Africa)Room: NDH 1-2Group: Cardiolog

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 065 Todung DA Silalahi Indonesia

The First Hybrid Coronary Revascularization Procedure in Indonesia for Multiple Vessels Coronary Artery Disease Management

15.40 - 15.50 OP 047 Skochko Olga Ukraine

Clinical Efficacy of 6 - Month Course of Treatment with Azithromycin and Pioglitazone in Patients with Coronary Heart Disease

15.50 - 16.00 OP 050 E.Gulderen Sahin TurkeyFluoxetine Prevents Ischemia Reperfusion Induced Acute Cardiac Inflammation and Injury

16.00 - 16.10 OP 058 Eka Ginanjar Indonesia

Modified Thrombolysis In Myocardial Infarction (TIMI) Risk Score as 30-Day Mortality Predictor in ST-elevated Myocardial Infarction (STEMI) Patients

16.10 - 16.20 OP 029 Wei-Syun Hu Taiwan

Cataract Increases the Risk of New-Onset Atrial Fibrillation: Insights from a Nationwide Cohort of 23 Million People

16.20 - 16.30 OP 082Naomi Niari Dalimunthe

Indonesia

Hyponatremia on Admission and Its Impact on Clinical Outcomes in Patients Hospitalized for Heart Failure

231

Oral Presentation 3, Tuesday, 23 August 2016Moderator: Hideo Wada (Japan)Room: NDH 3Group: Cardiology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 069 Sally Aman Nasution Indonesia

Role of Modified Acef Score in Predicting Coronary Lesion Complexity in CKD Patients with Acute Coronary Syndrome

15.40 - 15.50 OP 006Yogi Agung Prima Wardhana

Indonesia

Managing Congestive Heart Failure With Comorbid Of Chronic Kidney Disease: Rationale Use Spironolactone

15.50 - 16.00 OP 084 Sally Aman Nasution Indonesia

Acute Coronary Syndrome (ACS) Patients with Non-significant Coronary Artery Disease: Profile and Comparison

16.00 - 16.10 OP 098 Hasanah Mumpuni Indonesia

Predicting The Value of Ejection Fraction in Patient with Heart Failure : Can It Be Applied by A Scoring System ?

16.10 - 16.20 OP 103 Muhadi Indonesia

Electrolyte Imbalances in Acute Coronary Syndrome (ACS) Patients: Prevalence and Its Associated Comorbidities

16.20 - 16.30 OP 024 Liu Cheng Wei Taiwan

Prevalence and Prognostic Association of Admission, Persistent, and New-Onset Anemia in Patients with Ischemic Cardiomyopathy and Left Ventricle Systolic Dysfunction

16.30 - 16.40 OP 046Ricardo Adrian Nugraha

Indonesia

Vitamin D Deficiency as Novel Risk Factor of Accelerated Atherosclerosis Cardioascular Diseases in Patients with Systemic Lupus Erythematosus

232

16.40 - 16.50 OP 104 Idrus Alwi Indonesia

High-Sensitivity C-Reactive Protein (HS-CRP) Levels in Coronary Heart Disease Patients with Type-2 Diabetes Mellitus

Oral Presentation 4, Tuesday, 23 August 2016Moderator: Philip Poi (Malaysia)Room: Uluwatu 1Group: Gastroenterology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 009 Madalina Ilie RomaniaRole of food Ig G 4 antibody exclusion diet and microbiota modification in IBS treatment

15.40 - 15.50 OP 097 Musa Salmanoğlu Turkey

Evaluation of The Relationship Between Pentraxin-3 Levels to The Clinical, Laboratory and Endoscopic Parameters in Patients with Ulcerative Colitis

15.50 - 16.00 OP 075 Dini Henriyanto Indonesia

Association between Ammonia Serum Level and Degree of Oesophageal Varices in Liver Cirrhotic Patients at Dr.Soetomo Hospital Surabaya

16.00 - 16.10 OP010 Guntur Darmawan Indonesia

Association between Helicobacter Pylori Infection and Graves’ Disease: A Meta-Analysis

Oral Presentation 5, Tuesday, 23 August 2016Moderator: Shiv K Sarin (India)Room: Uluwatu 5Group: Geriatric

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 021Jerry Eanes Sanches Simões

PortugalOne of The Principals Cause of Morbility in Elderly People in Portugal

233

15.40 - 15.50 OP 028 Omar Al-Mukhtar Australia

Factors Associated with Statin Cessation Among Elderly Patients Admitted To A Large Australian Geriatric Subacute Unit

15.50 - 16.00 OP 053 Seyit Ahmet Uslu TurkeyRelationship between Polypharmacy, Comorbidities and Dementia in Elderly

16.00 - 16.10 OP 073 Ari Christy Muliono IndonesiaAssociation between Total Testosteron Serum Level and Frailty in Older Men

16.10 - 16.20 OP 107 R Purnami Indonesia

Correlation between Depression and Cognitive Impairment in Elderly Patients in Sanglah Hospital, Bali: A Cross-Sectional Study

16.20 - 16.30 OP 108Purwita Wijaya Laksmi

Indonesia

Muscle Mass and Function and Their Association with Daily Protein Intake among Non-Diabetic Pre-Frail Geriatric Patients

16.30 - 16.40 OP 094Maximilao Amietniansky

ArgentinaActive Surveillance and Fragility in Elderly in Patients with Renal Mass

Oral Presentation 6, Tuesday, 23 August 2016Moderator: Elsa van Duuren (South Africa)Room: Uluwatu 7Group: Hematology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 001 Tatsuo Misawa Japan

Safety And Efficacy Of Rivaroxaban 10 Mg In Advanced Aged Patients With Non-Valvular Atrial Fibrillation And Preserved Renal Function

15.40 - 15.50 OP 003 Andrew Huynh Australia

Time to antibiotics administration in cancer patients with febrile neutropenia; a rural Australian experience

234

15.50 - 16.00 OP 008 Kim Seung Tae South KoreaThe impact of PD-L1 expression in patients with metastatic GEP-NETs

16.00 - 16.10 OP 013 HoChun Choi South KoreaFactors Associated with Physical Activity in Cancer Survivors

16.10 - 16.20 OP 015 Chiachun Tsai Taiwan

Hyperferritinemia is Associated with Lower Height-Adjusted Skeletal Muscle Index in Taiwanese Elderly Men.

16.20 - 16.30 OP 027 Cheng-Wei Liu japan

Baseline Hemoglobin Levels Associated with One-Year Mortality in ST-segment Elevation Myocardial Infarction Patients

16.30 - 16.40 OP 031 Amaylia Oehadian Indonesia

The effect of Chemotherapy on High Fluorescence Lymphocyte Count and Lymphocyte in Lymphoma non Hodgkin

16.40 - 16.50 OP 076 Zoubida Tazi Mezalek Morocco

Thromboprophylaxis Use and Concordance with Guidelines Among Medical and Surgical Patients in Morocco

Oral Presentation 7, Tuesday, 23 August 2016Moderator: Neil Sheerin (UK)Room: Kintamani 1Group: Hematology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 093Maria Florencia Grande Ratti

Argentina

Clinical Course of Patients with Venous Thromboembolism and Inferior Vena Cava Filter: Cohort Study

15.40 - 15.50 OP 091Steffie Simpinano Solin

IndonesiaRelation between Anemia and Clinical Outcomes in Patients Hospitalized for Heart Failure

15.50 - 16.00 OP 081Ugroseno Yudho Bintoro

Indonesia

Survival in Chronic Myelogenous Leukemia Patiens- A Single Center Data in Surabaya Indonesia

235

16.00 - 16.10 OP 071Arlyando Hezron Saragih

IndonesiaThe Role of Fecal Immunochemical Test to Detect Colorectal Cancer

16.10 - 16.20 OP 077 Rudi Putranto Indonesia

Quality of Cancer Pain Treatment Using the Pain Management Index in Hospitalized Patients

16.20 - 16.30 OP 090 Erty Sundarita Indonesia

Diagnostic Test of Fecal Immunochromatographic Tumor M2 Pyruvate Kinase in Patients with Clinical Suspicion of Colorectal Cancer in Moehammad Hoesin Hospital Palembang

Oral Presentation 8, Tuesday, 23 August 2016Moderator: Julie Li Yu (Philippines)Room: Kintamani 2Group: Hepatology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 092 Guntur Darmawan Indonesia

Association between Serum Uric Acid and Non-Alcoholic Fatty Liver Disease: A Meta-Analysis Study

15.40 - 15.50 OP 037 Mika Yamaneki Japan

The Association Between an Increase of Alanine Aminotransferase and Arteriosclerosis Related Factors in Japanese Individuals.

15.50 - 16.00 OP 041 Chia-Yen Dai Taiwan

The Association between Glucose Status in Development of Liver Cancer in Patients With Hepatitis C after Cure by Interferon-Based Therapy

236

16.00 - 16.10 OP 045 Chia-Yen Dai TaiwanThe Prevalence of Chronic Hepatitis B: A Community-Based Study from Southern Taiwan

16.10 - 16.20 OP 068 Zeynep Altin Turkey

Influence of Pegylated Interferon and Ribavirin on Insulin Resistance and Metabolic Factors in Patients with Chronic Hepatitis C

16.20 - 16.30 OP 019 Eda Kaya Turkey

Prevalence of Hepatic Steatosis in Apparently Healthy Medical Students: a Transient Elastography Study based on Controlled Attenuation Parameter

Oral Presentation 9, Wednesday, 24 August 2016Moderator: Rodolfo Bado (Argentina)Room: NDH 4Group: Immunology & Infectious

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 014 Gerhard Sissolak South AfricaTreatment Oucome and Management of AIDS Defining Lymphoma

15.40 - 15.50 OP 074 Ihwan Arifiyanto Indonesia

Comparison Of Effects Of Meningococcal MenACWY–CRM197 Vaccination To Meningococcal Specific Total IgG Serum Levels In Elderly And Young Adults : Pre-Post Test Study for Surabaya Hajj and Umra Pilgrims Candidate 2015

15.50 - 16.00 OP 087 Alvina Widhani Indonesia

Effect of Ramadan Fasting on Inflammation and Oxidative Stress an HIV Patients Receiving Antiretroviral Therapy

237

16.00 - 16.10 OP 048 Dejan Pilcevic Serbia

Microbiological Profile of Capd Peritonitis: 10 Years of Expirience – Our Way to Empirical Therapy

16.10 - 16.20 OP 059 Hiromasa Yakushiji Japan

Analysis of Blood Cultures in Patient Presenting with Sepsis due to Pneumonia at the Emergency Department in Japan

16.20 - 16.30 OP 066 Khwaja Nazim Uddin BangladeshMelioidosis in Bangladesh-An Update

16.30 - 16.40 OP 080Muhammad Abdur Rahim

Bangladesh

Frequency, Risk Factors and Antibiotic Sensitivity Pattern of Extended-Spectrum Beta-Lactamase Producing Uropathogens: Single-Center Experience from Dhaka, Bangladesh

16.40 - 16.50 OP 088 I Ketut Agus Somia Indonesia

Does Syphilis Infection Influence The Change of HIV-1 RNA and Cd4 Count in Blood ? A cohort study among MSM with HIV infection in Sanglah Hospital Bali

16.50 - 17.00 OP 101Pliego-Reyes Carlos Lenin

Mexico

The Effect Of The Intravenous Immunoglobulin In The Immunomodulation And Clinical Evolution On Elder Patient With Sepsis

Oral Presentation 10, Wednesday, 24 August 2016Moderator: Aslam Amod (South Africa)Room: NDH 1-2Group: Endocrinology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 005 Bruno Almeida Portugal

Starting Insulin In Type 2 Diabetes: Cross-Sectional Study Of Portuguese Data From 2006 To 2014

238

15.40 - 15.50 OP 012 Dwi Septian Wijaya Indonesia

The Effect of Negative Pressure Wound Therapy (NPWT) for Management Wound Healing Process Gangrene in Patients with Diabetes Mellitus

15.50 - 16.00 OP 016 Dae Hyun Lee Netherlands

A 16-Week Very Low Calorie Diet Improves The Endothelial Glycocalyx in Obese Type 2 Diabetic Subjects

16.00 - 16.10 OP 018 Ramona S. DeJesus USA Detection of Prediabetes and Its Progression to Diabetes: A Population Based Study

16.10 - 16.20 OP 044 Fatimah Eliana IndonesiaThe Role of Metformin in Improving Endothelial Dysfunction in Prediabetes

16.20 - 16.30 OP 113 Sunju Choi South Korea

Evaluation of a Newly Synthesized Ligand as Peptide Radionuclide Therapy on Neuro-Endocrine Tumor

16.30 - 16.40 OP 105Abu Shahin Mohammed Mahbubur Rahman

BangladeshDepression In Patients With Diabetes Mellitus- An Analytical Study In Bangladesh

Oral Presentation 11, Wednesday, 24 August 2016Moderator: Suthat Fucharoen (Thailand)Room: NDH 3Group: Endocrine

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 007 Jaehyuk Lee South Korea

Controlled Attenuation Parameter (CAP) have close relationship with the Prevalence and the severity of NAFLD in a T2DM population

15.40 - 15.50 OP 017 Pinar Karakaya Turkey

Relation of Serum Paraoxonase-1 Activity with Biochemical Variables and in Obese Versus Non-Obese Diabetic Patients

239

15.50 - 16.00 OP 079 Okan Bakiner Turkey

Plasma Fetuin-A Levels and Its Relation with Cardiovascular Risk Factors in Patients with Hypothyroidism

16.00 - 16.10 OP 086 Hendra Zufry Indonesia

Radiofrequency Ablation of Benign Symptomatic Thyroid Nodules: Efficacy and Safety Profiles

16.10 - 16.20 OP 096 Dicky L Tahapary IndonesiaMetabolic Adaptation to A 5-days High-Fat High-Calorie Diet: Rural and Urban Comparison

16.20 - 16.30 OP 102 Maria Paula Russo Argentina

Prevalence of Hyperglycemia and Incidence of Stress Hyperglycemia in Hospitalized Patients: A Retrospective Cohort

16.30 - 16.40 OP 002Radityo Bagus Wicaksono

Indonesia

Diabetes Mellitus as A Risk Factor of Surgical Site Infection and Perioperative Antibiotic Use Following Major Surgical Procedure

Oral Presentation 12, Wednesday, 24 August 2016Moderator: Yoshio Yamaoka (Japan)Room: Uluwatu 1Group: Lab Research

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 040Siriyaporn Dhammachat

ThailandPara Grass Beta-Expansins with IgE-Reactivity Against Sera of Thai Atopic Donors

15.40 - 15.50 OP 055 Neneng Ratnasari Indonesia

Association between Insertion/Deletion of Promoter DNA VEGF (rs699947) with VEGF/sVEGFR-2 Ratio in Chronic Liver Disease

240

15.50 - 16.00 OP 078 Raveinal Indonesia

The Influence of Cumin Extract (Nigella Sativa) for Inflammation Marker sTREM-1 and Eosinophil Count at Asthma Bronchial Patients

16.00 - 16.10 OP 109Made Ratna Saraswati

Indonesia

Single Nucleotide Polymorphisms Variants of Transcription Factor 7- Like 2 Gene Expressed Different MRNA Isoforms In The Peripheral Blood

Oral Presentation 13, Wednesday, 24 August 2016Moderator: Kong Kok Ooi (Singapore)Room: Uluwatu 5Group: Nephrology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 035 Arief Nurudhin Indonesia

Effect of Secretome Messenchymal Stem Cell to HsCRP levels and TNF α in Mice Model of Lupus Nephritis

15.40 - 15.50 OP 056 Rien Afrianti Indonesia

Clinical risk factors profile for Intradialytic hypertension in End Stage Renal Disease at hospital dialysis units in Bandung

15.50 - 16.00 OP 060 IBN Mahendra Indonesia

Relationship between Intradialytic Blood Pressure Variability (BVP) and Ultrafiltration Removed (UFR) During Hemodialysis (HD) Session in Badung District Hospital

16.00 - 16.10 OP 106 Berns Russia

Registry Data Show That Hypertension Combined with Comorbid Disorders is A Risk Factor for Adverse Perinatal Outcomes In Pregnant Women

241

16.10 - 16.20 OP 111 Emel Gokmen Turkey

Evaluation Of The Effect Of Fgf-23, Il-1 Beta And Kim-1 On Disease Progression And Mortality In Patients With Chronic Kidney Disease

16.20 - 16.30 OP 011 Teslime Ayaz Turkey

Modified Body Mass Index Predicts Poor Outcome of Patients with Biopsy-Proven AA Amyloidosis with Renal Involvement.

16.30 - 16.40 OP 030 Masaki Hara Japan

Decline of estimated glomerular filtration rate is a risk of poor outcome for HIV-infected patients

16.40 - 16.50 OP 067 Adhi Permana Indonesia

Effectiveness Grant of Zinc to Nutritional Status and Inflammation in Chronic Kidney Disease Patients Those Undergoing Haemodialysis Regular in Mohammad Hoesin Hospital Palembang

Oral Presentation 14, Wednesday, 24 August 2016Moderator: Sandra V. Navarra (Philippines)Room: Uluwatu 7Group: Nephrology & Nutrition

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 070 Seyit Ahmet Uslu TurkeyEffects of Anemia and Renal Failure on the Survival in Elderly Patients

15.40 - 15.50 OP 085 Ivan Pchelin Russia

Clinical Correlates of Hemoglobin Level and Pathogenesis of Anemia in Patients with Early Diabetic Nephropathy

15.50 - 16.00 OP 020 Koichi Miyakoshi JapanImpact of Nutritional Status on Length of Hospital Stay

242

16.00 - 16.10 OP 032 Hiroto Tanaka Japan

Differeces of Polyunsaturated Fatty Acid in Healthy Japanese Living in Inland and Seacoast Area at Wakayama Prefecture

16.10 - 16.20 OP 036 Valery Gafarov Russia

Sleep Disturbances and Risk of Stroke in Men Aged 25-64 Years: Who Epidemiological Program Monica -Psychosocial

16.20 - 16.30 OP 057 Nyoman Kertia Indonesia

Javanese Traditional Massage Combined with Extract of Curcuma xanthorrhiza radix, Centella asiatica leaf, and Clarias batrachus, could Improve Dementia in Geriatric Patients

Oral Presentation 15, Wednesday, 24 August 2016Moderator: Paweena Susantantiphong (Thailand)Room: Kintamani 1Group: Rheumatology & Pulmonology

TimeCode Number

Name Country Tittle

15-30 - 15.40 OP 083 Ika Trisnawati Indonesia

The Effect of Erdosteine Administration on Neutrophils Sputum in Patients with Stable Chronic Obstructive Pulmonary Disease

15.40 - 15.50 OP 110Restuti Hidayani Saragih

IndonesiaRifampicin Resistance Tuberculosis in HIV Patients : A Retrospective Study

15.50 - 16.00 OP 043 Lya Rosita Indonesia

Serum Complement and Anti-dsDNA levels in Relation to Renal and Non-renal Manifestations of Systemic Lupus Erythematosus

243

16.00 - 16.10 OP 064Bernard Agus Sakti Dakhi

Indonesia

Correlation between Disease Duration, Disease Activity Score, Disability Score with Diastolic Dysfunction in Rheumatoid Arthritis Women in Ciptomangunkusumo National Central General Hospital

16.10 - 16.20 OP 039Herman Bagus Trianto

Indonesia

The Relationship of Adequacy and Serum Insulin-like Growth Factor-1 (IGF-1) and Insulin-Like Growth Factor Binding Protein-1 (IGFBP-1) on Peritoneal Dialysis Patient

244

OP 022Vitamin D Supplementation in High-Fat Diet Decreases Plasma Acylation Stimulating Protein and Complement C3 Levels in Rats

Fatih Tangı (Turkey)

Background: Although previous studies suggested that there is an association between vitamin D and adipokines such as leptin and adiponectin, the relationship between vitamin D and acylation stimulating protein (ASP) has not been established.

Aim: The aim of the current study was to examine the effects of supplementation of vitamin D on circulating ASP, C3 and C-reactive protein (CRP) levels in young growing rats provided with a high-fat diet (HFD). Materials/Subjects and Methods: Twenty-one, 4 weeks of age, male Sprague- Dawley rats were randomly divided into 2 groups. One of them served as the HFD group (n = 14), while control group (n = 7) remained on normal laboratory chow food for 6 weeks. Then, rats in the HFD group were randomly divided into two groups, HFD with vitamin D or HFD with no added vitamin D for 6 weeks.

Results: The addition of vitamin D to short-term HFD, compared with both rats on normal diet and vitamin D restricted group, led to both reduced plasma ASP and C3 levels. Moreover, vitamin D concentrations negatively correlated with circulating ASP and C3 levels. Interestingly, the levels of CRP among these 3 groups were not different at the end of the experimental period. Conclusions: Our results demonstrated that, when compared with rats on a normal diet or vitamin D restricted HFD, the addition of vitamin D to the shortterm HFD may have contributed to reduction in both plasma ASP and C3 levels without altering CRP levels and body weight.

245

OP 034Balsamic Vinegar Ameliorates Liver Injury and Protects It Against Apoptosis in Rat Under High Fat Diet

Fahimeh Mohammadghasemi (Iran)

1. Cellular & Molecular center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht-Ira n

2. Student Research Center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht-Iran

3. Anatomy Department, Faculty of Medicine, Guilan University of Medical Sciences, Rasht-Iran

4. Biochemistry Department, Faculty of Medicine, Guilan University of Medical Sciences, Rasht-Iran

5. Social Medicine Department, Faculty of Medicine, Guilan University of Medical Sciences, Rasht-Iran

Background: High fat diet leads to liver apoptosis, steatosis, inflammation, elevated liver enzymes and lipid peroxidation. Vinegars contribute on apoptosis pathway and can reduce steatosis, inflammation and lipid profile.The aim of this study was to evaluate the effect of balsamic vinegar, on liver injury and apoptosis in rats under high fat diet (HFD).

Methods: In this experimental study, 24 male wistar rats were divided into 3 groups (n=3): control, high fat diet (HFD), HFD & balsamic vinegar (BV). Control group received 16.6 % Kcal per day, and the other groups received high fat diet (HFD) 51.6 % containing canola oil. After getting HFD for 4 months, group 3 received oral balsamic vinegar (5%), through water for 6 weeks. After 22 weeks, biochemistry profiles were evaluated with photometric and ELISA methods. Evaluation of liver tissue lesion was performed with immunohistochemistry and histopathology methods. Data were analyzed using ANOVA and Tuckey post hoc test.

Results: High fat diet induced fatty liver and apoptosis. Vinegar decreased liver tissue lesion and apoptosis (p< 0.05). It also improved serum lipid profiles. Significant differences in LDL level were not observed among groups. Significant alternation was not seen in tissue total antioxidant status, but serum antioxidant in HFD group was significantly decreased compared with control (p< 0.001).

Conclusion: This study revealed that daily use of balsamic vinegar (5%) in rats under high-fat diet for 6 weeks, can improve tissue liver and apoptosis. It also modified lipid profile, such as TG & HDL.

246

OP 049Effect of Ethanoliic Extract of Sea Cucumber (Holothuria scabra) on the Blood Glucose Level Reduction of Alloxan Inducted Male White Rat (Rattus novergicus L)

Indah Prasetya Putri (Indonesia)

Faculty of Medicine, University of Riau

Background : Sea cucumber (Holothuria scabra) is one of Indonesian marine resources and it has already know can be used for traditional oral antidiabetic drug. Sea cucumber has many chemical compunds, which it has been suspected has antidiabetic, one of which is flavonoid. The purpose of study is investigate the effect of sea cucumber ethanol extract to reduce blood glucose level of alloxan induced male white rat.

Methods: This experimental laboratory used post test only control group design with 25 rats by completely randomized design at 2-3 months with 154-270 gram/body weight. Alloxan induced diabetic male wistar strain.The dose of alloxan 150 mg/BW given by intraperitoneal.The rats divided in 5 groups, each group consist 5 rats. Group I as negative control given aquadest orally,group II as positive control given glibenclamide with dose 0.18 mg/200gram BW, the etanol extract concentration of sea cucumber given 25% for group III, 50% for group IV and 100% for group V.

Result: The result showed that the rats given ethanol extract of sea cucumber with concentration 100% is the highest average decrease of blood glucose level (90,3 mg/dl) than given concentration 25% (153,3 mg/dl), 50% (103,9 mg/dl) and glibenclamide (113,7 mg/dl). There are significantly different between given ethanol extract of sea cucumber 100% and glibenclamide (p<0.05).Rats given ethanol extract of sea cucumber 100% show decrease of blood glucose is more lower than glibenclamide. But,ethanol extract of sea cucumber with concentration 25% and 50 % was not effective significantly.

Conclusion: This research found that the ethanol extract of sea cucumber (Holothuria scabra) has glucose level reduction effect of alloxan inducted male white rat (Rattus novergicus L)

247

OP 052Effect of Ethanol Extract of Bee Propolis on The Expression ff NF-ΚB, Lymphocyte Count and The Degree of Intestinal Inflammation in The Rat Model of Sepsis

Eva Niamuzisilawati (Indonesia)

Sub Division Tropic Disease and Infection Internal Medicine DepartmentMedical Faculty of Sebelas Maret Univercity/Moewardi HospitalSurakarta,Central Java,Indonesia

Background: The mortality rate from sepsis is still high thus requiring innovation and clinical therapy to address fundamental. The main immunopathogenesis is infectious, inflammatory processes and apoptosis pathways mainly lymphocytes and gastrointestinal tract epithelium. This study aimed to Proving influence bee propolis ethanol extract on the expression of Nuclear Factor-κB (NF-κB),lymphocyte count and the degree of intestinal inflammation rat model of sepsis.

Subjects and Metods: This laboratory experimental study used post-test only control group design, 18 samples of rats Balb / C males divided into 3 groups (control, sepsis, sepsis + propolis 200 mg/kg/day/oral). Sepsis induction of experimental animals with intraperitoneal injection of cecal inoculum (200 mg /kg). Research in the laboratory of Histology, Biomedical and Pathology Anatomy Faculty of Medicine, Sebelas Maret University Surakarta. ANOVA statistical analysis for result of NF-κB and lymphocyte count, Kruskall Wallis test for the degree of intestinal inflammation.

Results: ANOVA test of NF-κB and lymphocyte count showed p <0.001. LSD post hoc test propolis administration decreased the expression of NF-κB significantly (p <0.001). LSD post hoc test propolis administration significantly increased lymphocytes (p = 0.023). Kruskall-Wallis test showed propolis significantly reduce the degree of intestinal inflammation (p = 0.005).

Conclusion: The ethanol extract of propolis proven effect on decreasing the expression of NF-κB, increased lymphocyte count and a decrease in the degree of intestinal inflammation mice model of sepsis.

Key words: Extracts Ethanol Propolis, NF-κB, count lymphocytes, degrees inflammatory

248

OP 061The Effects of Aluminum Administration in Different Doses and Durations to Rats on Tissue Trace Element

Semra Ozdemir (Turkey)

1Istanbul University Cerrahpasa Medical Faculty Department of Biophysics,

Istanbul, Turkey

Background: Aluminum (Al) is the third most abundant element in the Earth’s crust. Aluminium is all around us in everyday life in buildings, boats, planes and cars, household appliances, packaging, computers, cellphones, containers for food and beverages, cosmetic products, medical treatments such as childhood and adult vaccines, hemodialysis fluids and antacids. The aim of the study was to investigate the possible effects of Al exposure in different durations and doses on trace elements in rat tissues.

Methods: 40 male Wistar Albino rats, weighing 240–260g, were randomly divided into five groups as Group I (3 weeks, 8 mg/kg AlCl3), Group II (6 weeks, 8mg/kg AlCl3), Group III (3 weeks, 16mg/kg AlCl3), Group IV (6 weeks,16mg/kg AlCl3) and control. AlCl3 was injected intraperitoneally five times a week. At the end of the treatment period, all animals were sacrificed and samples of spleen, pancreas, thymus, testis and heart were removed. Cr, Cu, Fe, Mg, Mn, Se, Zn, Al, As, B, N, and Si elements were measured in the tissues by using ICP-OES.

Results: There were no significant difference in Cr and Fe levels. Spleen Cu levels were higher in Group I and II according to the control (p<0,05). The statistically significant decreases were determined in pancreas Mg and Mn levels in Group III and IV according to the control. Both the spleen Mn and Zn levels and thymus Se level were determined higher in Group II than Group IV which exposured more Al dose. Conclusion: The results indicate that Al exposure can lead to significant changes in the tissue distribution of a number of essential elements dependent on dose and duration.

249

OP 063Effectiveness Test of Ciplukan (Physalis Angulata) Extract as an Antimicrobial in Salmonela-Induced Wistar Rat

Andika Agus Budiarto (Indonesia)

Andika Agus Budiarto1, Febrianto Pandapotan Simanullang2, Komang Veni Widiyanti3, Gianina Dinda Pamungkas4, V. Rizke Ciptaningtyas51. Faculty of Medicine, Universitas Diponegoro2. Faculty of Public Health, Universitas Diponegoro3. Faculty of Psychology, Universitas Diponegoro4. Faculty of Medicine, Universitas Diponegoro5. Department of Microbiology, Faculty of Medicine, Universitas Diponegoro

Background Salmonella typhi is a gram negative bacteria that causes typhoid fever. The first line treatment of typhoid fever is chloramphenicol, thiamphenicol, or ampicillin/amoxicillin. However, studies conducted in the last five years reported that many drug resistance in Salmonella thypii. Ciplukan plants contains ethanol that can potentially kill the bacteria Salmonella thypii and alkaloids to reduce fever. The purpose of this study is to prove the effectiveness of the Ciplukan extract as an antimicrobial in Wistar rat induced bySalmonella typhii.

Method This studyused true experimental design with post test randomized controlled group design. 20 Wistar rats were divided into 4 groups : normal control group as K1, typhoid fever control group as K2, P1 group was given 100 mg/kg Ciplukan extract and P2 group was given 0.5 mg/kg chloramphenicol. Inducing Salmonella typhii with the concentration of 1.5 x 105 CFU/ml intraperitoneally was given for 1 week followed by giving Ciplukan extractand chloramphenicol in the next 2 weeks. Effectiveness test of bacterial culture used Mac Conkey media, then identify with biochemical TSIA-IMViCMo test.

Result From the biochemical test showed positive growth of Salmonella typhii, 80% in K2 group, 40% in P1 group, and 20% in P2 groups. Mean while from the negative growth of Salmonella typhii,100% in K1 group, 20% in K2 group, 60% in P1 group, and 80% in P2 group. In the ANOVA test obtained a significant difference (p = 0.046).

Conclusion Ciplukan extract is effective as antimicrobial in Wistar rats induced by Salmonella typhii.

Key words : Ciplukan, Salmonella thypii, kloramfenikol.

250

OP 065The First Hybrid Coronary Revascularization Procedure in Indonesia for Multiple Vessels Coronary Artery Disease Management

Todung DA Silalahi*, Ismail Dilawar**, Andreas M Siborutorop*

Division of Cardiovascular, Department of Internal Medicine, Jakarta Heart Center Hospital, Jakarta, Indonesia.

Department of Cardiothoracic Surgery, Jakarta Heart Center Hospital, Jakarta, Indonesia.

Abstract

Background: Hybrid Coronary Revascularitzation (HCR) procedures introduced in 2011 by the American Hearth Association/ American College of Cardiology Foundation updated guidelines for coronary artery bypass grafting (CABG) surgery, combine the superiority of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) revascularization with percutaneous coronary intervention (PCI) by means of drug-eluting stents (DES) for non-LAD vessels. Various minimally invasive surgical approaches are used to perform LIMA to LAD graft. The advantages of this procedures is no need for open hearth surgery, off pump surgery, less pain, easier and faster recovery, shorter hospital stay, lower risk of infection, minimal scarring and decrease blood clots. It has been described as a “best of both worlds” strategy for treating multi-vessel coronary artery disease. Jakarta Heart Center Hospital is the first hospital in Indonesia which have been conducting HCR procedures since 2013 with a good final result.

Case: A good candidates for HCR is patients with Ostial, complex or occluded LAD lesion with simple lesions of other coronary arteries, elderly patients ( left main disease with low syntax score ), overweight or diabetic patients, comorbidities making sternotomy high-risk, patients requiring redo revascularization for multivessel disease and the LIMA is not utilized for the LAD. There are four cases of Hybrid Coronary Revascularization in Jakarta Heart Center which has the varies characteristics of a blockage in coronary arteries with a good final result.

Conclusions: Multiple Vessels Disease in the coronary arteries is a problem that is quite complicated in patients with Coronary Artery Disease (CAD). Hybrid coronary revascularization represents an alternative approach for patients with multivessel coronary disease with excellent short-term angiographic and clinical outcomes. HCR provides a minimally-invasive alternative to traditional coronary artery bypass surgery and may provide a more durable alternative to multivessel PCI. HCR can more enhance the circulation pump function of the heart and coronary arteries.

Keywords: Hybrid Coronary Intervention, Percutaneous Coronary Intervention, Minimal Invasive Direct Coronary Arterial Bypass, Multiple Vessels Coronary Disease

251

OP 047Clinical Efficacy of 6 - Month Course of Treatment with Azithromycin and Pioglitazone in Patients with Coronary Heart Disease

Skochko Olga (Ukraine)

Higher State Education Institution of Ukraine “Ukrainian Mediical Stomatological Academy”, Poltava, Ukraine

Background : In case of pathophysiology the atherosclerosis is a proliferative granulomatous inflammation localized in the connective tissue of the intima of vessels. One of the important mechanisms in the development of atherosclerosis in patients with type 2 diabetes is insulin resistance. The aim is to evaluate the clinical effectiveness of a 6-month course of azithromycin and pioglitazone in the treatment of patients with coronary heart disease (CHD).

Methods : The study were conducted on the basis of 1 City Clinical Hospital in Poltava, during the period 2012 – 2014 and included 63 male and female CHD patients ages 45 to 68 who were randomized to receive the complex therapy of the observation group (n=23) or azithromycin (AZ) (n=20): 500 mg/d for 3 days, then 500 mg/wk for 6 months; or pioglitazone (PG) (n=20) : 15 mg/d for 6 months. It was carried out clinical, and laboratory tests (lipid methabolism, of TIMP-1, hs-CRP, glycemic profile) instrumental (ECG, cardiac stress test, ultrasonography of the neck vessels).

Results: Addition to standard therapy as AZ and PG resulted in a reduction in systolic and diastolic blood pressure (BP, p <0.05), an increase in the number of people with normal or optimal blood pressure levels (p <0 , 05). In both treatment groups (AZ or PG) tended to improve functional class (FC) of heart failure and angina, reducing the number complained of pain duration and frequency of angina attacks. The therapy AZ unlike PG therapy had greater reduction in the size of atherosclerotic plaques in blood vessels of the neck (p <0.05) reduction of complex intima-media (p <0.05). As a result, the treatment of AZ showed a significant reduction of systemic inflammatory markers (ESR, hs-CRP), and of PG - reducing carbohydrate metabolism markers (indicators of oral glucose tolerance test and hyperglycemic coefficient), on the background of the two drugs decreased lipid markers (cholesterol, LDL), increasing rates of TIMP-1.

Conclusions. The additional advantages of using AZ, in patients receiving combination therapy of CHD, consist in providing pronounced systemic anti-inflammatory effect, while the benefits of PG - beneficial effect in reducing insulin resistance and lipid markers.

252

OP 050Fluoxetine Prevents Ischemia Reperfusion Induced Acute Cardiac Inflammation and Injury

E.Gulderen Sahin (Turkey)

Gulderen Sahin1, Onur M Yaman1, Ibrahim Guner1, Olgu Enis Tok2, Mukaddes Pala3 Mukaddes Esrefoglu2, Nermin Yelmen1

1. Department of Physiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, TURKEY

2. Department of Histology and Embryology, Faculty of Medicine, Bezmialem Vakif University

3. Department of Physiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, TURKEY

Background: Aortic ischemia reperfusion (IR) is an important factor in development of postoperative acute cardiac injury following abdominal aortic surgery. Inflammatory mediators has been implicated as a corner stone of reperfusion injury. Hence, anti-inflammatory therapies take important place. The aim of the present study was to examine the possible anti-inflammatory effects of fluoxetine, which is already used as a preoperative anxiolytic in the context of ischemia - reperfusion induced by occlusion of infrarenal abdominal aorta (60 min of ischemia) and its effects on cardiac inflammation, cardiac function and cellular integrity in reperfusion (120 min post-ischemia).

Methods: Male wistar rats were randomly assigned as control(Sham), IR, and pretreated groups. The pretreated group animals received Flx (20 mg/kg, i.p.) for three days before surgery. The serum creatine kinase (CK) and creatine kinase-MB (CK-MB) levels were considered markers for cardiac function. Cardiac tissue myeloperoxidase (MPO) activity, pro-inflammatory cytokines (tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6) and anti-inflammatory cytokine; interleukin-10(IL-10) were assessed. Tissue leucocytes infiltration and cellular integrity was assessed by histologically. Statistical analysis was performed by One-way ANOVA as post-hoc Bonferroni test. p < 0.05 was considered significant.

Results: IR resulted in increased CK and CK-MB levels (p<0.01). IR without Flx led to significant increase in MPO, TNF-α, IL-1β, IL-6 (p<0.001) and significant decrease in IL-10(p<0.01). Pretreatment with Flx significantly reduced CK and CK-MB levels when compared to the IR group (p<0.05). Flx significantly decreased the concentrations of TNF-α, IL-1β, IL-6, and MPO activity in cardiac tissue caused by IR (p<0.001). IL-10 was found to be increased in Flx pretreated group(p<0.01). Histological evaluation showed that Flx attenuated the morphological changes associated with cardiac injury.

Conclusion: Our study clearly demonstrates that fluoxetine confers protection against aortic IR-induced cardiac inflammation, tissue leucocyte infiltration and cellular integrity.

253

OP 058Modified Thrombolysis In Myocardial Infarction (TIMI) Risk Score as 30-Day Mortality Predictor in ST-elevated Myocardial Infarction (STEMI) Patients

Eka Ginanjar (Indonesia)

Departement of Internal Medicine, Faculty of Medicine Universitas Indonesia –Cipto Mangunkusumo Hospital. Jakarta, Indonesia

Correspondence mail:

Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital. Jl. Diponegoro no. 71, Jakarta 10430, Indonesia. email: [email protected].

ABSTRAK

Tujuan: Memodifikasi skor TIMI STEMI dengan memasukkan variabel fraksi ejeksi ventrikel kiri (FEVK) dan laju filtrasi glomerulus (LFG) sebagai prediktor mortalitas dalam 30 hari pada pasien STEMI di Rumah Sakit Umum Pusat Nasional (RSUPN) Cipto Mangunkusumo. Metode: Studi kohort retrospektif terhadap 487 pasien STEMI yang dirawat di RSUPN Cipto Mangunkusumo pada periode 2004-2013. Besar sampel dihitung dengan menggunakan rumus rule of thumbs. Data diperoleh dari penelusuran rekam medis dan dianalisis secara bivariat dan multivariate. Model sistem skor baru dibuat berdasarkan hasil analisis kemudian diujikan pada seluruh data dan dinilai risiko mortalitasnya. Kemampuan presisi dan dan diskriminasi dari model sistem skor baru ditinjau dengan menggunakan uji Hosmer-Lemenshow dan AUC (area under receiver operating characteristic curve). Hasil: Analisis secara bivariat dan multivariat menunjukkan bahwa hanya dua variabel yang dapat digunakan dalam model sistem skor baru yaitu kelas Killip II-IV dan LFG dengan kisaran total skor 0-4.6. Klasifikasi risiko mortalitas dalam 30 hari pada pasien STEMI adalah tinggi (total skor >3,5; 46,5%), sedang (total skor 2,5-3,5;23,2%), dan rendah (total skor <2,5;5,95%). Skor TIMI STEMI termodifikasi memiliki presisi (p > 0,05) dan modifikasi (AUC 0.816; IK 95%; 0.756-0.875) yang baik. Kesimpulan: Skor TIMI STEMI termodifikasi terdiri dari dua variabel yaitu kelas Killip dan LFG. Modifikasi ini memiliki kalibrasi dan diskriminasi yang baik sebagai prediktor mortalitas 30 hari pada pasien STEMI.

Kata kunci: Skor TIMI, Skor TIMI Termodifikasi, Mortalitas 30 hari, LFG, FEVK

ABSTRACT

254

Aims: To modify TIMI STEMI score, which is a 30-day mortality predictor in STEMI patients, by including left ventricle ejection fraction (LVEF) and glomerulus filtration rate (GFR) as variables. Methods: Retrospective cohort study was done toward 487 STEMI in-patients in RSUPN Cipto Mangunkusumo in 2004-2013. Data were obtained from medical records and analyzed with bivariate and multivariate method using Cox’s Proportional Hazard Regression Model. Subsequently, a new scoring system was developed to predict 30-day mortality rate in STEMI patients. Calibration and discrimination features of the new model were assessed with Hosmer-Lemeshow test and Area Under Receiver Operating Characteristic Curve (AUC) respectively. Results: Bivariate and multivariate analyses show only two statistically significant variables which are Killip class II-IV and GFR with total score values ranging between 0-4.6. Thirty-day mortality risk stratification for STEMI patient is high if total score >3.5 (46.5%), moderate if the total score is 2.5-3.5 (23.2%), and low if the total score < 2.5 (5.95%). Modified TIMI STEMI score has satisfactory calibration (p > 0,05) and discrimination (AUC 0.816 (0.756-0.875; CI 95%)). Conclusion: Modified TIMI STEMI score has two variables, which are Killip Class and GFR, and satisfactory calibration and discrimination.

Keywords: TIMI Score, Modified TIMI Score, 30-Day Mortality, GFR, LVEF.

BACKGROUND

Acute Coronary Syndrome (ACS) is a global problem, judging from the staggering morbidity and mortality rate in developed countries as well as in developing countries such as Indonesia.1 Although there is no national scoped study yet in Indonesia, Rumah Sakit Umum Pusat Nasional (RSUPN) Cipto Mangunkusumo has data that show an increase in inpatients with ACS in ICCU.2 Setyawan et al (2011) demonstrates that mortality rate of STEMI patients in RSUPN Cipto Mangunkusumo is 18,6%.3

Early and accurate treatment for ACS patients is necessary to diminish mortality rate. Therefore, a mortality risk scoring system is designed to allow practitioners to predict mortality risk and devise a management plan. At the moment, mortality risk prediction scoring system called Thrombolysis in Myocardial Infarction (TIMI) is widely used.4 TIMI STEMI score is a simple risk stratification, which consists of parameters obtained directly when patients arrive in the hospital.4 This score has been validated in Indonesia by Setiawan dkk3 and has shown evidence of calibration and discrimination ability in 30-day mortality prediction with calibration plot value 0,98, Hosmer-Lemeshow test value 0,93, and AUC 0,801 (0,759-0,844; CI 95%). However, this score is not reliable for high risked ACS patients with diabetes mellitus and chronic renal failure.5

Another parameters are glomerulus filtration rate (GFR) and left ventricle ejection fraction (LVEF), which are known to affect prognosis of STEMI patients. Studies done by Gibson et al6, Akif et al1, and Selvarajah et al7 exhibit correlation between high creatinine and

255

low GFR value in STEMI patients and TIMI score and increase of mortality rate in these patients.1,6,7 Vivian G Ng8 et al has proved that 30-day mortality in STEMI patients is related to left ventricle dysfunction. The study explains that patients with normal LVEF have lower mortality rate than the ones with low LVEF. When In TIME II (2000) study was done, these parameters were suggested to be included in TIMI score calculation. Nonetheless, since creatinine test and echocardiography were unfavorable at that time, these parameters were excluded.

We attempt to modify TIMI STEMI score as 30-day mortality predictor in STEMI patients by including GFR and LVEF, which we consider to be necessary and easy to obtain today. The modification of this score is expected to allow more accurate 30-day mortality prediction in STEMI patients.

METHODS

study subjects and sample size

Study subjects are all STEMI patients who undergo revascularization therapy (PPCI and thrombolytic) and conservative therapy in RSUPN Cipto Mangunkusumo Jakarta and may be followed up. STEMI patients with severe comorbidities, such as acute stroke, hepatic cirrhosis, acute complication of diabetes mellitus, sepsis, chronic inflammation disease, or malignancy, were excluded as well as STEMI patients who are pregnant, breastfeeding, or without complete medical record. Sample size was calculated with rule of thumbs formula. This study needed 484 samples to answer the research question.

study design and procedure

The design of this study is retrospective cohort based on prognostic studies. Data was collected from inpatients medical record and 30-day mortality outcome after onset STEMI was recorded from December 2013 onwards. Main data are TIMI STEMI score and its components, GFR and LVEF, and 30-day mortality rate post STEMI. Basic demographic data such as age, sex, smoking history, dyslipidemia history, and location of infarction are recorded.

statistic analysis

Data were analyzed using SPSS 21.0. Basic data were evaluated with descriptive statistic. To answer research question, analysis is carried out with bivariate and multivariate method using Cox’s Proportional Hazard Regression Model. After new prognostic scoring model was obtained, its calibration and discrimination features were tested using Hosmer-Lemeshow test and by evaluating area under receiver operating characteristic curve (AUC) respectively. Classification based on risk death was constructed. The classification derives from score interval that was obtained from the new scoring system. This model

256

of new scoring system is tested on all data and compared to the pre-existing TIMI score.

RESULTS

subject characteristics

This research has 487 subjects with STEMI, which more than the estimated necessary sample size, as shown on table 1.. There are 371 male patients (76,2%) and 116 female patients (23,8%) with age ranging between 28-91 years old and 57 year old as median. There are 247 subjects who received reperfusion therapy and 213 subjects who received conservative therapy.

Bivariate analysis with p<0.25 shows that there is association between 30-day mortality in STEMI patients and several parameters, which are age, systolic blood pressure, heart rate, Killip class, LVEF, and GFR,as shown in table 2.

Table 1. Basic and clinical characteristic in subjects

Parameter score Nilai p HR (IK95%)Age< 65 years old Reff65-74 years old 0.001 2.564 (1.443-4.555)≥75 years old 0.373 1.607 (0.566-4.561)Systolic blood pressure <100 mmHg 0.008 2.276 (1.236-4.912)Heart rate >100x/menit < 0.001 1.643 (1.248-2.164)Killip class II-IV < 0.001 3.466 (2.187-5.494)Comorbidity (diabetes mellitus/ hypertension/angina) 0.606 1.164 (0.654-2.072)Reperfusion therapy >4 hours 0.711 1.213 (0.438-3.361)Anterior infarct location/ left bundle branch block 0.383 1.303 (0.719-2.360)Glomerulus Filtration Rate (GFR)≥60 ml/minute Reff30-59 ml/minute 0.006 2.523 (1.300-4.895)<30 ml/minute <0.001 7.426 (3.789-14.555)Left Ventricle Ejection Fraction (LVEF) <40% 0.027 2.089 (1.087-4.014)

*Reff: Referensi

257

OP 029Cataract Increases the Risk of New-Onset Atrial Fibrillation: Insights from a Nationwide Cohort of 23 Million People

Wei-Syun Hu (Taiwan)

1 School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan

2 Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan

Author for correspondence: Wei-Syun Hu, M.D., Ph.D,

Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital 2, Yuh-Der Road, Taichung 40447, Taiwan

Tel: 886-4-22052121, ext. 3483 Fax: 886-4-22065593

E-mail: [email protected]

Abstract

Background: There is limited data regarding the association between cataract and the incident atrial fibrillation (AF) risk in the literature.

Purpose: We attempted to determine the relationship between cataract and subsequent risk of new-onset AF development.

Methods: Our retrospective cohort study was conducted to analyze the Longitudinal Health Insurance Database 2000 (LHID2000) of the Taiwan NHI program. We established a cataract cohort (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 366) (n = 39347) and a non-cataract cohort (n = 39347) and observed the incidence of atrial fibrillation. Propensity score matching was calculated the probability by using logistic regression model and included the baseline variables as age, sex, index year and comorbidities. Univariable and multivariable Cox proportional hazards regression models were used to estimate the hazard ratios (HRs) of AF associated with cataract.

Results: During 12 years of follow-up, the cumulative incidence curves of atrial fibrillation showed that the cataract cohort had a significantly higher risk of developing atrial fibrillation than did the non-cataract cohort (P < .001). Moreover, compared to patients without cataract, the risk of atrial fibrillation was 1.32-fold (95% CI=1.18-1.48) higher in the cataract patients with surgery and was 1.21-fold (95% CI=1.06-1.37) higher in the cataract patients without surgery.

258

Conclusions: The patients with cataracts had a greater risk of developing new-onset AF, particularly in the age ≤49 years. Future studies to verify our finding and detect the underling mechanism are mandatory.

Key words: Atrial Fibrillation, Cataract, Cataract Surgery, Cohort Study, Incidence

Running title: Association between Cataract and Atrial Fibrillation

259

OP 082Hyponatremia on Admission and Its Impact on Clinical Outcomes in Patients Hospitalized for Heart Failure

Naomi Niari Dalimunthe, Zainal Safri, Refli Hasan, Rahmad Isnanta, Sari Harahap

Division of Cardiology, Department of Internal MedicineFaculty of Medicine, Sumatera Utara University

Background. Hyponatremia is a common electrolyte disorder among patients with heart failure and associated with poor clinical outcomes. This study aims to assess the prevalence and clinical outcomes in hyponatremia compared to normonatremia patients hospitalized for heart failure.

Methods. This was a cohort retrospective study using medical record of patients hospitalized for heart failure between January and December 2015 in Adam Malik Hospital, Medan, Indonesia. Patients were assigned to one of two groups; hyponatremia with admission serum sodium <135 mg/dl or normonatremia with admission serum sodium ≥135 mg/dl. Differences in variables between two groups were evaluated using chi-square test for categorical variables and independent samples t test or Mann Whitney U test for continuous variables. Futhermore, hyponatremia group was classified into mild, moderate and severe to analyse outcomes based on severity of hyponatremia.

Results. Of 497 patients, hyponatremia was present in 230 patients (46.27%) with mean admissions serum sodium 129.16±5.17 mg/dl. Patients with hyponatremia had significantly higher in-hospital mortality (p=0.034, OR=1.999, 95% CI 1.044-3.828) and longer hospital stays (p=0.023) compared to normonatremia but no difference in readmission rate was observed between groups (p=0.414). Among hyponatremia group, severe hyponatremia have worse clinical outcomes, with highest in-hospital mortality (19.35%) and longest length of stays (11.16±8.04 days).

Conclusion. Hyponatremia was a relatively common condition found in patients hospitalized for heart failure and associated with higher in-hospital mortality and longer hospital stays. Poorer clinical outcomes were observed in severe hyponatremia group.

Key words : Hyponatremia, heart failure, in-hospital mortality, length of stays, readmission

RELATION BETWEEN HYPONATREMIA ON ADMISSION AND CLINICAL OUTCOMES IN PATIENTS HOSPITALIZED FOR HEART FAILURE

Naomi Niari Dalimunthe, Zainal Safri, Refli Hasan, Rahmad Isnanta, Sari Harahap

260

Cardiology Division Internal Medicine Department

Faculty of Medicine Sumatera Utara University

Background. Hyponatremia is the most common electrolyte disorder encountered in hospitalized patients included heart failure and associated with poor clinical outcomes. This study aims to assess the prevalence and outcomes in hyponatremia compared to normonatremia patients hospitalized for heart failure.

Methods. This retrospective observational study used medical record data of patients hospitalized for heart failure between January and December 2015 in Adam Malik Hospital, Medan, Indonesia. Data were assigned to one of two groups; hyponatremia with admission serum sodium <135 mg/dl or normonatremia with admission serum sodium ≥135 mg/dl. Differences in variables between two groups were evaluated using chi-square test for categorical variables and independent samples T test or Mann Whitney U test for continuous variables.

Results. Of 497 data, hyponatremia was present in 230 patients (46.27%) with mean admissions serum sodium 129.16±5.17 mg/dl. Patients with hyponatremia had significantly longer hospital stays (p=0.036) and higher in-hospital mortality compared to normonatremia (p=0.034).

Conclusion. Hyponatremia was a relatively common condition found in patients hospitalized for heart failure. Lower admission serum sodium was associated with longer hospital stays and higher in-hospital mortality.

Key words : Hyponatremia, heart failure, mortality

261

OP 069Role of Modified Acef Score in Predicting Coronary Lesion Complexity in CKD Patients with Acute Coronary Syndrome

Bhanu1, Sally Aman Nasution1, Aida Lydia2, Arif Mansjoer1, Ika Prasetya Wijaya1

1. Cardiology Division, Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

2. Nephrology Division, Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: Cardiovascular disease is one of the main causes of death in Indonesia mainly due to complex coronary lesions or delays in revascularization. Delayed revascularization is often related to lack of facility. Coronary lesions are usually worse in patients with CKD. Modified ACEF (mACEF) score provides crucial information in determining cardiovascular mortality of patients undergoing revascularization therapy and has never been used to evaluate the complexity of coronary lesions before. Further information is required to evaluate mACEF’s potential as a diagnostic tool to assist clinicians in stratifying patients eligible for coronary angiography especially in places with limited facilities.

Purpose: To evaluate mACEF score’s diagnostic value and cut-off point as a predictor of coronary lesion complexity in patients with CKD stages 3 and 4 admitted with Acute Coronary Syndrome (ACS).

Methods: This is a diagnostic study with a cross-sectional design conducted retrospectively involving 179 subjects with CKD stages 3 and 4 who were admitted to the ICCU of Cipto Mangunkusumo Hospital with acute coronary syndrome within the year 2012 to 2014. Modified ACEF scores were evaluated on admission and coronary lesion complexity assessment was evaluated using Gensini score. Cut-off analysis was performed using ROC curve and diagnostic accuracy of mACEF was analyzed to generate sensitivity, specificity, Positive Likelihood Ratio (LR+), and Negative Likelihood Ratio (LR-).

Result: The optimal cut-off point for mACEF score was 2,288 with AUC of 80,6% (p <0,001). mACEF score showed overall sensitivity of 90,9% and overall specificity of 63,7% with LR+ of 2,5, LR- of 0,14, and prevalence of 55,3%.

Conclusion: The optimal cut-off point for mACEF score in subjects with CKD stage 3 and 4 with ACS was 2,288, respectively. mACEF has a good diagnostic accuracy as a predictor of complex coronary lesions in patients with CKD stages 3 and 4.

Keywords: acute coronary syndrome, chronic kidney disease, coronary lesion complexity, gensini, mACEF

262

OP 006Managing Congestive Heart Failure With Comorbid Of Chronic Kidney Disease: Rationale Use Spironolactone

Yogi Agung Prima Wardhana (Indonesia)

Ricardo Adrian Nugraha, Michael Jonatan, Radityo Bagus WicaksonoFaculty of Medicine, Universitas Airlangga – Dr Soetomo General Hospital

Introduction. Congestive heart failure (CHF) is frequent in patients with chronic kidney disease (CKD), and may contribute to high cardiovascular morbidity and mortality. Half of deaths in patients with CKD arise from cardiovascular events. Spironolactone which block aldosterone’s effects on renin-angiotensin-aldosterone system have become a mainstay of therapy for CHF. Given that Spironolactone could increase serum potassium level and worsening kidney function, the question of whether these spironolactone can be employed in dialysis and non-dialysis CKD patients arises.

Objective. Hyperkalemia and deterioration of kidney function are major challenges in treating congestive heart failure (CHF) patients with comorbid of CKD. Spironolactone may beneficial in reducing cardiovascular events, but the safety and the impact thereof on glomerular filtration rate (GFR) is still unknown. We investigated the effects of Spirnolactone on worsening renal function (WRF) and the relationship to outcome.

Methodology. PubMed/MEDLINE and Web of Knowledge were searched for relevant randomized, controlled studies (RCTs) or quasi-RCTs of the effects of adding spironolactone to standard treatment in CKD patients with Congestive Heart Failure. Results were summarized with a random-effects model or a fixed-effects model.

Results. Literature consists of 1.035 congestive heart failure (CHF) patients with chronic kidney diseases (CKD). In Kaplan-Meier Survival Analysis, an overall 3-year mortality rate of 6.4% in CKD patients on spironolactone 25 mg daily vs. 19.7% in CKD patients on no spironolactone therapy (p = 0.002), without a significantly increased risk of hyperkalemia. (18,1% vs 24,9%, log rank p = 0,028). Incidence of cardiac arrhythmias during 8 weeks observation weren’t statistically different (3,8% vs 3,0% [p = 0.371]).

Discussion. The renin-angiotensin-aldosterone system (RAAS) has been implicated as an important maladaptive neurohormonal pathway in heart failure. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to suppress it ineffectively. Current guidelines support the use of spironolactone for more comprehensive suppression of the RAAS in heart failure patients. Most supporting trials have however excluded patients with renal dysfunction resulting in a dearth of data to support use of spironolactone in CKD patients with CHF. Several small studies that prospectively interrogated the benefits of augmented RAAS blockade with spironolactone

263

in CKD patients have shown improvement in predictors of cardiovascular mortality.

Conclusion. Low dose titrated Spironolactone, starting from 25 mg once daily has its benefit in reducing cardiovascular mortality in CKD patients. More recently, improved mortality outcomes were demonstrated with the use of spironolactone in hemodialysis patients. Although reduction in GFR and hyperkalemia are potential adverse effects with its use, the available evidence suggests that it is uncommon and serious consequences can be avoided with close monitoring. Studies told optimal treatment in outpatient setting recommend starting with a low dose and careful uptitration.

Keywords : Congestive Heart Failure, Chronic Kidney Disease, Spironolactone, Hyperkalemia, Worsening Renal Function

264

OP 084Acute Coronary Syndrome (ACS) Patients with Non-significant Coronary Artery Disease: Profile and Comparison

Sally Aman Nasution1, Devi Felicia1, Bhanu1


Background

Approximately 8-25% patients with ACS were reported to have normal/non significant coronary stenosis. There are several factors and etiologies underlying this process. Careful evaluation of the patient is needed to judiciously weigh the risk and benefit of angiography, as it is not without complications and risks.

Methods

We reviewed case records of patients diagnosed with ACS who were admitted in the ICCU of Cipto Mangunkusumo hospital between January 2012 and June 2015. We compared data between non-significant and significant coronary lesion, including age, gender and risk factors.

Results

We collected 621 data records of patients undergoing coronary angiography, 10% of which were normal or with non-significant coronary stenosis. Almost all patients in both groups presented with typical angina at admission, and no difference in the frequency of other symptoms (cold sweat and dyspnea) were noted. In non-significant CAD, younger patients were significantly more common (15.8% vs. 7.3%, p=0.011), and so was female gender (56.6% vs. 24.0%, p<0.001). In non-significant CAD group, 67.1% were diagnosed with UAP, 26.3% with NSTEMI, and 6.6% with STEMI. Meanwhile, the distribution is even in the significant CAD group (29.2% vs. 36.5% vs. 34.4%, respectively). The amount of smokers in the non-significant group was lower compared to the significant group (21.3% vs. 42.9%, p<0.001). There was no difference in the prevalence of hypertension (65.2%), diabetes mellitus (39.4%), and dyslipidemia (83.2%) between the two groups. Levels of CK and CKMB were not statistically different between non-significant and significant CAD in each type of ACS.

265

Conclusion

Non-significant CAD was present in 10.0% of patients with ACS. The strongest predictors of non-significant CAD are young age, female gender, and non-smokers. Therefore, it is important to evaluate other possible causes of angina in this group to assess the needs for prompt angiography, thereby reducing its risks and complications.

Keywords: non significant CAD, angiography, normal coronary artery, myocardial infarction, acute coronary syndrome

266

OP 098Predicting The Value of Ejection Fraction in Patient with Heart Failure : Can It Be Applied by A Scoring System ?

Mumpuni H*, Bagaswoto HP**

*Division of Cardiology, Department Internal Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta-Indonesia

*Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta-Indonesia

Introduction:To know the value of ejection fraction in patient is as important as to learn the prognostic of patient. It is known that the lower value of ejection fraction, the higher likely patient’s mortality will be in this disease. Echocardiography examination actually has been chosen as the gold standard examination for over the years. Unfortunately, an expert is required to conduct the examination and not all health facilities provide an echocardiography machine. Thus, a simple device that can measure both systolic and diastolic function could help a physician to determine the diagnosis. This study aims to know whether the ejection fraction can be predicted or not by a scoring system.

Methods: We performed a cross-sectional analytic study by analyzing ECG and echocardiography data from 483 subjects with chronic heart failure patients hospitalized at Sardjito General Hospital since January 2016. HFrEF is defined as heart failure with an ejection fraction ≤40%.

Results: Of the 483 subjects, 252 people have HFpEF, while 231 people suffered HFrEF. Multiple logistic regression analysis showed some ECG variables that became independent predictor of HFrEF, i.e. AF (OR 0,431), LAH (OR 0,502), Poor R Wave (OR 0,473), Q wave (OR 0,510), Wide QRS (OR 0,261), RBBB (OR 2,641) and ST-T segment changes (OR 0,385) From statistical analysis, we got a score for each ECG variables above i.e. AF (point 1), LAH (point 1), Poor R Wave (point 1), Q wave (point 1), Wide QRS (point 2), RBBB (point -1) and ST-T segment changes (point 2). Furthermore, based on ROC curve analysis, we obtained a score for HFpEF -1 to +2, while HFrEF has a score of +3 to +8 with sensitivity 69%, specificity 83%, positive predictive value 81%, negative predictive value 72% and accuracy 76%.

Conclusion: Scoring system derived from this study, including the presence or absence of AF, LAH, Poor R Wave, Q Wave, Wide QRS, RBBB and ST-T segment changes can be used to predict the type of heart failure in patients with chronic heart failure with good sensitivity

267

and specificity value.

Keywords: chronic heart failure, scoring system, electrocardiographic features, type of heart failure

268

OP 103Electrolyte Imbalances in Acute Coronary Syndrome (ACS) Patients: Prevalence and Its Associated Comorbidities

Muhadi1, Devi Felicia1 (Indonesia)


Background

Hyponatremia, hyperkalemia, and hypokalemia are reported to be associated with higher both short and long term morbidity and mortality in ACS patients. We intend to study the prevalence of these abnormalities in ACS patients and its associated comorbidities.

Method

We reviewed records of ACS patients admitted in the ICCU of Cipto Mangunkusumo hospital (January 2014-June 2015). We described and compared patients with and without electrolyte abnormality (sodium and potassium).

Result

There were 435 cases, with mean age 6010 years old, and 69.2% were male. Diabetes was present in 36.8% patients, chronic kidney disease (CKD) in 27.4% patients, acute kidney injury (AKI) in 21.1% patients, and heart failure in 49% patients. Wall motion abnormality was present in 57% patients, and ejection fraction was reduced in 48.3% patients. Most patients (75.6%) presented with normal sodium, while 10.6% had hyponatremia, and the remaining 13.1% had hypernatremia. Potassium level was normal in 61.8% ACS patients, low in 14% patients, and high in 23.4% patients.

The prevalence of electrolyte imbalance was only statistically different in ACS patients with AKI, CKD, as well as diabetes. Hyponatremia was more prevalent in CKD patients (18.5% vs. 7.6%, p=0.011), and so was hyperkalemia (44.5% vs. 15.5%, p<0.001). Patients with AKI more often presented with hyponatremia (20.7% vs. 7.9%, p=0.004), and hyperkalemia (38% vs. 19.5%, p=0.002). Hyperkalemia was more common in diabetic group (35% vs. 16.7%, p<0.001). Diabetic patients more commonly found to have CKD compared with nondiabetic (40.6% vs. 19.6%, p<0.001), which might explain the association of diabetes with hyperkalemia. Other comorbidities and echocardiography were not associated with a difference in electrolyte imbalance prevalence.

269

Conclusion

Hyponatremia was present in 10.6% of patients and potassium imbalance was present in 37.4% of patients. The comorbidities associated are AKI, CKD, and diabetes (which might have been caused by the more prevalent CKD in this group).

Keywords: ACS, acute coronary syndrome, electrolyte imbalance, hyponatremia, hypokalemia, hyperkalemia, prevalence.

270

OP 24Prevalence and Prognostic Association of Admission, Persistent, and New-Onset Anemia in Patients with Ischemic Cardiomyopathy and Left Ventricle Systolic Dysfunction

Liu Cheng Wei (Taiwan)

Introduction

Baseline anemia was increasingly reported as an independent predictor of mortality in patients with acute decompensated heart failure (ADHF). Limited evidence showed changes in hemoglobin (Hb) levels associated with outcomes in patients with ADHF. This study was conducted to investigate associations among baseline, persistent and new-onset anemia (NOA) and cardiovascular outcomes in patients with ADHF.

Material and methods

Study population consisted of those patients enrolled in TSOC-HF registry. Anemia was defined as Hb < 13 mg/dl in men or < 12 mg/dl in female. The definition of NOA was a decline of Hb more than 2 mg/dl during hospitalization.

Results

A total of 1,509 patients being admitted due to ADHF were enrolled. Of them, 270 patients met the inclusion criteria. The incidence of baseline anemia, persistent anemia and NOA were 62.9%, 51.1% and 12.6%, respectively. Baseline characteristics were comparable among the three groups except that the patients with persistent anemia had the highest incidence of diabetes, CKD and admission NYHA class III/IV. In univariate analyses, there was a trend toward significant association between baseline anemia and 6-month cardiac mortality (crude OR: 1.77, 95% CI: 0.98-3.22, P = 0.06). NOA was significantly associated with 6-month cardiac mortality (Crude OR: 2.67, 95% CI: 1.05-6.78, P=0.039) but no significant association was found between persistent anemia and 6-month cardiac mortality. A borderline significance was found between NOA and 6-month mortality after age, gender, BMI, diabetes, CKD, peripheral vascular disease, admission NYHA class III/IV were adjusted (adjusted OR: 2.44, 95%: 0.91-6.5, P = 0.075).

Conclusions

There was only a trend toward a signification association between New-onset anemia and 6-month cardiac mortality. No prognostic roles existed among baseline anemia and persistent anemia and 6-month mortality.

271

OP 046Vitamin D Deficiency as Novel Risk Factor of Accelerated Atherosclerosis Cardioascular Diseases in Patients with Systemic Lupus Erythematosus

Ricardo Adrian Nugraha (Indonesia)

Ricardo Adrian Nugraha1, Firas Farisi Alkaff1, Michael Jonatan1, Radityo Bagus Wicaksono1, Tan Nicko Octora2, Rina Judiwati2

1 Faculty of Medicine, Universitas Airlangga – Surabaya2 Department of Biomedics, Faculty of Medicine, Universitas Airlangga – Surabaya

Background. Environmental factors plays a significant role in the appearance of atherosclerotic cardiovascular disease (ASCVD) in patients with chronic inflmmatory diseases such as systemic lupus erythematosus (SLE). It is believed that deficiency of vitamin D could lead to more severe manifestation of SLE, especially in vascular.

Objective. We aimed to evaluate the impact of vitamin D deficiency in the severity of SLE, especially in the appearance of ASCVD in SLE patients.

Design. Systematic review and meta-analysis.

Data Sources. Electronic databases (CENTRAL; Medline; Springerlink; Cochrane Database) were searched up to May 2015.

Review Methods. Longitudinal study that compared level of serum vitamin D in SLE patients with and without ASCVD manifestation were included. Study selection, data extraction and risk of bias assessment (Cochrane risk of bias tool) were performed by five reviewers.

Results. A total of 16 trials (1723 participants) were included. Meta-analysis of 8 trials (781 participants) found that serum vitamin D (25-hydroxyvitamin D) levels in severe SLE patients with ASCVD manifestation were significantly lower compared to non-ASCVD SLE patients during remission (pooled RR 0.64; 95% CI=0.34-0.77; p = 0.005). No statistically significant difference in serum vitamin D were observed in meta-analysis of other 8 trials (pooled RR 0.96; 95% CI=0.54-1.7; p = 0.12). Moreover, there is a significant inverse correlation between serum vitamin D levels and Systemic Lupus Erythematosus Disease Activity Index 2000 (r = -0.373, p = 0.016).

Conclusion. The results demonstrate that vitamin D deficiency could be a novel risk factor for accelerating endothelial dysfunction and ASCVD in SLE patients. Vitamin D supplementation can modulate an immunosuppressive effects, endothelial repair mechanisms, and endothelial function in SLE patients with significant ASCVD risk.

KEYWORDS: ASCVD, Endothelial Dysfunction, SLE, Vitamin D

272

OP 104High-Sensitivity C-Reactive Protein (HS-CRP) Levels in Coronary Heart Disease Patients with Type-2 Diabetes MellitusRicardo

Idrus Alwi MD. PhD*, Teguh Santoso MD. PhD*, Slamet Suyono MD**

*Cardiology Division, Department of Internal Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

**Division of Endocrinology and Metabolism, Department of Internal Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

ABSTRACT

Background: High-sensitivity C-reactive protein (hsCRP) plays an important role in patients with acute coronary syndrome. Previous studies have indicated that hsCRP is able to predict instability when it is found conjointly with the complements in acute myocardial infarction (AMI), may affect the onset pattern of AMI and act as an independent prognostic factor.

Methods: In this cross-sectional study, 62 coronary heart disease (CHD) subjects were analyzed, consisting of 25 diabetics and 37 non-diabetic patients. The subjects were patients with CHD who visited the Cardiology Outpatient Clinic at Department of Internal Medicine, Cipto Mangunkusumo Hospital / Faculty of Medicine, Universitas Indonesia (CMH/FMUI) and Integrated Cardiac Service Outpatient Clinic at Cipto Mangunkusumo Hospital were selected using consecutive sampling method. The study was carried out between May 2005 and May 2006.

Results: The hsCRP levels was higher in the group of CHD patients with diabetes mellitus (mean 7.46 mg/L, SD, CI 95% 2.54 – 12.38) than in the group of non-DM CHD patients (mean 3.53 mg/L, SD, CI 95% 2.06 – 5.01).

Conclusions: The hs-CRP levels in patients with CHD and type-2 diabetes mellitus was higher than patients with CHD only.

Keywords : hs-CRP, Coronary Heart Disease, type-2 DM

273

OP 009Role of food Ig G 4 antibody exclusion diet and microbiota modification in IBS treatment

Madalina Ilie (Romania)

Cecilia Vasilescu2, Gabriel Constantinescu3, Daniela Bartos4Clinical Emergency Hospital Bucharest1,3,4, World Clinic Romania2

IntroductionTreatment of Irritable Bowel Syndrome (IBS) is classically based on the use of antispasmodics, antidepressants, and medications that modify bowel habit. Even if patients try all this therapeutic options, there is often frustration both from the patients and doctors, due to the failure of these drugs to improve symptoms.

AimThe role of this study is to determine the therapeutic effect of food Ig G 4 antibody exclusion diet and microbiota modification in Irritable Bowel Syndrome

MethodsWe had two grups of 300 outpatients each and they received either food Ig G4 antibody exclusion diet and microbiota modification or for the other group classical treatment with antispasmodics and/or antidepressants. We have used Ig G4 radioallergosorbent test(RAST) for determining 256 different food allergens titres and microbiota quantitative/qualitative determination including identification of Candida, Lactobacillus, Bacteroides, Bifidobacterium. Food allergens with titres over 10 kU/l were excluded from the diet 3 months in the first group. Also in this group, patients received non absorbable antibiotics if they had an increased number of aerobic bacteria and multistrain probiotics depending on the Lactobacillus/Bifidobacteria deficit. For assessing the therapeutic results both groups were asked to complete IBS-36 Quality of Life Questionnaire(QLQ) at baseline and after 3 months.

ResultAfter 3 months, first group with food Ig G4 antibody exclusion diet and microbiota modification reported symptoms improvement by a decrease a score on IBS-36 QLQ with 75% in comparison with the second group treated by classical treatment where we obtained only a 10% score decrease.

ConclusionsCombining diets based on avoiding Ig G4 food allergens and interventions that modify microbiota represent an effective solution in treating IBS, interfering with IBS pathogenesis not only with symptoms as classical therapy does.

274

OP 097Evaluation of The Relationship Between Pentraxin-3 Levels to The Clinical, Laboratory and Endoscopic Parameters in Patients with Ulcerative Colitis

Musa Salmanoğlu (Turkey)

Introduction: Ulcerative colitis (UC) is a chronic inflammatory bowel disease of which etiology is not yet fully understood. Long Pentraxin 3 (PTX3) is a multimeric inflammatory mediator. It is believed that PTX3 levels are the actual independent index of the disease activity since they are synthesized directly in the area of inflammation. There are few studies which compares the disease activity to PTX3 serum levels in UC patients and these studies were conducted with a limited number of patients. In our study, we aimed to investigate the relationship between serum PTX3 levels and disease activity in UC patients.

Key words: ulcerative colitis, PTX3, NLR, inflammatory bowel disease

Methods: Total of 112 patients were included in the study; 72 of them were with ulcerative colitis and 40 of them were the healthy control group. We measured serum PTX3, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels and neutrophil lymphocyte ratio (NLR) and used version of SPSS 20 for statistical analysis.

Results: PTX3, ESR, CRP and NLR were significantly higher in the group of patients with the disease than in the control group. However, ESR, CRP levels and NLR were found to be statistically significant to show disease activity in ROC analysis while PTX3 were not statistically significant. No statistically significant correlation between PTX3 levels and UC clinical, endoscopic and histological activity index were found in the correlation analysis that was carried out.

Conclusion: These results suggests that serum PTX3, ESR, CRP levels and NLR can be used as biomarkers to distinguish UC patients from healthy controls. In addition, ESR, CRP levels, and NLR may be useful in determining the disease activity, however, PTX3 may not be useful at the same rate.

275

OP 075Association between Ammonia Serum Level and Degree of Oesophageal Varices in Liver Cirrhotic Patients at Dr.Soetomo Hospital Surabaya

Dini Henriyanto (Indonesia)

Poernomo Boedi Setiawan, Titong Sugihartono

Division of Gastro-enterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background : Portal hypertension in liver cirrhosis patients caused portosystemic shunt and esophageal varices. Theoritically, it can be estimated that high degree of esophageal varices can increase the serum ammonia level, accord to the degree of esophageal varices. For the time being, there was no noninvasive identification method yet for esophageal varices in liver cirrhosis patient. This study is aimed to confirm whether there is association between the serum ammonia level with the degree of esophageal varices. If the association can be proven, so examination of serum ammonia level can be used as an alternative of low-cost noninvasive examination to detect the presence of esophageal varices in liver cirrhosis patient. This study determined the association between the serum amonia level and The degree of esophageal varices.

Methods : Fourty-five consecutive liver cirrhosis patients with esophageal varices were measured serum ammonia levels. Endoscopy of upper gastrointestinal was done by gastroentero-hepatology consultant. This is a cross-sectional study. Association analysis between serum amonia level with the degree of esophageal varices using Spearman rank correlations.

Result : Patient with the grade II esophageal varices 33patient (73,3%) dan grade III esophageal varices 12 (26,7%). The Average serum ammonia level patient with grade II esophageal varices 54,43 µg/dL dan grade III esophageal varices 97,56 µg/dL. Association analysis between the serum amonia level with the degree of esophageal varices resulted coefisien corelation 0,639 (p-value 0,000) that means in the same direction positive association.

Conclusion : The serum ammonia level has a significant association with the degree of esophageal varices

Keywords : Liver cirrhosis, Esophageal varices, serum ammonia level

276

OP 010Association between Helicobacter Pylori Infection and Graves’ Disease: A Meta-Analysis

Guntur Darmawan, Marcellus Simadibrata, Indah Widyahening

Faculty of Medicine, University of Indonesia

Background & Aims: Helicobacter pylori (H. pylori) infection is proposed to have extra-gastrointestinal manifestation, such as autoimmune diseases. The interaction of H. pylori and genetic factor in pathogenesis of Graves’ Disease (GD), one of autoimmune disorder, has become an appealing issue. This study aimed to assess the association between H. pylori infection and GD.

Methods: A systematic literature review was conducted using Pubmed and Cochrane library. The quality of enrolled studies was assessed by the Critical Appraisal Skills Program Oxford. The Mantel-Haenszel method was used to weight the studies included. A fixed-effect model approach was used if there was no heterogeneity; otherwise, a random-effect model was used. Heterogeneity was assessed using I2. Publication bias was assessed by funnel plot. All data were analyzed using REVIEW MANAGER 5.2 and p<0.05 was defined as statistically significant in all analysis.

Results: Six studies from Europe and Asia involving 983 patients were included. Overall H. pylori infection was significantly associated with GD (OR 2.7; 95% CI: 1.47-4.99; p < 0.001). In subgroup analysis of 3 studies using non-serological diagnostic method, the prevalence rate of H. pylori infection was higher in GD group (78.26% VS 42.42%) with significant relationship (OR 4.93; 95% CI: 3.16-7.69; p < 0.00001; I2 = 0%). The CagA antibody prevalence was significantly higher in GD group (46.57% VS 20.29%; OR 4.41; 95% CI: 2.65-7.33; p < 0.00001; I2 = 56%). No publication bias was observed.

Conclusion: Our study showed association between H. pylori infection and GD. It might suggest the need of H. pylori examination in GD patients and the impact of H. pylori eradication in the treatment of GD.

277

OP 021One of The Principals Cause of Morbility in Elderly People in Portugal

Jerry Eanes Sanches Simões (Portugal)

Urinary tract infection (UTI) is the second most common clinical indication for empirical antimicrobial treatment in primary and secondary care, and urine samples constitute the largest single category of specimens examined in most medical microbiology laboratories.

Healthcare practitioners regularly have to make decisions about prescription of antibiotics for urinary tract infection. Criteria for the diagnosis of urinary tract infection vary greatly in Portugal, depending on the patient and the context.

The diagnosis of UTI is particularly difficult in elderly patients, who are more likely to have asymptomatic bacteriuria as they get older.The prevalence of bacteriuria may be so high that urine culture ceases to be a diagnostic test. Elderly institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit.

They were evaluated 3219 urine cultures for a period of 28 months. Having found a higher incidence in females (68.5%).

Having been isolated E. coli as the most prevalent agent (54.08%), Proteus mirabilis (11.89%) and Klebsiella pneumoniae (11.77%). Being less atypical Enterobacter aerogenes (0.52%), Serratia marcescens (0.40%) and Acinetobacter baumannii (0.40%).

In accordance with antibiotic resistance, the three principal agents have great current strength AAC (27 to 46%), Ampicillin (57.3 to 100%) and ciprofloxacin (29.1 to 44.1%).

The responsible bodies usually result from endogenous flora, but occasionally may result from the hospital environment. We have to have a wiselly aproach to promote Health Care Preventive Medicine to prevent resistence specimens.

Authors: Jerry Simões; Dr. José Lourenço e Dr. José Barata.

Hospital Vila Franca de Xira- Portugal.

278

OP 028Factors Associated with Statin Cessation Among Elderly Patients Admitted To A Large Australian Geriatric Subacute Unit

Omar Al-Mukhtar1, Sheri Abramovic1, Samer Noaman1, Cheng Yee Goh1, David Tsang1, Claire Long2, Nicholas Cox1, Christopher Neil1, William Chan1. 3.

1 Department of Cardiology, Western Health, Victoria, Australia2 Department of Geriatric Medicine, Western Health, Victoria, Australia3 Department of Cardiovascular Medicine, Alfred Hospital, Victoria, Australia

Background

Statin prescription in the elderly for primary and secondary prevention of cardiovascular disease (CVD) remains controversial. There is a lack of data pertaining to factors that affect in-hospital practice of statin continuation and cessation in elderly patients admitted to subacute geriatric wards.

Methods

We retrospectively evaluated patients discharged from the subacute geriatric evaluation unit at Williamstown hospital, Western Health, a large Australian geriatric admission and assessment unit, over a year. Comprehensive review of digital medical records including medication history, baseline demographic data and discharge status was performed.

Results

Of 741 elderly patients (>60 years), a total of 333 (44.9%) were already taking statins prior to admission (65.5% females and 34.5% males). Baseline characteristics demonstrated high rates of CVD risk factors in the group receiving statins prior to admission including diabetes, hypertension, dyslipidaemia and chronic kidney disease, all p<0.05. A secondary prevention indication for CVD prevention was significantly associated with statin prescription prior to admission (p Value <0.01), while a history of pre-admission dementia was associated with absence of statin prescription (p Value <0.01).

Upon discharge, 57 (17.1%) of those who were already prescribed a statin in the community had their statin discontinued during their hospital admission. Independent multivariable predictors of statin cessation on discharge include octogenarian status (OR 11.8, 1.8-10.2), high level care facility discharge destination (OR 10.1, 1.5-5.9) and primary prevention indication for prescription (OR 7.2, 1.2-4.5), all p<0.05 respectively.

Conclusion

A significant proportion of elderly patients (about 1 in 5) had their statin discontinued during their admission. Factors perceived to be associated with poor prognosis such as age and discharge destination were strongly associated with statin cessation.

279

OP 053Relationship between Polypharmacy, Comorbidities and Dementia in ElderlyJerry

Seyit Ahmet Uslu (Turkey)

MD1, Yasar Kucukardali, MD2, Musa Salmanoglu, MD1, Betul Kucukardali,BS2, Nihat Alpay, MD3, Ozlem Cakir, MD4, Cigdem Kaspar,BS2

1GATA Haydarpasa Training Hospital, Istanbul, Turkey2Yeditepe University, School of Medicine, Istanbul, Turkey3Bakırkoy Psychiatric Hospital, Istanbul, Turkey4Istanbul Avicenna Hospital, Istanbul, Turkey

Introduction: This study investigates the role of polypharmacy and comorbidities which are considered to contribute dementia among elderly living in nursing home.

Materials and methods: Six hundred and twelve old people of whom 256 (41%) were diagnosed with dementia (mini-mental state examination<24) during their first admission to special nursing home were included in this study. Demographic properties, comorbidities, laboratory test results and the number of medicines used daily were compared between dementia and non dementia group. Groups with regard to number of medicines used were classified as follows; 0-1 medicine: 1st group, 2-4 medicine: 2nd group, 5-9 medicine: 3rd group, >=10 medicine: 4th group.

Results: Among 612 subjects, 360 (58%) were women and 252 42(%) were men. Parameters between dementia and non-dementia groups were as follows: Mean age; 80,3±9,1 years vs 73,6±11,9. Percentage of women: 65% vs 54%. Mean body mass index: 22±4 kg /m2 vs 23±5. Independency in daily activities: 27% vs 72%. Mortality: 48% vs 32%. Frequency of infections: >3 9% vs 3%. Mean glomerular filtration rate: 53,1±24,8 ml/min vs 61,9 ±29,3. Diabetes Mellitus: 21% vs 29%. No significant differences were found on other comorbidities. 39% of dementia group were found to be taking 5-9 medicines daily whereas only 25% of non-dementia group were taking the same amount of medicine daily.

Conclusion: The incidence of dementia was found to be higher in multimedicine users among elderly. Older age, female sex, lower weight, number of infections, lower glomerular filtration rate were also found to be related with dementia.

280

OP 073ASSOCIATION BETWEEN SERUM TOTAL TESTOSTERONE AND FRAILTY IN OLDER MEN : AN OBSERVATIONAL CROSS-SECTIONAL ANALYSIS STUDY IN INDONESIAN VETERAN LEGION COMMUNITY IN SURABAYA, INDONESIA 2015

Ari Christy Muliono, Jusri Ichwani, Novira Widajanti

Division of Geriatric, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background : The change of body composition in elderly played a key role in the development of frailty. Serum testosterone which regulate body composition, declined with age. There was not enough data about Indonesian elderly men testosterone profile and frailty especially in Indonesian Veteran Legion community.

Methods : It was a cross-sectional study of 48 men aged 60 years old or older in Indonesian Veteran Legion community. Frailty was defined by Fried criteria. Subjects with MMSE ≥ 18 were included. Subjects with Parkinson, stroke with motoric limitation, on steroids, opioids, ketokonazol and testosterone replacement therapy, with BMI ≥ 30 kg/m2, history of malignancy and spondyloarthropathy were excluded. Serum total testosterone was measured by Electrochemiluminescence Immunoassay (ECLIA). Spearman correlation test was performed to determine association between serum total testosterone (TT) and frailty.

Result : Of total 48 elderly men, 43,7% were assessed as robust, 39,6% as prefrail and 16,7% as frail. There were differences in Geriatric Depression Scale, Mini Nutritional Assessment, and Barthel-Activity Daily Living between frailty status. Mean TT were lower in frail than in prefrail and robust men but the association did not reach statistical significance (TT : (frail) 378,47±175,24 ng/dL vs. (prefrail) 458,65±156,27 ng/dL vs. (robust) 461,49±110,37ng/dL, p =0,796, r =0,038). Of frailty components, physical activity was the only associated with TT ( p= 0,047), different with other study which TT is associated with weakneess. In subanalysis showed correlation between TT and BMI ( p= 0,011, r= -0,362)

Conclusion : serum total testosterone could not determine frailty severity in elderly men in Surabaya Indonesian Veteran Legion community

Key words : elderly men, Indonesian, serum total testosterone, frailty

281

OP 107CORRELATION BETWEEN DEPRESSION AND COGNITIVE IMPAIRMENTIN ELDERLY PATIENTS IN SANGLAH HOSPITAL, BALI:A CROSS-SECTIONAL STUDY

R Purnami, T Kuswardhani, IB PutrawanGeriatric Division of Internal Medicine Department,Udayana School of Medicine/ Sanglah HospitalBali, Indonesia

Background: Depression is highly prevalent in mild cognitive impairment. It may be a risk factor, so that it is important to detect and effectively treat depression because the comorbidity of depression and cognitive impairment is associated with greater cognitive and functional decline.

The aim of this study is to evaluate whether depression has correlation with cognitive impairment in elderly patient at Sanglah Hospital on July 2015 until December 2015.

Methods: A cross sectional study was carried out from July 2015 to December 2015 at Sanglah hospital, with primary data from 139 medical records consecutively included in the study.

Results: As basic characteristics from geriatric patients (age ≥60 yo) that hospitalized in Sanglah hospital during July 2015 until December 2015, we found that: there are 64 males (46%) and 75 females (54%) included in this study. Based on age, we divided into 3 groups: 60-70 yo (44,6%), 71-80 yo (33,1%), only 22,3% samples more than 80 yo. We found that there are 42 patients (30,2%) with depression, and 97 (69,8%) without depression. In screening of cognitive impairment, we found 63 patients (45,3%) with cognitive impairment, and 76 (54,7%) patients without cognitive impairment. We analyzed data using Lambda correlation test and found that there are significant correlation (p = 0,000) between depression and cognitive impairment in elderly patients with r = 0,635.

Conclusions: There are significant correlation between depression and cognitive impairment in elderly patients. Further study is needed to evaluate others factor that also contribute to development of cognitive impairment in elderly patients.

Keywords: Depression, Cognitive Impairment, Elderly.

282

OP 108MUSCLE MASS AND FUNCTION AND THEIR ASSOCIATION WITH DAILY PROTEIN INTAKE AMONG NON-DIABETIC PRE-FRAIL GERIATRIC PATIENTS

Purwita Wijaya Laksmi,* Siti Setiati*, Rahmi Istanti*

*Geriatric Division Department of Internal Medicine – Dr. Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia

Background: Elderly people have an increased risk to be frail. Sarcopenia contributes greatly in the manifestation of frailty. Consuming an adequate amount of protein intake daily and at each meal is necessary to slow the progression of sarcopenia. This study aims at describing protein intake and its relation with muscle mass and function.

Method: This was a cross-sectional study at tertiary hospital of non-diabetic pre-frail geriatric outpatients based on CHS and FI 40 items criteria aged 60 years or older enrolled in RCT of effects of metformin in pre-frail elderly project from March 2015 till March 2016. A 3-day-food record, measurement of skeletal muscle mass index using BIA TANITA SC 330, handgrip strength using JAMAR hydraulic hand dynamometer model J00105 and 15 feet gait speed were evaluated. Man-Whitney statistic test were used to determined the differences between ≥80% or <80% of the Indonesian RDA protein groups.

Results: One hundred and three subjects with mean age 68.9 (5.2) years old were participated in this study. The median energy intake was 1376.2 (1000.6 - 2234.6) Kcal/day, whereas the median protein intake was 48.7 (24.4 – 100.3) gram/day representing 0.78 (0.33 - 3.63) gram protein/kg body weight/day. Fifty six (54.4%) subjects were in the low protein group. Subjects consumed 13.9 (2.3 - 49.3), 19.2 (2.7 – 39.6) and 15.1 (1.3 - 57.3) gram of protein at each meal time respectively. Subjects in the lower protein group tended to have lower muscle mass index [15.9 (13.4 - 21.1) vs. 16.2 (13.8 - 20.3), p=0.28], slower gait speed [4.2 (1.0) vs. (3.9 (0.9), p=0.27] but higher hand grip strength [22.0 (10.0 - 37.0 vs. 20.0 (12.0 - 45.0), p=0.49].

Conclusion: No significant differences were found in muscle mass index, hand grip strength and gait speed between low and high protein intake group.

283

OP 094ACTIVE SURVEILLANCE AND FRAGILITY IN ELDERLY IN PATIENTS WITH RENAL MASS

Bruno Rafael Boietti, MAXIMILIANO SMIETNIANSKY, MARIA EUGENIA RIGGI, GISELLE PAOLA FUCILE, MARIELA ANDREA DEL ROSARIO CAL, VALERIA ANDREA ABELLAN, PATRICIO AITOR GARCIA MARCHIÑENA, Gabriel Dario Waissman, Luis Alberto Camera, Diego Hernan Giunta, Maria Lourdes Posadas de Martinez.

Objectives: To assess the association between fragility and Active Surveillance in elderly with a renal mass

Methods: Retrospective Cohort of Adults over 65 years with renal mass under 4 cm, which integrate Tumor Registry Urologic of Urology in the period between 2007 and 2015 at a university hospital in Argentina. Fragility was defined as compromise of at least three dimensions of the fragility in the past year from the date of diagnosis. All patients were followed up for type of treatment, active surveillance or surgery of the renal tumor. Factors Associated with active Surveillance were modeled with a logistic regression model.

Results: The study included 322 patients with renal tumor, 68% (219) were male with the mean age of 73 years (SD 6). The overall prevalence of fragility was 13% (41), being higher for the active surveillance compared with surgery (43% vs 8%). The more frequent fragilitys affected diimensions were: 42% (135) Poli medication, 22% (71) depression and 13% (43) hospitalization in the last year. Patients with fragility presented nine times more likely Active Surveillance than Surgery. Protective factors associated Surveillance Were one size smaller than 40 mm tumor (crude OR 0.3 and Adjusted OR 0.3) and Risk Were Mayor Age 75 years (crude OR 6 and Adjusted OR 6), the mayor of exophytic 25% tumor (crude OR 18 and Adjusted OR 20).

Discussion: Elderly with renal mass with fragility were more likely to have active surveillance

Keywords: Depression, Cognitive Impairment, Elderly.

284

OP 001Safety And Efficacy Of Rivaroxaban 10 Mg In Advanced Aged Patients With Non-Valvular Atrial Fibrillation And Preserved Renal Function

Tatsuo Misawa - Japan

Background: The safety and efficacy of rivaroxaban 10 mg, which is given to advanced aged Japanese patients (75 years old or older) with preserved renal function, is un-known. To investigate the plasma concentration of rivaroxaban, a follow-up survey was performed with regard to the activated partial thromboplastin time (APTT) and the prothrombin time (PT). APTT and PT have been known to correlate closely with plasma levels of rivaroxaban.Method: The study group consisted of 50 patients (mean age 84 ± 5 years, 23 men) who had received 10 mg once-daily rivaroxaban, regardless of their renal function. The control group consisted of 30 patients with preserved renal function (mean age 68 ± 7 years, 16 men) who had received 15 mg once-daily rivaroxaban. Results: There was no correlation among renal function (eGFR), APTT, and the PT-international normalized ratio (PT-INR) in the study group. Therefore, using multiple regression analysis we examined factors that affected APTT and PT-INR in the study group. The multiple regression models: APTT = -17.072 + 0.676*(age) + 3.169*(sex) – 0.051*(body weight) R² = 0.342 P < 0.001, PT-INR = -0.103 + 0.017*(age) + 0.081*(sex) – 0.002*(body weight) R² = 0.292 P < 0.01. The ages in APTT and PT-INR models were the most significantly affected factors (standardized partial regression coefficient, β : 0.407, P < 0.01 and 0.366, P < 0.05). APTT and PT-INR in the study group were 39.5 ± 6.5 seconds and 1.33 ± 0.16, while those in the control group were 39.6 ± 7.1 seconds and 1.34 ± 0.19, respectively. There was no significant difference between the two groups regarding APTT and PT-INR.Conclusion: The safety and efficacy of rivaroxaban 15 mg were consistent with ad-vanced aged patients with preserved renal function who had received rivaroxaban 10 mg once-daily.

285

OP 003TIME TO ANTIBIOTICS ADMINISTRATION IN CANCER PATIENTS WITH FEBRILE NEUTROPENIA; A RURAL AUSTRALIAN EXPERIENCE

Andrew Huynh¬1, Raymond Wong1, Carmel O’Kane1, George Kannourakis1

1. Wimmera Base Health, Horsham, Victoria, Australia

Background/Rationale:Febrile neutropenia in an oncological emergency. Increased time-to-antibiotics administration has been associated with an increased length of hospital stay and adverse outcomes. Current guidelines recommend time-to-antibiotics administration to be within sixty minutes. We aim to investigate the outcomes of patients presenting with febrile neutropenia in a rural Australian hospital.

Methods:Retrospective study of patients admitted for febrile neutropenia at Wimmera Base Hospital between June 2012 to July 2015. Data collected included patient characteristics, underlying malignancy treated with chemotherapy, time-to-antibiotics administration, antibiotics given, source of infection, outcome and the Multinational Association for Supportive Care Cancer (MASCC) score. Time-to-antibiotic administration was defined by time presented to the emergency department to when antibiotics were administered as per the medication records.

Results:In the 37 months, 430 patients were treated with chemotherapy. Twenty-four patients (6%, median age 67.5 [Interquartile range {IQR} 60.0-81.0], 9 male) treated with chemotherapy were admitted for febrile neutropenia. Seven patients had a principle diagnosis of breast cancer, with the remaining were haematological malignancies.The median time-to-receiving antibiotics from presentation to the emergency department was 130.5 minutes (IQR 91.3-181.3). Two (8%) patients received antibiotics within the recommended sixty minutes. The median MASCC score was 21.0 (IQR 14.8-23.0). Twenty-two (92%) patients were initially treated with tazocin, with the remaining patients treated with either cefepime (1 patient), or vancomycin alone (1 patient).

The sources of infection ranged from respiratory (6 patients [25%]), urinary tract (5 patients [21%]), abdominal (2 patients [8%]) and unknown (9 patients [38%]). Eight (33%) patients had a bacteraemia. 1 (4%) patient died. The mean length of stay was 4.0 days (IQR 2.5-7.5). Two patients were transferred to another hospital.

Conclusion:This study demonstrates an increased time to antibiotics administration in a rural setting compared to current recommendations. Further work is required to reduce the time for antibiotic administration.

286

OP 008The impact of PD-L1 expression in patients with metastatic GEP-NETs Seung Tae Kim1*,Jeeyun Lee1, Joon Oh Park1 and Young Suk Park1†

1Division of Hematology-Oncology, Department of Medicine,

†Corespondence should be addressed to

Young Suk Park, M.D., Ph.D.

Division of Hematology/Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Korea

Tel.: +82-2-3410-3451, Fax: +82-2-3410-1754

Email: [email protected]

Short title: PD-L1 in GEP-NETs

Keywords: Programmed death-ligand 1 (PD-L1), Gastroenteropancreatic neuroendocrine tumor (GEP-NET), WHO classification

Abstract

Programmed death-ligand 1 (PD-L1), which is expressed on many cancer cells, interacts with PD1 expressed on the surface of T cells, inhibiting the T cells and blocking the antitumor immune response. Expression of PD-L1 in gastroenteropancreatic neuroendocrine tumors (GEP-NETs) has not been studied. We investigated the impact of PD-L1 expression in 32 patients with metastatic GEP-NET. The expression of PD-L1 was evaluated using an anti–PD-L1 immunohistochemistry (IHC) antibody optimized for staining of formalin-fixed paraffin-embedded (FFPE) tissue samples. The correlation between PD-L1 and clinicopathological data including survival and response to systemic treatments was analyzed. Primary sites were 24 foregut-derived GEP-NETs, including stomach (n = 1), duodenum (n = 2), biliary tract (n = 7), and pancreas (n = 14), and 8 hindgut-derived GEP-NETs of the distal colon and rectum. Among the 32 patients with metastatic GEP-NET analyzed in this study, 7 (21.9%) had expression of PD-L1 in tumor tissues. Expression of PD-L1 was significantly associated with high-grade WHO classification (grade 3) (P = 0.008) but not with gender, primary site, and number of metastatic sites (P > 0.05). The status of PD-L1 expression was statistically associated with progression-free survival (PFS) for first-line systemic treatment (P = 0.047). Moreover, the status of PD-L1 expression could significantly predict overall survival (P = 0.037). The expression of PD-L1 was associated with higher WHO tumor grade (grade 3) in metastatic GEP-NETs. PD-L1 expression had both predictive and prognostic value for survival of patients with metastatic GEP-NETs.

287

OP 013Factors associated with physical activity in cancer survivors

HoChun Choi (South Korea)

Background

Physical activity is important for the healthcare of cancer survivor but it is hard to correct the Physical inactivity (PInA). We tried to investigate socioeconomic factors related to physical activity in cancer survivors considering demo-biologic, psychological, behavioral and caner related factors.

Methods

We selected patients in each regional cancer center with quota sampling. At first, we analyzed the associations between PInA and socioeconomic factors such as income, job status, type of health insurance, marital status and education level after adjusting demo-biologic, psychological, behavioral and caner related factors. We performed sub-group analyses with the same method across cancer related factors.

Results

In total 1,673 persons, each number of men and women was 847(50.6%) and 826(49.4%). Average ages were 58.4yr in total, 62.1yr in men and 54.8yr in women. In overall analysis, odds ratio (OR) of PInA was 1.6(p=0.070) in the low income men and PInA OR was 1.8(p=0.040) in the low education men. PInA OR was 1.7(p=0.089) in the low education women. In men, PInA OR was 2.2(p=0.023) in the low income and PInA OR was 2.5(p=0.024) in the low education when time since diagnosis was more than one year. However, in women, PInA OR was 1.3(p=0.049) in the low education when time since diagnosis was less than one year. In survivors with localized cancer, PInA OR was 1.8(p=0.045) in the low income men. In survivors with metastatic cancer, PInA OR was 7.6(p=0.021) in the low education men and PInA OR was 3.6(p=0.038) in the low income women.

Conclusion

Physical activity in cancer survivors was associated with income and education level in the socioeconomic status. However, this study investigated the association in the individual level, and so the multilevel analysis is needed to investigate associations between physical activity and the inter-sector interaction with factors of different level.

288

OP 015HYPERFERRITINEMIA IS ASSOCIATED WITH LOWER HEIGHT-ADJUSTED SKELETAL MUSCLE INDEX IN TAIWANESE ELDERLY MEN.

Chiachun Tsai (Taiwan)

Background/Rationale: The purpose of the study is to investigate the association between sarcopenia and serum ferritin level in Taiwanese elderly men.

Method: A cross-sectional study was conducted with 786 men and 550 women who aged 60 years and older and received health examination during 2013 to 2015 in a medical center in Taiwan. Skeletal muscle mass was measured by bioelectrical impedance analysis. Serum ferritin and other biochemical data of health examination were collected for analysis. Descriptive statistics and Binary logistic regression analysis were used in this study.

Result: The prevalence of hyperferritinemia is 19.1% in elderly men (ferritin >336.2 ng/mL) and 7.6% in elderly women(ferritin >306.8 ng/mL). The height-

adjusted skeletal muscle indices (hSMI) are 8.38±1.65 in men and 7.21±1.60

in women. Men with hyperferritinemia are statically significantly with higher diastolic pressure(p=0.019), body fat percentage(p=0.031), fasting glucose(p=0.008), total cholesterol (p=0.001), CRP(p<0.001), and lower hSMI(p=0.042). Women with hyperferritinemia are significantly with higher fasting glucose(p=0.006), triglycerol(p=0.001), uric acid(p=0.01), homocysteine(p=0.045), and lower HDL-C (p=0.004). After adjustment for diastolic pressure, body fat percentage, fasting glucose, total cholesterol, CRP by binary logistic regression, the association between hyperferritinemia and hSMI, remained significant in men (OR=0.830, 95% CI=0.719~0.957, p=0.010).

Conclusion: The hyperferritinemia in elderly Taiwanese men is related to decreased skeletal muscle mass, suggesting iron overload might be a risk factor for sarcopenia.

289

OP 027Baseline Hemoglobin Levels Associated with One-Year Mortality in ST-segment Elevation Myocardial Infarction Patients

Cheng-Wei Liu1, Pen-Chih Liao2, Kuo-Chin Chen2, Chung-Ming Tu2, Jung-Cheng Hsu2, Ai-Hsien Li2, Yen-Wen Wu2

Background:

The association between hemoglobin (Hb) levels and mortality in patients with ST-

segment elevation myocardial infarction (STEMI) remains controversial. This study aimed to examine the mortality among STEMI patients with anemia or erythrocytosis, and further establish the relationship of mortality in the increment of Hb levels.

Methods:

Between 2006 and 2012, 951 consecutive patients with STEMI undergoing

primary percutaneous coronary intervention in a medical center in Northern Taiwan were enrolled, including 535 patients with normal Hb level, 148 with anemia (male Hb 13g/dl, female 12) and 268 with erythrocytosis (male Hb 16, female 15).

Results:

Anemia group was the oldest and greatest comorbidity than the normal Hb

group, followed by erythrocytosis group. In regression analyses, neither anemia nor erythrocytosis was associated with 30-day and 1-year mortality. Each 1-g/dl increment of Hb level was not associated with 30-day mortality both in patients with anemia or erythrocytosis. However, it was associated with a decreased risk of 1-year mortality in anemic patients (hazard ratio [HR]: 0.756, 95% confidence interval [CI]: 0.608-0.938, P=0.011) and an increased risk of 1-year mortality in those with erythrocytosis (HR: 2.086, 95%CI: 1.106-3.937, P=0.023). In multivariate analysis, each 1-g/dl increment of Hb levels was associated with 1-year mortality both in anemic patients and those with erythrocytosis (HR: 0.788, 95%CI: 0.621-0.999, P=0.0049; HR: 2.302, 95%CI: 1.051-5.04, P=0.037).

Conclusions:

Higher hemoglobin levels in STEMI patients with anemia were associated with

decreased risks of 1-year mortality, whereas higher hemoglobin levels in those with erythrocytosis were associated increased risks of one-year mortality.

290

OP 031The effect of chemotherapy on High Fluorescence Lymphocyte Count and Lymphocyte in Lymphoma non Hodgkin

Amaylia Oehadian1, Lusi Mersiana1, Delita Prihatni2

1. Hematology and Medical Oncology Division, Department of Internal Medicine Dr. Hasan Sadikin Hospital, Bandung , Indonesia

2. 2Clinical Pathology Department Dr. Hasan Sadikin Hospital, Bandung, Indonesia

Chemotherapy could affect lymphocytes count. High fluorescent lymphocytes count (HFLC) is reflected lymphocyte cells with high fluorescence because they contain high ribonucleic acid (RNA). High fluorescent lymphocytes count also represent activated lymphocytes. The aim of this study was to evaluate changes in lymphocytes and HFLC in lymphoma subjects who underwent chemotherapy and to correlate with chemotherapy response. This was prospective study, lymphocyte and HFLC were examined with hematology analyzer Sysmex XN-1000A1 using blood withdrawal from lymphoma subjects in 3 times period; before and after 1st cycle and after 6th cycle of chemotherapy. We have 14 subjects, consist of 8 male. The median age was 57 (26-71 years old). Thirteen subjects had only 2 examinations (before and after cycle 1 chemotherapy). Ten subjects had completed 3 examinations (before, after cycle 1 and cycle 6 chemotherapy). There was significant difference in lymphocytes count before and after cycle 1 chemotherapy (1838+764/mm3vs 1418+331/mm3, p 0.038). There was no significant difference in HFLC before and after cycle 1 chemotherapy (10 (0-30)/mm3vs 10 (0-20)/mm3, p 1). In 10 subjects with complete examination, lymphocytes count was also significantly different between before and after cycle 6 chemotherapy (2059+715/mm3vs 1468+362/mm3, p<0.001), between cycle 2 and cycle 6 chemotherapy (1468+362/mm3vs 827+335/mm3, p<0.001). HFLC not significantly different between all examinations. The HFLC percentage after cycle 1 was higher than before chemotherapy, although the difference was not significant (0.25 (0.0-0.4)% vs 0.1(0.0-0,4)%, p 0.710). Seven (50%) subjects had complete response. The lymphocyte percentage was significantly higher in subjects with complete response than no response (29.7+7.2 vs 18.2+7.7%, p 0.014). There was no significantly different in HFLC between subjects with complete response than no response.

Chemotherapy decreases lymphocyte count, but has not influence on HFLC. Lymphocyte count before chemotherapy could be used to predict chemotherapy response in Non-Hodgkin lymphoma

Key words : lymphocyte cells , High fluorescent lymphocytes count, non Hodgkin lymphoma, chemotherapy

291

OP 076Thromboprophylaxis use and concordance with guidelines among medical and surgical patients in Morocco

Tazi Mezalek Zoubida a,, Abderahim Azzouzi b,Wafaa Bono c, Rajae Tachinante d, Mamoun Faroudy e, Lamiaa Essaadouni f, Chakib Nejjari g

a. Internal Medicine Department, Ibn Sina University Hospital, Rabat, Moroccob. Anaesthesiology and Critical Care Department, Ibn Sina University Hospital, Rabat,

Moroccoc. Internal Medicine Department, Hassan II University Hospital, Fez, Moroccod. Intensive Care Unit – Maternity, Souissi Maternity, Rabat, Moroccoe. Emergency Surgical Intensive Care Unit, Ibn Sina University Hospital, Rabat, Moroccof. Internal Medicine Department, Ibn Tofail University Hospital, Marrakech, Moroccog. Epidemiology and Clinical Research Department, Hassan II University Hospital, Fez,

MoroccoIntroduction: No data are available on thromboprophylaxis use inMorocco. Our aim was to characterize patients at risk of venous thromboembolism and assess the rate of appropriate thromboprophylaxis.

Materials and Methods: This was a national, observational, multicentre survey of venous thromboembolism risk and thromboprophylaxis use in hospitalized patients. Data were collected on a predefined date in three university hospitals in Morocco using a standardized pre-printed form. Thromboembolic risk was assessed according to the American College of Chest Physicians (ACCP) 2008 guidelines. Patients were classified as “thromboprophylaxis indicated” or “thromboprophylaxis not indicated”.

Results: 784 patients were analysed: 307 (39.2%) medical and 477 (60.8%) surgical. 421 (53.7%) were female. Medical patients were older than surgical patients (57.6 ± 11.5 vs. 46.2 ± 16.9 years, p b 0.0001) and were more likely to have risk factors for thromboembolism (50.5% vs. 45.7% of patients, p = NS). 57% of patients without contraindications or bleeding risk were at risk of thromboembolism according to ACCP guidelines and thromboprophylaxis was prescribed to 42.8% of these patients. In contrast, 7.4% of patients with no thromboembolic risk also received thromboprophylaxis (proportion agreement: 61.0%; Kappa = 0.296). Over half (54.5%) of medical patients at risk of thromboembolism did not receive thromboprophylaxis whereas 6.3% of those with no risk did receive it (proportion agreement: 76.4%; Kappa = 0.433). These figures were 57.9% and 9.2%, respectively, for surgical patients (proportion agreement: 52.7%; Kappa= 0.191). Thromboprophylaxis was given to 19.2% of patients with contraindications or a bleeding risk.

Conclusions: Educational initiatives are imperative to inform doctors about appropriate thromboprophylaxis.

292

OP 093CLINICAL COURSE OF PATIENTS WITH VENOUS THROMBOEMBOLISM AND INFERIOR VENA CAVA FILTER: COHORT STUDY.

Authors: Maria Lourdes Posadas-Martinez, María Florencia Grande-Ratti, Paula Gutiérrez, Lucia Vijande-Diaz; Sol Barrientos; Juan Fornos; Alejandra Romero; Carolina Antonietti; Bruno Boietti, Cristina Elizondo; Fernán González Bernaldo De Quirós, Gabriel Waisman; Diego Hernán Giunta, Fernando Javier Vázquez

Background: Despite the current growing use of inferior vena cava filters in patients with venous thromboembolism, there is little data on the evolution of these patients, and how this is influenced by concomitant anticoagulant therapy. The aim was to describe the evolution of patients with acute episode of symptomatic VTE requiring FVCI, according subgroup of concomitant therapy received (nothing, prophylaxis or anticoagulation).

Methods: Retrospective cohort of all patients with acute symptomatic VTE, included in the Institutional Register of Thromboembolism (Institutional Registry of Thromboembolic.-Home-ClinicalTrials.gov, NCT01372514) between 2006 and 2014, in the Hospital Italiano, Buenos Aires, Argentina. We modeled the cumulative incidence of filter retrieval in the presence of competing event death, estimated with competitive risk regression, according to the type of treatment. Crude and adjusted sub hazard ratios (HR) were reported.

Results: Three hundred and twenty one patients were included with VTE and IVCF. The indications for placement were absolute contraindication to therapeutic anticoagulation (41%), and need to suspend anticoagulation for invasive procedure (35%). The overall mortality was 47%, and 70% in those without treatment (p0.01). The main complications during follow-up were the recurrence of VTE (15.9%) and higher bleeding (11%), with no difference between groups. Filter removal was attempted in 51%, but was successful in only 77%. The main causes of no retreat were: use of permanent FVCI (36%) and death before retirement attempts (35%). The withdrawal rate was higher in patients with anticoagulation HR 1.69 (CI95%1.32-2.15), and lower in patients with cancer HR 0.35 (CI95%0.23-0.53).

The cumulative incidence of filter retrieval in the presence of competing event death, was associated with the type of treatment and cancer. Compared with no treatment group: crude HR 7.09 (CI95%2.5-20.11) and adjusted HR 6.70 (CI95%2.35-19.06) for prophylaxis group, crude HR 10.48 (CI95%3.86-28.45) and adjusted HR 9.82 (CI95%3.60-26.76) for anticoagulation group. The cumulative filter retrieval at 30 days and 90 days were: 6% and 8% for no treatment, 21% and 28% for unknown treatment, 30% and 38% for prophylaxis, and 40% and 50% for anticoagulation group.

Conclusions: Mortality in this group of patients was high. Failure to filter removal was associated with concomitant cancer and no anticoagulation.

293

OP 091RELATION BETWEEN ANEMIA AND CLINICAL OUTCOMES IN PATIENTS HOSPITALIZED FOR HEART FAILURE

Steffie Solin,Naomi Niari Dalimunthe, Sari Harahap, Zainal Safri, Refli Hasan, Rahmad Isnanta

Division of CardiologyDepartment of Internal MedicineFaculty of Medicine, Sumatera Utara University

Background : Anemia is common in patients with ambulatory and hospitalized heart failure, and has been associated with poor functional status, longer hospitalizations, re-hospitalizations, and higher mortality. This study aims to analyzed the relation of anemia and clinical outcomes in patients hospitalized for heart failure.

Methods : This retrospective observational study used medical record data of patients hospitalized for heart failure between January and December 2015 in Adam Malik Hospital, Medan, Indonesia. For the purposes of our analysis, data were assigned to one of two groups, anemia with admission hemoglobin was defined by World Health Organization criteria (hemoglobin <12 g/dL for women and <13 g/dL for men) or non-anemia. Differences in variables between two groups were evaluated using chi-square test for categorical variables and independent samples T test or Mann Whitney U test for continuous variables.

Results : Of 467 data, anemia was present in 199 patients (42.61%) with mean admissions hemoglobin 10.48 ±2.1 mg/dl for men and 9.69±1.89 for women. Patients with anemia had significantly longer hospital stays (p=0.000) and higher in-hospital mortality compared to non-anemia group (p=0.03).

Conclusion : Anemia is frequently present in patients hosptitalized for heart failure. Lower hemoglobin is associated with longer hospital stays and higher in-hospital mortality.

Key words : anemia, heart failure, mortality

294

OP 081Survival in Chronic Myelogenous Leukemia Patients-A Single Center Data in Surabaya, Indonesia

Ugroseno YB

Haematology and Medical Oncology Division Department of Internal MedicineAirlangga School of Medicine dr Soetomo Teaching HospitalSurabaya Indonesia

Background : Chronic Myelogenous Leukemia (CML) is the most common myeloproliferative disorder in our center. Imatinib recently available in our center by Universal Government Health Coverage and revolutionized the treatment of CML.

Objective : To describe survival in CML patients in our center

Material and Method : Restrospective medical records data analysis on 396 CML patients referred to our center since 2008 to 2015.

Result : There were 396 CML patients, 380 (95.96%) were in Chronic Phase, 10 (2.53%) were in Accelerated Phase and 6 (1.52%) were in Blastic Phase. The median survival time patients in CP were 104 ± 8.3 months, patients in AP were 49 ± 11.92 months and in BP were 3 ± 0.7 months. We also analyzed based on patients treatment, some of our CP and AP patients did not receive Imatinib as their treatment due to access and financial reasons. The median survival time patients in CP receiving Imatinib were 107.9 ± 8.6 months, and Hydroxyurea were 39.6 + 4.5. Median survival time patients in AP receiving Imatinib were 55.3 ± 16.8 months, and Hydroxyurea were 27 ± 8.2 months. Patients in BP received Imatinib, their median survival time were 5.5 ± 0.3 months. Patients receiving supportive care only and or acute leukemia chemotherapy survival were 2.6 ± 0.66 months.

Conclusion : Majority patients came in our center in CP. The median survival patients in CP receiving Imatinib were better than patients receiving hydroxyurea.

Keywords : chronic myelogenous leukemia, survival, imatinib, hydroxyurea

295

OP 071Peran Fecal Immunochemical Test untuk Deteksi Kanker Kolorektal

Saragih AH1, Abdullah M1, Yusra2, Handjari DR3

1. Division of Gastroenterology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

2. Department of Clinical Pathology, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

3. Department of Anatomical Pathology, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Latar Belakang: Pemeriksaan endoskopik saat ini merupakan standar metode penapisan, tetapi dianggap invasif, memerlukan sedatif dan persiapan kolon secara khusus. Fecal immunochemical test (FIT) merupakan pemeriksaan yang menggunakan immunoassay untuk mendeteksi protein globin dalam tinja dan dapat menjadi modalitas non invasif untuk mendeteksi kanker kolorektal.

Tujuan: Mengetahui akurasi FIT dalam mendiagnosis kanker kolorektal.

Metode: Studi potong lintang pada pasien yang dicurigai kanker kolorektal. Dilakukan pemeriksaan FIT pada sampel feses subyek dan hasilnya dianalisis untuk mendapatkan akurasi uji diagnostik.

Hasil: Terdapat total 96 sampel yang ikut serta dalam penelitian dengan rerata usia 56,22 tahun. Sampel dengan jenis kelamin laki-laki sebanyak 51 orang dan perempuan sebanyak 45 orang. Sebanyak 14 sampel merupakan pasien dengan kanker kolorektal dan 82 pasien bukan dengan kanker kolorektal. Akurasi diagnostik FIT adalah sebagai berikut, sensitivitas 78,57%, spesifisitas 71,95%, nilai prediksi positif 32,35%, nilai prediksi negatif 95,16%, ratio kemungkinan positif 2,8011, ratio kemungkinan negatif 0,2978.

Kesimpulan: Pemeriksaan FIT memiliki sensitivitas dan spesifisitas yang cukup tinggi untuk mendeteksi kanker kolorektal.

Kata kunci: Akurasi diagnostik; fecal immunochemical test; kanker kolorektal.

296

The Role of Fecal Immunochemical Test to Detect Colorectal Cancer

Saragih AH1, Abdullah M1, Yusra2, Handjari DR3

1. Division of Gastroenterology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

2. Department of Clinical Pathology, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

3. Department of Anatomical Pathology, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Background : Endoscopy is the standard method of screening, but it is considered invasive, requires sedation and need particular colonic preparation. Fecal immunochemical test (FIT) is a test using an immunoassay to detect the globin protein in feces and can be non-invasive modality for the detection of colorectal cancer.

Objective: Analyzing the accuracy of FIT in diagnosing colorectal cancer.

Methods: This is a cross sectional study in patient who is suspected colorectal cancer. Fecal immunochemical test was carried out on the subject faecal samples and the results were analyzed to obtain the diagnostic test’s accuracy.

Results: There were 96 total samples included in this research with the mean age of 56,22 years old. There were 51 male subjects and 45 female subjects 14 subjects with colorectal cancer and 82 subjects without colorectal cancer. The followings were the diagnostic accuracy of FIT; sensitivity 78,57%, specificity 71,95%, positive predictive value 32,35%, negative predictive value 95,16%, positive likelihood ratio 2,8011, negative likelihood ratio 0,2978.

Conclusion : FIT has high sensitivity and specificity to detect colorectal cancer.

Keyword: Diagnostic accuration; fecal immunochemical test; colorectal cancer.

297

OP 077Quality of Cancer Pain Treatment Using the Pain Management Index in Hospitalized Patients

Rudi Putranto*, HE Mudjaddid*, H Shatri**Division of Psychosomatic and Palliative Medicine , Department of Internal MedicineUniversity of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Introduction: Cancer is the burden of health in Indonesia. Pain is an important health care problem for patients with cancer . In cancer patients, pain is one of the most frequent and feared symptoms. Pain can interfere with all aspects of daily life and pain relief is an important component of patient quality of life. In Indonesia, opioid consumption rates are among the lowest in south east Asia. The pain management index is a score linking the severity of pain with the medication recommended to treat it.

The purpose of study is to measure the quality of analgesic pain treatment by estimation of pain management index.

Methods: The study was conducted on patients who admitted in Internal Medicine wards at Cipto Mangunkusumo National Hospital, Jakarta Indonesia for different malignancies between January to November 2014. The following socio-demographic and medical variables were collected from all participating patients: age, gender, site of cancer, tumor stage and analgesic. We analyzed intensity of cancer pain with numerical patient-rated pain scores (numerical scores 0-10), pain type and analgesic treatment. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (numerical scores 1-3), moderate (numerical scores 4-7), or severe pain (numerical scores 8-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients had no pain medication, non opioid, ‘‘weak’’ opioids, and ‘‘strong’’ opioids. The Pain Management Index (PMI) was developed as a simple and objective tool for evaluating the quality of analgesic prescriptions, and breakthrough pain was recognized as a separate entity. The PMI is a composite measure computed by subtracting a patient’s worst pain intensity from the rating of the most potent analgesic prescribed. The PMI is considered a conservative estimate, since it does not take into consideration the doses of the analgesics used or the schedule. The PMI is the single most often used outcome measure for quality of pain treatment. The pain management index (PMI) was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain treatment.

Results: The study found 200 subject were included and the complaint of pain found from 127 patients (63%). Patients were reporting 36,5% no pain, 55,5% mild pain, 8% moderate pain and none patients with severe pain. Depending on the primary tumor site, patterns of cancer were 6% genital tumors, 12% were gastrointestinal cancers, 8% were breast cancer, 35% were head and neck cancer, 6.5% were bronchopulmonary cancer,

298

11.5% were follicular lymphoma and 21% were carcinoma without starting point. Most patients (39,5%) used weak opioid, fifteen patients (14%) used NSAID and three patient (2%) used strong opioid . A negative PMI reflected the under treatment of cancer pain was calculated for 16 patients (12,7). Patients with non and an advanced cancer (local cancer or no evidence of any recurrent cancer) were more likely to receive inadequate treatment (p = 0.003)

Discussion: The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization’s “analgesic ladder” approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain. Our study less negative PMI if compare with other study such as Mitera (2010) that found the PMI was 25,8%.Limitation of PMI were we did not know how doses the analgesic and contribution of others confounding factors.

Conclusions: The quality of treatment of cancer pain need attention. The prevalence of inadequate cancer pain management was 12,7%. Weak opioid frequently used by physician.

Key worlds : cancer pain, pain management index (PMI)

299

OP 090DIAGNOSTIC TEST OF FECAL IMMUNOCHROMATOGRAPHIC TUMOR M2 PYRUVATE KINASE IN PATIENTS WITH CLINICAL SUSPICION OF COLORECTAL CANCER IN MOEHAMMAD HOESIN HOSPITAL PALEMBANG

Erty Sundarita, Suyata, Mediarty

Department of Internal Medicine Faculty of Medicine Sriwijaya UniversityMohammad Hoesin Hospital Palembang, South Sumatera, Indonesia

Background. Colorectal cancer is malignancy from colon to rectum with predicted natural history and ideal for screening. Noninvasif screening modality nowadays, still having low sensitivity and specificity especially in microbleeding case of colorectal cancer. Fecal tumor M2 pyruvate kinase expected to be a good noninvasif screening modality to diagnose patients with microbleeding colorectal cancer that can’t be detected by another modality.

Objective. Analyzing the sensitivity and specificity of immunochromatographic fecal tumor M2 pyruvate kinase (iM2-PK) for diagnosing colorectal cancer in patients with clinical suspicion at Moehammad Hoesin Hospital Palembang.

Methode. This was an analytic prospective observational study with with consecutive sampling methods.

Results. From January until March 2016, 90 patients planned undergo colonoscopy and 59 patients was enrolled for this study. Besides the history taking, physical examination, and routine laboratory findings, all patients also collect the fresh stool speciment for the iM2-PK stool test, before the colonoscopy procedure. Based on the histological examination obtained from colonoscopy biopsy, there are 38 patients with colorectal cancer and 21 patients noncolorectal cancer. Results from the iM2-PK stool test then compared with the histological examination and analyzed with SPSS version 22.0 for Windows. The sensitivity and spesificity of iM2-PK are 89,74% and 80,95%.

Conclusion. Fecal tumor M2 pyruvate kinase can be used as noninvasif screening modality with high sensitivity and specificity in diagnose colorectal cancer.

Keyword: colorectal cancer, iM2-PK stool test, diagnostic test

300

OP 092Association between Serum Uric Acid and Non-Alcoholic Fatty Liver Disease: A Meta-Analysis

Guntur Darmawan1, Laniyati Hamijoyo1, Irsan Hasan2

1. Internal Medicine Department, Faculty of Medicine University of Padjadjaran2. Internal Medicine Department, Faculty of Medicine University of Indonesia

Background & Aims: Non alcoholic fatty liver disease (NAFLD) is known to be associated with some disorders such as obesity, diabetes, dyslipidemia. Recent studies suggested the role of uric acid in NAFLD. Inflammation and oxidative stress are hypothesized to play the role in this relationship. Our study aimed to evaluate the association between serum uric acid and NAFLD.

Methods: A systematic literature review was conducted using Pubmed and Cochrane library. The quality of all studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The Mantel-Haenszel method was used to weight the studies included. A fixed-effect model approach was used if there was no heterogeneity; otherwise, a random-effect model was used. Heterogeneity was assessed using I2. Publication bias was assessed by funnel plot. All data were analyzed using REVIEW MANAGER 5.3 and p<0.05 was defined as statistically significant in all analysis.

Results: Eleven studies from America and Asia involving 100,275 subjects were included. The pooled adjusted OR for NAFLD was 1.92 (95% CI: 1.66-2.23; p: < 0.00001). Subgroup analyses were done based on study design, gender, non-diabetic subjects, non-obese subjects. All subgroup analyses showed statistically significant adjusted OR and most of which having low to moderate heterogeneity. In addition, 2 studies revealing relationship between increased serum uric acid levels and increased in severity of NAFLD. No publication bias was observed in the funnel plot.

Conclusion: Our study demonstrated association between serum uric acid level and NAFLD. This finding brings a new insight of uric acid in clinical practice. Increased in serum uric acid levels might serve as a trigger for physician to screen for NAFLD.

301

OP 037The Association Between an Increase of Alanine Aminotransferase and Arteriosclerosis Related Factors in Japanese Individuals.

Mika Yamaneki, Hiroto Tanaka, Hideyuki Sasaki, Mikio AritaThe Department of Intertnal Medicine, Wakayama Medical University, Kihoku Hospital

Background: Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NAFLD/NASH) is a liver phenotype of metabolic syndrome with abnormal glucose tolerance, hyperlipemia and hypertension. In this study, we investigated the association an increase of alanine aminotransferase (ALT) and arteriosclerosis related factors and the difference between male and female. Methods: A total of 452 individuals underwent the comprehensive health examination such as body mass index (BMI), blood pressure (BP), the serum data of ALT, triglyceride, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), uric acid, γ-GTP, glucose, HbA1c, creatinine (Cr), insulin, and iron. Results: Serum ALT showed a significant positive correlation to BMI, blood pressure (BP), triglyceride, uric acid, γ-GTP, glucose, HbA1c, Homeostasis model assessment-Insulin resistance (HOMA-IR), insulin, Cr, number of red blood cells, and iron and did a significant negative correlation to HDL-C. In the multiple regression analysis of involved factors for an increase of ALT, HOMA-IR (p<0.0001), γ-GTP (P<0.0001), uric acid (P=0.0183), number of red blood cells (P=0.026), and iron (p=0.0147) were significantly associated. To investigate the difference between male and female, in the multiple regression analysis of involved factors for an increase of ALT by only male or only female, HOMA-IR (p=0.0093) were significantly associated in male and HOMA-IR (p=0.0265), γ-GTP (p<0.0001), uric acid (p=0.0246), and number of red blood cells (p=0.0162) were significantly associated in female. Conclusion: It has been suggested that an increase of ALT is associated with the arteriosclerosis related factors, especially insulin resistance and oxidant stress. In addition, the arteriosclerosis related factors associated with an increase of ALT showed the difference between male and female.

302

OP 041The Association between Glucose Status in Development of Liver Cancer in Patients With Hepatitis C after Cure by Interferon-Based Therapy

Chia-Yen Dai,1,2,3,4 Chung-Feng Huang,1,2,3,4 Ming-Lun Yeh,1,3Cing-Yi Huang,1 Pei-Chien Tsai,1 Zu-Yau Lin,1,3 Shinn-Cherng Chen,1,3 Jee-Fu Huang,1,3 Wan-Long Chuang,1,3 Ming-Lung Yu1,2,3

1. Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital,

2. Department of Occupational and Environmental Medicine, 3. Faculty of Internal Medicine, College of Medicine, 4. Health Management Center, Kaohsiung Medical University Hospital, Kaohsiung

Medical University, Kaohsiung, Taiwan

Background/Rationale: Occurrence of hepatocellular carcinoma (HCC) is a major complication in patients with chronic hepatitis C (CHC). Diabetes mellitus (DM) has been known to increase the risk of hepatitis C virus (HCV)-related HCC, the impact of dynamic glucose status on HCC occurrence in CHC patients after cure by the interferon-based therapy remains unclear.

Methods: We have enrolled 1112 biopsy-proven patients treated with peginterferon/ribavirin in this study. They received both pretreatment and post-treatment glucose status, including 75g oral glucose tolerance test (OGTT).

Results: Of the 1112 patients, 93 (8.4%) developed HCC over 5183.8 person-years of follow-up. DM was found to only influence the risk of HCC in patients with mild liver disease (fibrosis 0-2) and a sustained virological response (SVR) but not in other patient subpopulations. Cox-regression analysis demonstrated that the strongest factor associated with HCC in patients with mild liver disease and SVR was the presence of DM (hazard ratio [HR]/95 % confidence intervals [CI]:3.79/1.420-10.136, P=0.008), older age (HR/CI:1.06/1.001-1.117, P=0.046) and lower platelet count (HR/CI:0.989/0.979-1.000, P=0.05). The percentages of HCC in patients with SVR and F0-2 with normoglycemia, sub-DM (pre-sDM) and DM were1.1 %, 3.7 %, and 11.1 %, respectively (trend p<0.001). Compared to patients with normoglycemia, the incidence of HCC increased gradually from pre-sDM (HR: 3.6, P=0.05) to DM (HR: 11.6, P=0.001) (adjusted trend P=0.004) . Conclusions: DM is a critical determinant for the development of HCC patients with mild liver disease and cure by the interferon-based therapy. After viral eradication, patients with pre-sDM status should also be more closely monitored and screened for HCC

303

OP 045The Prevalence of Chronic Hepatitis B: A Community-Based Study from Southern Taiwan

Chia-Yen Dai,1,2,3,4 Pei-Chien Tsai,1 Ming-Lun Yeh,1,4 Chung-Feng Huang1,2,3,4, Jee-Fu Huang, 1,4 Shinn-Cherng Chen, 1,4 Wen-Yu Chang1,4, Wan-Long Chuang1,4 , Ming-Lung Yu1,4

1. Hepatobiliary Division, Department of Internal Medicine, 2. Health Management Center, 3. Department of Occupational and Environmental Medicine, Kaohsiung Medical

University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan4. College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Background/Rationale: The prevalence of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is high in Taiwan. We have conducted a community-based study aimed to assess the prevalence of HBV and HCV infection in southern Taiwan.

Methods: Total 84,834 subjects received blood tests for serum liver anzyme (AST and ALT levels), hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCV) from 2000 to 2015, Total 2,875 patients with positive HBsAg (1,209 males, aged 13-93 years, mean 52.4 ± 13.5) have been tested for hepatitis B e antigen (HBeAg).

Results: The overall prevalence of HBsAg and anti-HCV was 13.4% and 7.4%, respectively. In the 2,875 HBV carriers the prevalence of HBeAg and anti-HCV was 6.3% and 6.6%. The prevalence of HBeAg and anti-HCV in <20, 20-29, 30-39, 40-49, 50-59, 60-69, and >=70 years groups was 50.0%, 26.0%, 12.8%, 6.1%, 3.6%, 3.4% and 2.0% (P<0.0001), and 0.0%, 2.7%, 2.2%, 4.6%, 7.1%, 10.1% and 11.4%, respectively (P<0.0001). In univariate analyses, the HBeAg-positivity is significantly associated with higher AST (P<0.0001) and ALT (P<0.0001) levels and female gender (P=0.029), significantly lower mean age (P<0.0001), BMI (P=0.0003), waist (P=0.0002). In multivariate analyses, the independent factors associated with positive HBeAg were female (P=0.007), younger age (P<0.0001), higher ALT (P=0.03) and lower BMI (P=0.01).

Conclusions: The prevalence of CHB and CHC was high in southern Taiwan, with a reduced prevalence of CHB in younger generation The prevalence of HBeAg and anti-HCV was associated with age and gender. Patients with positive HBeAg have a significantly higher ALT level and lower BMI.

304

OP 068Influence of pegylated interferon and ribavirin on insulin resistance and metabolic factors in patients with chronic hepatitis c

Background:

It was aimed in this study to evaluate the effect of pegylated interferon alfa 2a/2b and ribavirin on insulin resistance and metabolic factors.

Methods:

A total of 104 chronic hepatitis c patients applying to Katip Celebi University Ataturk Research and Training Hospital, Department of Gastroenterology between 01.01.2005 - 01.11.2012 with ages ranging from 20 to 75 years having serum insulin (0 and 48 weeks) and HCV-RNA (0, 12, 24, 48 and 72 weeks) levels available were included in the study. These parameters were assessed according to the groups based on response to therapy (sustained virologic response –SVR, relapse and non-responders).

Results:

Of the 104 patients, SVR was achieved in 55 but 49 (non-SVR). In univariate analyses, no statistically significant association was obtained in gender, age, body mass index, waist circumference, total cholesterol, triglyceride, LDL-cholesterol, HDL-cholesterol, fasting plasma glucose plus insulin and HOMA score at week 0, platelet, arterial blood pressure, degree of steatosis and the last but not least histological activity index between SVR and non-SVR groups. However; a statistically significant difference was noted in GGT, insulin level plus HOMA score and existence of insulin resistance at week 48, log HCV-RNA and fibrosis between the aforementioned groups (p<0,05). In multivariate analysis, it was concluded that log HCV-RNA, triglyceride and week 48 insulin resistance had influence on SVR (p<0,05) while age, body mass index and fibrosis did not.

Conclusion:

Insulin resistance is accepted to have a negative effect of SVR. Insulin resistance may improve once SVR is achieved. In this context, it can be advocated that the regression of insulin resistance at week 48 detected in week 0 may be a predictive factor for SVR at week 72.

305

OP 019Prevalence of Hepatic Steatosis in Apparently Healthy Medical Students: a Transient Elastography Study based on Controlled Attenuation Parameter

Eda Kaya1, Dogac Demir1, Yesim Ozen Alahdab2,3 and Yusuf Yilmaz2,3

1. School of Medicine, Marmara University, Istanbul, Turkey2. Department of Gastroenterology, School of Medicine, Marmara University, Istanbul,

Turkey 3Institute of Gastroenterology, Marmara University, Maltepe, Istanbul, Turkey

Objective. Despite the increasing burden of non-alcoholic fatty liver disease (NAFLD) in modern societies, the optimal screening method to detect hepatic steatosis in the general population remains to be established. Controlled Attenuation Parameter (CAP) measured with transient elastogrophy (TE) has recently emerged as a reliable imaging tool for the screening and diagnosis of NAFLD. Here, we sought to investigate the prevalence of TE-defined hepatic steatosis in a sample of apparently healthy medical students. We also assessed the relationships between CAP and traditional NAFLD risk factors.

Methods. A total of 112 Turkish medical students (48 females and 64 males, mean age 20.5 ± 1.1 years) underwent transient elastography (TE). Based on previous studies, a cutoff value of 238 dB/m for CAP was used for the diagnosis of hepatic steatosis.

Results. Based on the selected cutoff for CAP, we identified 26 students (23.2%) with TE-defined NAFLD. Univariate correlation analyses demonstrated that CAP values were significantly associated with body mass index (r = 0.40, P < 0.001), waist circumference (r = 0.39, P < 0.001), and hip circumference (r = 0.34, P < 0.001). In multivariable analysis, only with body mass index retained its independent association with CAP (beta = 0.36, t = 3.4, P < 0.001).

Conclusions. NAFLD is highly prevalent even in apparently healthy young subjects. CAP assessment with TE may be useful for early, noninvasive identification of hepatic steatosis.

Key Words hepatic steatosis, non-alcoholic fatty liver disease, screening, transient elastography, controlled attenuation parameter

306

Wednesday, 24 August 2016OP 014Title: Treatment oucome and management of AIDS defining Lymphoma

Gerhard Sissolak (South Africa)

Aims: Outcomes of AIDS defining non-Hodgkin lymphomas (ADL) such as Burkitt lymphoma (BL) or Diffuse Large B-cell Lymphomas (DLBCL) in a resource-constrained setting have not yet been defined.

Methods: Our primary objective was to document 2 year overall survival (OS) in South African ADL patients at an academic institution. Secondary objectives included evaluation of response rates, progression or event free survival (PFS, EFS) and prognostic factors for death. We performed 2 retrospective studies in patients with newly diagnosed ADL.

Results: In the first study 35 HIV-associated BL or B-cell lymphoma unclassifiable, intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma (BL/DLBCL) were analyzed. 89% of patients presented with advanced disease and 25% had baseline central nervous system (CNS) involvement. Chemotherapy regimens consisted of LMB 86 (57%), hyper-CVAD (20%), Stanford (14%) or CHOP-like (9%) regimens. Two year overall survival was 38% (95% CI 22-54%) and 2 year event-free survival was 23% (95% CI 11-38%), with no difference between histologic subtypes.

In the second study 36 patients with HIV associated DLBCL were evaluated; median age was 37.3 years, 52.8% men and 61.1% black South Africans. 80% were high-risk according to the age-adjusted International Prognostic Index. Concurrent Mycobacterium tuberculosis infection was 25%. Two-year overall survival (OS) was 40.5% (95%CI 6.5 – 31.8). ECOG performance status of 2 or more (p = 0.01) and poor response to cART (p = 0.03) predicted inferior 2-year overall survival. No difference in 2-year OS was demonstrated in patients co-infected with either Mycobacterium tuberculosis or Hepatitis B.

Conclusions: Two-year OS for patients with ADL treated with conventional chemo regimens and cART is comparable to that seen in the US and Europe.Cure of HIV-associated BL, BL/DLBCL and DLBCL with intensive regimens is possible in resource-limited settings, but lower toxicity regimens, improved CNS prophylaxis, and increased resources for supportive care are required.

307

OP 074COMPARISON OF EFFECTS OF MENINGOCOCCAL MenACWY–CRM197 VACCINATION TO MENINGOCOCCAL SPECIFIC TOTAL IgG SERUM LEVELS IN ELDERLY AND YOUNG ADULTS : PRE-POST TEST STUDY FOR SURABAYA HAJJ AND UMRA PILGRIMS CANDIDATE 2015

Ihwan Arifiyanto, Ari Baskoro, Gatot Soegiarto

Division of Allergy and Immunology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background : Elderly experience the process of decline in the function of the body organs including the immune system, known as immunosenescence that cause risk of infection and low vaccine response. Elderly who attend hajj and umra have high risk of meningococcal infection. In Indonesia there are no studies that evaluate the levels of meningococcal specific total IgG serum in elderly after meningococcal MenACWY-CRM197 vaccination. This study identified differences in the levels of meningococcal specific total IgG serum of elderly group and young adult group before and after meningococcal MenACWY-CRM197 vaccination.

Methods : The study was a pre - post test clinical trial for Surabaya hajj and umra pilgrims, elderly > 60 years old and young adults. ELISA performed to measure levels of meningococcal specific total IgG serum. Independent sample t test performed to determine differences in IgG levels between the elderly group and young adult group.

Results : Total of 68 subjects obtained 34 subjects of elderly group and 34 subjects of young adults group. Vaccine MenACWY-CRM197 significantly increase the levels of meningococcal specific total IgG serum in elderly group (p= 0.000 ) and young adult group (p= 0.000), but increased levels of meningococcal specific total IgG serum in elderly group was significantly lower than the young adult group (10.509 ± 3.079 μg/ml vs 12.921 ± 2.769 μg/ml, p= 0.001).

Conclusion : Increased levels of meningococcal specific total IgG serum after vaccination with MenACWY-CRM197 in the elderly group was significantly lower than in the young adult group. It may be caused by the immunosenescence process.

Keywords : MenACWY-CRM197 , elderly , immunosenescence , meningococcal specific total IgG serum.

308

OP 087EFFECT OF RAMADAN FASTING ON INFLAMMATION AND OXIDATIVE STRESS IN HIV PATIENTS RECEIVING ANTIRETROVIRAL THERAPY

Alvina Widhani1, Evy Yunihastuti1, Siti Setiati2, Fiastuti Witjaksono3

1. Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia

2. Geriatrics Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia

3. Department of Nutrition, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia

Background: Inflammation and oxidative stress were increased among HIV patients. Studies showed Ramadan fasting improve inflammation and oxidative stress, but none of them conducted in HIV patients receiving antiretroviral therapy (ART). This study aimed to know the effect of Ramadan fasting on hs-CRP and total antioxidant status in HIV patients on ART.

Methods: A prospective cohort study comparing 29 HIV-infected patients on stable ART doing Ramadan fasting versus 29 non-fasting patients. Inclusion criteria were male, 20-40 years old, receiving first line ART for at least six months, and not on opportunistic infection’s treatment. Patients who consumed steroid or immunosuppressant or patients with poor ART adherence were excluded. Level of hs-CRP and total antioxidant status were obtained before and during Ramadan after 14 days fasting.

Results: Baseline age, CD4 cell count, HIV-RNA, ART combination, hepatitis B and hepatitis C status, and hs-CRP level were similar for both fasting and control groups. After 2 weeks, a significant hs-CRP decrease was found in fasting group compared to non-fasting one (p=0.004). Median difference of hs-CRP in fasting group was -0.41 (IQR -1 and 0.1) mg/L, while in control group was 0.2 (IQR -0.3 and 1.5) mg/L. Polyunsaturated fatty acid consumption, body weight, amount of cigarette smoking, and total sleep hours per day were decreased significantly during Ramadan fasting (p=0.029; p<0.001, p<0.001, p<0.001 respectively). There was no statistically significant changes in total antioxidant status between the two groups (p=0.405). Median total antioxidant status changes in fasting group was 0.05 (IQR -0.03;0.12) mmol/L, while in control group was 0.04 (IQR -0.13; 0.36) mmol/L.

Conclusion: Ramadan fasting decreased hs-CRP level among HIV patients on ART. Ramadan fasting had not changed total antioxidant status among HIV patients on ART.

Key words: Ramadan, fasting, HIV, hs-CRP, antioxidant

309

OP 048Microbiological Profile of Capd Peritonitis: 10 Years of Expirience – Our Way to Empirical Therapy

MD Dejan Pilcevic

Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia

OBJECTIVES: To identify the most common infectious organisms in PD –associated peritonitis, their susceptibility to empirical antibiotic treatment, evaluate the clinical outcomes, the survival of the technique and of patients and to establish our center-based guidelines for the initial treatment of PD –associated peritonitis.

METHODS: Clinical records and reliable reports evaluated from the patients who attended the PD program in Military Medical Academy since 2005 to 2015. We analyzed 186 patients (98 males, 88 females; mean age 58,4 +/- 12,4 years -range 18-85 years). A total of 147 peritonitis episodes were identified. Diagnosis of peritonitis was made based on clinical signs of inflamation, number of white blood cells and culture fron the PD fluid. Dyalisate specimens were obtained from all cases and were examined for microbilogic culture and antibiotic resistance.

RESULTS: The incidence of peritonitis in our centre was 1 episode / 29,86 patient months. Culture revealed: a positive culture in the peritoneal fluid was found in 87,07 % of the peritonitis episodes. A single gram (+) organisms were found in 71,88 % of the positive culture cases with Staphylococus coag. negative (CNS) in 55/92 (59,78%) cases. There was 2 cases vankomycin resistence staphylococcus aureus, 1 case of vankomycin resistence staphylococcus haemolithicus and 2 cases vankomycin resistence enterococcus. A single gram (-) organisms were found in 21,88 % of the positive culture cases, polymicrobial peritonitis occured in 6 cases (4,67%) and fungal peritonitis in 2 cases (1,57%) . The overall cure rate was 87.4 %, 10 patients required transfer to hemodialysis. There were 3 peritonitis –related deaths.

CONCLUSIONS: Gram positive microorganisms are the most common finding in a CAPD peritonitis in our hospital with CNS as leading causal. Dominating clinical symptoms were abdominal pain and blurred effluent in 90% of total episodes. The most of patients (80%) is within the acceptable time (less than 12h) launched its antibiotic therapy. Based on previous results we established our center specific empirical тherapy-combination of first-generation cephalosporins with aminoglycosides in anuric and third-generation cephalosporins in patients with RRF. Vancomycin is part of the second line therapy due to the emergence of therapeutic vancomycin-resistant strains and the preservation of RRF.

310

OP 059ANALYSIS OF BLOOD CULTURES IN PATIENT PRESENTING WITH SEPSIS DUE TO PNEUMONIA AT THE EMERGENCY DEPARTMENT IN JAPAN

Hiromasa Yakushiji (Japan)

Background:Blood cultures are routinely used to investigate suspected sepsis with pneumonia in the emergency department. However, recent studies have reported the low impact of these cultures on therapy of pneumonia. The purpose of this study is to assess the clinical utility of blood cultures for patient presenting with sepsis due to pneumonia.

Methods: This is three-years retrospective study. The patients (age 15 years) who were transported to our hospital by ambulance and hospitalized with sepsis due to pneumonia from Janualy 1, 2013 to December 31, 2015, were enrolled. The blood culture results, treatment for pneumonia, and severity were investigated.

Results: The study involved 276 of the total of 26482 cases transported by ambulance. 34 cases were septic shock. Of all cases of pneumonia, 26 (9.4%) had positive blood cultures and 7 (2.5%) resulted in changed in management. Those with septic shock were higher positive blood culture ratio than those with not, but we found no significant difference (17.6% vs 9.0%, OR 2.36, P=0.10).

Conclusion: Even the patients were septic state, positive blood culture rates were low in pneumonia cases and had low clinical impacts.

311

OP 066MELIOIDOSIS IN BANGLADESH-AN UPDATE

Khwaja Nazim Uddin (Bangladesh)

Melioidosis is an infectious disease (also known as whitmore’s disease)caused by gm(-)ve nonaerogenosa Pseudomonus bacteria known as Burkholderia peudomallei.First case was published in Bangladeshi journal in 2001. First case reported in foreign journal in 1988.The organism was detected in Gazipur soil in June 2013.Since then Bangladesh is the 18th definite country of Melioidosis in world.So far 31 cases has been reported in Bangladesh. Our cases were detected through a pathway of microbiological analysis. All of them were treated with initial intensive phase with IV high dose of Ceftazidime for 2-4 weeks followed by the eradication phase with combination of Co- Trimoxazole and Doxycycline for minimum 6 months. Mortality rate was 50%.

Data of our cases were collected from previously published literatures and information regarding Melioidosis in or outside Bangladesh was searched in Medline, BanglaJoL using key words ‘melioidosis’, ‘ Bangladesh’ ‘Burkholderiapsuedomallei’.Data of unpublished cases were gathered from hospital registry and through personal communication .Among 31 cases 6 were reported by United kingdom melioidosis diagnostic services. All cases were culture confirmed using blood agar media.

28 of our patients were Diabetic, majority are farmer working in muddy land with pooled surface water field. Our farmers don’t use bush shoes or boots in field. Commonest presentation in our cases were chronic with disseminated infection. Seropositivity rate in Bangladesh appears to be 20-27% which is similar to Malaysia and nearer to Australia.

It is difficult to accept that we have only 31 cases over so many years in a country with heavy rainfall and a population of 160 million.Physiscians, Microbiologists and people at large should be acquainted and remain survillent for this emerging new infectious disease of Melioidosis in our country.

312

OP 080FREQUENCY, RISK FACTORS AND ANTIBIOTIC SENSITIVITY PATTERN OF EXTENDED-SPECTRUM BETA-LACTAMASE PRODUCING UROPATHOGENS: SINGLE-CENTER EXPERIENCE FROM DHAKA, BANGLADESH

Muhammad Abdur Rahim1, Palash Mitra1, Samira Rahat Afroze2, Tabassum Samad1, Wasim Md. Mohosinul Haque1, Khwaja Nazim Uddin2

1Nephrology, 2Internal Medicine, BIRDEM, Dhaka, Bangladesh

Presenter: Muhammad Abdur Rahim

Background/Rationale: The incidence of urinary tract infection (UTI) due to extended-spectrum beta-lactamase (ESBL) producing organisms are increasing through-out the world. This study was designed to describe the frequency of ESBL-positive organisms causing UTI, their antibiotic sensitivity pattern and to evaluate possible risk factors.

Methods: This case-control study was done in BIRDEM General Hospital, Dhaka, Bangladesh from January to March 2016. UTI due to ESBL-positive organisms were cases and non-ESBL organisms were taken as controls.

Results: Total patients were 136 (mean age 55.4±13.8 years) with 2.7:1 female predominance. Most (97.1%) were diabetic (mean duration 8.3±6.5 years) with poor glycaemic control (mean HbA1c 8.9±2.0%). E. coli (84, 61.8%) was the commonest aetiological agent followed by Klebsiellae (14, 10.3%). Two-thirds of E. coli and two-fifths of Klebsiellae were ESBL-positive. Overall 47.8% cases were due to ESBL-positive organisms. Imipenem (97.8%), amikacin (91.9%), gentamycin (80.1%) and nitrofurantoin (91.2%) were among the most sensitive antibiotics. Long duration (>5 years, OR=2.07, 95% CI=0.90-4.70, p=0.04) and poor control of diabetes (HbA1c >7%, OR=1.30, 95% CI=0.49-3.48, p=0.59), past history of UTI (OR=1.3, 95% CI=0.67-2.60, p=0.42), prior antibiotic use (OR=1.5, 95% CI=0.76-2.95, p=0.24) and prior hospitalization due to UTI (OR=2.8, 95% CI=1.32-5.81, p=0.006) were risk factors for UTI with ESBL-positive organisms. Acute kidney injury (p=0.0002) and septicaemia (p=0.14) were more common in ESBL-positive cases.

Conclusion: Almost half of the UTI cases were due to ESBL-positive organisms in this study. Imipenem, amikacin, gentamycin and nitrofurantoin were most sensitive antibiotics. Long duration of diabetes and past history of hospitalization appeared as significant risk factors for ESBL-positivity.

313

OP 088DOES SYPHILIS INFECTION INFLUENCE THE CHANGE OF HIV-1 RNA AND CD4 COUNT IN BLOOD ?

A cohort study among MSM with HIV infection in Sanglah Hospital Bali

I Ketut Agus Somia1,3, Ketut Tuti Parwati Merati1,3, Dewi Dian Sukmawati1,3,Nittaya Phanuphak5, IGAA Elis Indira2, Made Yogi Oktavian Prasetia3, Komang Agus Trisna Amijaya3, AA Sagung Sawitri4,

1. Tropical and Infectious Disease Division, Department of Internal Medicine, Udayana University- Sanglah Hospital Bali

2. Department of Dermatology and Venerology,Udayana University - Sanglah Hospital Bali

3. Nusa Indah VCT Clinic,Sanglah Hospital Bali4. Department of Public Health, Udayana University Bali5. The Thai Red Cross AIDS Research Centre

BackgroundMen who have sex with men (MSM), particularly those with HIV infection, are at high risk of contracting syphilis. However, little is known about the effect of syphilis on HIV-1 RNA and CD4 count among HIV infected MSM.

Material and Methods.MSM were enrolled into the MSM-VCT study cohort at Sanglah Hospital in Bali between June 22nd 2011 to February 13rd 2012. All participants had anti-HIV test and VDRL test at baseline, with TPHA confirmation for reactive VDRL results. Syphilis cases were treated with benzathine penicillin G injection. Antiretroviral therapy (ART) was initiated for HIV-positive MSM who had CD4 count below 350 cells/mm3. Plasma HIV-1 RNA levels and CD4 counts were measured at baseline and month 6 visits among those who were HIV-positive. T-test or non-parametric Man-Withney test were used to compare changes in CD4 counts and HIV-1 RNA levels from baseline to month 6, respectively between those with and without syphilis.

ResultOf 89 MSM enrolled, 49 (55.1%) were HIV positive. Syphilis was diagnosed in 14 (28.6%) HIV positive MSM at baseline. ART was started in 3 (21.40 %) of HIV positive MSM with syphilis and 10 (28.57 %) of those without syphilis. HIV positive MSM with syphilis co-infection (n=14) had significantly higher mean (± SD) baseline CD4 count (426.71 ± 177.98 vs. 305.74 ± 145.24 cells/mm3, p=0.017) than those without syphilis (n=35). No difference was seen for median baseline plasma HIV-1 RNA between HIV positive MSM with and without syphilis [12243 (400 to 200899) vs. 23074 (400 to 485615) copies/ml, p=0.885]. At six months follow up, no significant difference in mean (± SD) CD4 count

314

change between HIV positive MSM with syphilis (n=11) and without syphilis (n=20) (30.63 ± 110.95 vs. 37.50 ± 82.68 cells/mm3, p=0.860). Similarly, no significant difference in median HIV-1 RNA change was identified between those with (n=8) and without syphilis (n=11) [- 6823.50 (-199626 to 128770 vs. - 21819.50 (- 483068 to 70981) copies/mL, p=1.000)

ConclusionSyphilis was found in one-fourth of HIV positive MSM in Bali. At diagnosis, HIV positive MSM with syphilis co-infection had higher CD4 cell counts. However, syphilis influences the changes of CD4 cell count and HIV-1 RNA 6 months after HIV diagnosis, but not statistically significance. Syphilis screening and treatment should be integrated into HIV prevention and care program for MSM.

315

OP 101The effect of the intravenous immunoglobulin in the immunomodulation and clinical evolution on elder patient with sepsis

Pliego-Reyes C, Álvarez-Licona N, Amezcua-Guerra L, Suárez-Cuenca J.

BACKGROUND: The aging process involves difficulties to confront routine environmental stimulation. Sepsis affects elderly patients, whereas immunological response may be either anergic or exaggerated, and both lead to functional dependency or death. Therefore, inmunomodulating approaches may improve general conditions and clinical outcome.

OBJECTIVE: To evaluate the impact of intravenous immunoglobulin (IVIG) in main outcomes (survival, hospital stay, residual damage or death) in geriatric patients enrolled with sepsis.

MATERIAL AND METHODS: Comparative, longitudinal, randomized controlled prospective, simple-blinded clinical trial. Sample: 100 geriatric patients with sepsis. They were divided in two groups of 50 patients each and. All patients sere managed for sepsis, according to international recommendation guidelines. Study treatment group received additional IGIV at unique dose of 0.5 g/kg, whereas control group received same volume of vehicle. Blood samples were taken on admission and after 3 and 10 days of hospital stay. Hemogram, microbiological cultures, hs-PCR, immunoglobulins, complement proteins and clinical outcome were determined.

RESULTS: No significant difference was observed in both groups regarding leucocytes number, hs-PCR, immunoglobulins and complement proteins, according to Mann Whitney U test. There was 35% of mortality in the non-treated group and 32% in the intervention group. Survival curve analysis of mortality showed no significant difference.

CONCLUSIONS: No significant benefit in mortality or time of hospital stay for the use of IGIV. However, it was a safe intervention with no adverse event reported. There were many uncontrolled variables, then more studies evaluating the effect of IGIV should be conducted.

316

OP 005STARTING INSULIN IN TYPE 2 DIABETES: CROSS-SECTIONAL STUDY OF PORTUGUESE DATA FROM 2006 TO 2014

B. Almeida1, B. Aguiar2, J. Raposo1;MD, MSc, PhD, APDP-ERC (Portuguese Diabetic Association-Education and Research Center), Lisbon, Portugal

MD, MSc, PhD (c), Public Health Unit- Aces Cascais, Lisbon, Portugal

BACKGROUND AND AIMS:The progressive nature of type 2 diabetes enables patients to require and benefit from earlier insulin therapy.

Our aim was to evaluate the age and years of duration of type 2 diabetes in patients who initiate insulin therapy.The HbA1c and BMI change during the first year, after insulin initiation, was evaluated.

MATERIALS AND METHODS:Electronic clinical records of 24929 patients with type 2 Diabetes at a tertiary referral center,APDP (from January 1,2006 to December 31,2014),were evaluated.From 15 952 insulin treated patients,we retrospectively evaluated 1 459 patients that started insulin in this period of time. Statistical analysis was performed with SPSS program (descriptive analysis and T student test).

RESULTS:The mean age of patients treated with insulin was 61±11 years for males and 62±8.5 years for females.The mean duration of the disease was 14±8.7 years for males and 14±8.3 years for females.Mean HbA1c for all patients at baseline was 10.1±1.7%(minimum of 7.6% and a maximum of 15.5%).Mean HbA1c decreased from baseline (10.1±1.7%)to 6 months (8.6±1.4%,p<0.0001)but with little further change through 12 months (8.7±1.4%,p<0.0001). Mean BMI for all patients at baseline was 29.9±14.6 Kg/m2.There was a little mean BMI increase from baseline (29.9±14.6 Kg/m2)to 6 months (30±5.8 Kg/m2,p<0.0001).After 12 months the mean BMI was 30.6±10.8 Kg/m2(p<0.0001).

CONCLUSION:It was observed a decrease of 1.5% in the mean of HbA1c,after 6 months of the beginning of treatment with insulin.Even though the weight gains on the 6th and 12th month it is considered that the gains with the decrease of values of HbA1c are compensatory for the improvement of life and for the decrease of complications related with diabetes.Insulin treatment was initiated(in a tertiary referral center of diabetes)in older patients with long duration of the disease and after HbA1c values were considerably higher than recommended in treatment guidelines for a sustained period of time.

317

OP 012The Effect Of Negative Pressure Wound Therapy (NPWT) For Management Wound Healing Process Gangrene In Patients With Diabetes Mellitus

Dwi Septian Wijaya1, Siswanto2, Hery Wibowo3

Master Progam In Biomedical Sciences, Brawijaya University, Malang, Indonesia1Lecture in Faculty of Medicine, Brawijaya University, Malang, Indonesia2Emergency Departement, Balangan Hospital, South Kalimantan, Indonesia3

Email : [email protected]

Abstract

Gangrenous wounds is a condition in which the body tissue damage to body tissue necrosis or death. This condition occurs due to an interruption in blood flow to the tissue. Pravelensi with cases of diabetes mellitus of 14.7% in urban areas and 5.8% in rural areas with the age group 45-54 years. One therapy techniques which might help the process of wound healing is diabetes mellitus gangrene using Negativ Pressure Wound Therapy (NPWT). NPWT is an advanced development of wound care procedures, the use of vacuum drainage helps to remove blood or serous fluid (pus) from the wound. NPWT is used for the management of wounds using negative pressure or sub-atmospheric pressure at the wound site. The method used in this literature study to collect and analyze research articles and journals (national and international) related to the effect of Negativ Pressure Wound Therapy (NPWT) on the wound healing process diabetes mellitus gangrene. Articles obtained from electronic journals from Google Scholar, Cochrane Database, SAGE Journals, PubMed Central International, Wiley Online Library, etc., using key words Negativ Pressure Wound Therapy, gangrene, diabetes mellitus. This literature review results obtained 6 research articles that analyze the effect of using Negativ Pressure Wound Therapy (NPWT) on the wound healing process. So it can be concluded that the Negativ Pressure Wound Therapy (NPWT) This effect is more effective in wound healing gangrenous diabetes mellitus.

Keyword: Diabtes Mellitus, gangrene, Negativ Pressure Wound Therapy (NPWT).

I.BACKGROUND

World Health Organization (WHO) estimates that the world population suffering from diabetes mellitus in 2030 is expected to increase at least to 366 million. Indonesia ranks - 4th in the number of people with diabetes mellitus with a prevalence of 8.6% of the total population. This shows that in Indonesia, diabetes mellitus is a public health problem is very serious. But attention to the treatment of diabetes mellitus in developing countries

318

is still lacking, especially about the complications caused by diabetes mellitus (Suyono, 2006).

Population of patients with diabetes mellitus (DM) in Indonesia is currently ranked fifth in the world. Based on data from the IDF Diabetes Atlas, by 2013 people with diabetes in the country reached 8,554,155 people. «Even these figures further increase in 2014 to reach 9.1 million people,» said Chairman of the Indonesian Association Endrokologi (Perkeni) Prof. Dr. Achmad Rudijanto in Jakarta, Saturday (25/04/2015). In 2035 the number of people with diabetes is predicted to soar up to a value of 14.1 million people with a prevalence rate of 6.67 per cent of the adult population. One in five people with diabetes are still aged under 40 years, namely between 20 to 39 years as many as 1.671 million people. While the age of 40 to 59 years as many as 4.651 million people. The rest aged 60 to 79 years (suara.com)

Diabetes or diabetes mellitus is a chronic disease characterized by metabolic disorders result from a lack of insulin production by the pancreas or it could be due to a lack of response to insulin, or it could be a result of the influence of other hormones that inhibit the action of insulin. Diabetes occurs when the pancreas can no longer produce insulin in sufficient quantities, or the body becomes less sensitive to insulin produced by the body that is a function of the hormone insulin to convert glucose into energy. If the insulin production is reduced or ineffective, the blood glucose levels become unmanageable with optimal this can lead to the occurrence of diabetes mellitus. The loss of the body’s ability to control the insulin produced by the pancreas or lack of insulin causes disturbances pruduksi metabolism of carbohydrates, protein and fat in the body. Glukusa is a natural carbohydrate that is used by the body as an energy source the body under normal conditions the body does require glucose, but if excessive and continues over time can cause Hyperglikemia and adversely affect the health of the body and some organs affected participate. Diabetes Mellitus symptoms begin to appear when the level of sugar in the blood has reached more than 200 mg / dL. It can happen suddenly, but in most cases of high blood sugar develops over several days. (Idmedis.com).

Patients with diabetes mellitus disturbances in the form of damage to the nervous system, damage to the nervous system (neurophati) can be divided into three groups, namely damage to the peripheral nervous system, damage to the autonomic nervous system and motor nervous system damage. Damage to the peripheral nervous system in general can cause tingling, pain in hands and feet, as well as reduced sensitivity or numbness. The legs are numb (insensitivity) would be dangerous because the patient can not feel anything even if his feet hurt, so in general people with diabetes mellitus too late to realize that there has been a wound in his leg, this is exacerbated because the injured leg was not treated and got a serious concern, and coupled with the disruption of blood flow to the legs due to peripheral macrovascular complications, resulting in the wound difficult to heal and will be ulcers / ulcer (Soebardi, 2006).

319

Ulcers are open sores on the skin surface or mucous membrane and ulceration is extensive tissue death and is accompanied invasive saprophyte germs. The existence of the saprophyte bacteria causes ulcers odorless, diabetic ulcers also one of the clinical symptoms and course of the disease diabetes mellitus with peripheral neuropathy, (Andyagreeni, 2010). Diabetic ulcers are chronic complications of diabetes Melllitus as a major cause of morbidity, mortality and disability Diabetes. High LDL levels play an important role for the occurrence of ulcers Uiabetik for the Diabetic ulcers through formation of atherosclerotic plaque in the walls of blood vessels, (zaidah 2005). Diabetic foot ulcers (UKD) is a complication associated with morbidity due to Diabetes Mellitus. Diabetic foot ulcers are serious complications due to diabetes, (Andyagreeni, 2010).

The ulcers can develop into tissue death, which, if not handled properly that extensively can lead to gangrene, which in people with diabetes called diabetic gangrene. Diabetic Gangrene is a complication caused by an infection or an inflammatory process in the advanced stages of the wound caused by degenerative changes or a less intensive treatment, which is associated with diabetes mellitus. Diabetic foot infections can occur in the skin, muscles and bones that generally can be caused by damage of blood vessels, nerves and reduced blood flow stricken wound (Erman, 1998).

Manifestations gangrene occurs due to thrombosis in the arteries that provide blood supply to the injured area. Thrombosis occurs will obstruct the flow of blood which transports nutrients, oxygen and nutrients needed in the process of regeneration to the injured area, causing tissue death and facilitate the development of saprophytic bacterial infection in the damaged tissue. On the issue of diabetes mellitus often arise diperifer vascular disease and will ultimately lead to an amputation (Erman, 1998).

Appropriate wound management is one factor that supports wound healing. New approaches to improve wound healing has recently been assessed, including the use of growth factors to accelerate healing (Morison, 2004).

One possibility therapies that can help aid the healing process is to penggunanan Negative Pressure Wound Therapy NPWT. Negative Pressure Wound Therapy (NPWT) is an advanced development of wound care procedures, the use of vacuum drainage helps to remove blood or serous fluid (pus) from the wound. NPWT is used for the management of wounds using negative pressure or sub-atmospheric pressure at the wound site. NPWT or vacuum wound closure by using a sponge on the wound, covered with hermetic tight dressing, which is then mounted vacuum. NPWT can be used for wounds with large lymph leakage and fistula. The main mechanism of NPWT is to eliminate the edema, NPWT eliminate blood or lymph fluid that is no interstitial, thus increasing interstitial diffusion of oxygen into the cell. NPWT also eliminates the enzyme - the enzyme collagenase and Matriks Metalloproteinas (MMP) levels are elevated in chronic wounds (Webster J, et al 2012).

320

II. METHOD

The method used in this literature review is to collect and analyze research articles and journals (national and international) related to the effect of penggunanan Negative Pressure Wound Therapy (NPWT) on the wound healing process. Articles obtained from electronic journals from Google Scholar, Cochrane Database, SAGE Journals, NCBI,

PubMed Central International, Wiley Online Library, etc., using the keyword Negative Pressure Wound Therapy (NPWT), Luka. Inclusion criteria for the study of literature is an article published between 2003 - 2014. From search articles found 6 articles were analyzed.

III. DISCUSSION

Gangrene is a process or condition characterized by tissue death or necrosis (Waspadji, 2006). Gangrene is a diabetic foot ulcers burgundy and malodorous due to blockage of blood vessels that occur in the medium or large limbs. Gangrenous wounds is one of chronic DM kornplikasi most feared by every diabetic patient (Tjokroprawiro, 2007).

In the event of injury to patients will be very difficult to recover (Wijayakusuma, 2004). Preventive measures to avoid the onset of diabetic gangrene is in addition to diabetes care melitusnya well, it is also necessary to avoid injury to the lower leg ankle. If it happens diabetic gangrene, the patient had to be hospitalized because they have received injections of insulin, high doses of antibiotics and intensive care (Tjokroprawiro, 2011).

Things that must be considered when caring for chronic wounds, one of which is a gangrenous wound is improving the quality of life of patients. Nurses are responsible for optimizing the quality of life of patients with wounds, especially diabetic wounds (Gitarja, 2008). Efforts have been made to heal the wounds gangrene which includes mechanical control, metabolic control, vascular control, infection control, wound control, and educational control (Perkeni, 2009). One wound control efforts that are being used to cope with gangrenous wounds is by using Negative Pressure Wound Therapy (NPWT).

The use of NPWT is done by giving local negative pressure on the wound surface. The surface of the wound will be closed by a water tight film that is connected to a suction tube (connected to the control unit) having a negative pressure on the wound surface pressure of 50-175 mmHg. Usually that is often used is 125 mmHg. Disuction fluid will be collected in a container on the control unit (Kirby, 2007)

Mechanism of NPWT in the process of healing of diabetic foot ulcers is to maintain the wound environment moist (moist), discard the liquid and material infections, decrease bacterial colonization, increase the formation of granulation tissue, cell growth faster, increasing local blood flow, decrease the amount of bacteria, and discard protease-

321

threatening wound healing process (Mendez-Eastman S. cit Kirby 2007).

According to Fleck and Frizzell cit Kirby (2007) indicated the use of this therapy is the most suitable mainly for wounds stage III and stage IV with granulation poor or inadequate and excessive eksudate. In general, the use of NPWT can be considered for chronic wounds, if wound size decreased only slightly (<30%) after 4 weeks of treatment with debridement or if exudate can not be effectively controlled with daily dressing. The indications for NPWT based on consensus approved by the US Food and Drug Administration (FDA) in addition to foot ulcers diabetic is for pressure ulcers, chronic wounds, acute wounds and traumatic wounds dehisiensi, burns partial, and injuries to the flaps and grafts (Andros, 2005).

Side Effects The application of NPWT patients should be done at the right time. Weaknesses of therapy should be considered. The need for professional health workers (nurses) should be a primary consideration. So the nurse must have the skills and knowledge on this therapy and use of decision when this therapy is used. According to Fleck and Frizzell cit Kirby (2007) side effects experienced by patients may experience discomfort or pain is when fluid dressing replaced. The pressure used should be determined based on the degree of pain that is felt by the patient. If the pain persists after the pressure to the presence NPWT therapy is stopped. Pain is felt to be a bit confused because of the pain may be related to this or negative pressure on the wound itself. Topical skin problems may arise during the use of NPWT, namely the emergence of a fungal infection, candida, and subepidermal granulation. However, this rarely happens. If for 7 or 8 days of use NPWT not show positive results, the indications for this therapy can be evaluated again and Therapy should be discontinued if pus continually emerge from the dressing or excessive bleeding.

Negative Pressure Wound Therapy (NPWT) is an advanced development of wound care procedures, the use of vacuum drainage helps to remove blood or serous fluid (pus) from the wound. NPWT is used for the management of wounds using negative pressure or sub-atmospheric pressure at the wound site. NPWT or vacuum wound closure by using a sponge on the wound, covered with hermetic tight dressing, which is then mounted vacuum. NPWT can be used for wounds with large lymph leakage and fistula. The main mechanism of NPWT is to eliminate the edema, NPWT eliminate blood or lymph fluid that is no interstitial, thus increasing interstitial diffusion of oxygen into the cell. NPWT also eliminates the enzyme - the enzyme collagenase and matrix metalloproteinase MMP levels are elevated in chronic wounds (Webster J, et al 2012).

IV. CONCLUSION

Based on the review of the literature, it can be concluded that although therapy Negative Pressure Wound Therapy (NPWT) has much to recommend it for the treatment of open

322

wounds, but it would be better to be careful in the handling of the wound with tissue perfusion that is not good.

V. REFERENCE

1. Andyagreeni. 2010. Tanda Klinis Penyakit Diabetes Mellitus. Jakarta: CV.Trans Info. Media

2. Andros, George et.al, (2005). Consensus Statement on Negative Pressure Wound Therapy (V.A.C.® Therapy) for the Management of Diabetic Foot Wounds. OWM Jounal.

3. Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M, Peinemann F, (2013). Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane library. Accesed from http://www.cochrane.org/. 20 mey 2015.

4. Dumville JC, Munson C, Christie J, (2014). Negative pressure wound therapy (NPWT) for treating partial-thickness burns. Cochrane library. Accesed from http://www.cochrane.org/. 20 mey 2015.

5. Fadil, (2015), Pengertian Diabetes Melitus, Gejala DM, Tipe Dm, Komplikasi Dm dan Cara Pencegahan kencing manis, Accesed from www.idmedis.com, 29/12/2015

6. Kirby, Michael. (2007). Negative Pressure Wound Therapy. The British Journal of Diabetes & Vascular Disease. Accesed from www.dvdsagepub.com, 29/12/2015

7. Madinah, Deni Yuliansari, (2015). Jumlah Penderita Diabetes Indonesia Terbanyak ke-5 di Dunia. Accesed from www.suara.com, 29/12/2015.

8. Nordmeyer M, Pauser J, Biber R dkk, (2015). Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care. PubMed Health. Accesed from http://www.ncbi.nlm.gov/. 20 mey 2015.

9. Philbeck TE Jr, Whittington KT, Millsap MH, Briones RB, Wight DG, Schroeder WJ, (1999). The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare Medicare patients. Europe PMC. Accesed from http://www.europepmc.org. 20 mey 2015.

10. Prof David G Armstrong, DPM, (2005). Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. The Lancet. Accesed from http://www.thelancet.com/. 20 mey 2015.

11. Rhee SM, Valle MF, dkk (2014). Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. PubMed Health. Accesed from http://www.ncbi.nlm.gov/. 20 mey2015.

12. Webster J, Scuffham P, Stankiewicz M, Chaboyer WP, (2014). Negative pressure wound therapy for acute surgical wounds. Cochrane library. Accesed from http://www.cochrane.org/. 20 mey 2015.

13. _____(2013), Negative Pressure Wound Therapy (NPWT) untuk Luka Insisi Bedah Abdomen, Accesed from www.kalbemed.com/ 29/12/2015

323

OP 016A 16-WEEK VERY LOW CALORIE DIET IMPROVES THE ENDOTHELIAL GLYCOCALYX IN OBESE TYPE 2 DIABETIC SUBJECTS

Authors:

Dae Hyun Lee1,2, *, Marieke Snel3, *, Martijn Dane1,2, Bernard van den Berg1,2, Margien Boels1,2, Juha Kotimaa1, Johan van der Vlag4, Anton Jan van Zonneveld1,2 , A. Edo Meinders3, Ingrid Jazet3, Ton J. Rabelink1,2

Affiliation:1Department of Nephrology and 2Einthoven Laboratory for Vascular Medicine, 3Department of Endocrinology, Leiden University Medical Center, the Netherlands 4Department of Nephrology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands

* Contributed equally

Abstract

Changes in endothelial glycocalyx is mediated by vascular inflammation as well as lipoprotein metabolism, as has been shown in type 2 diabetes mellitus (T2DM). Here we study the hypothesis that prolonged caloric restriction through a very-low calorie diet (VLCD), for 16 weeks, both with or without exercise, can restore the endothelial glycocalyx. At baseline, no differences were found in absolute plasma levels of shed glycocalyx components syndecan-1 and thrombomodulin between obese T2DM and non-diabetic lean- or obese control subjects. However, longitudinal assessment of syndecan-1 levels showed a significant decrease after VLCD, which sustained up to 14 months after returning to a regular diet (mean difference: -21.98±4.91ng/ml [p<0.001], -13.24±3.91ng/ml [p=0.014], and -10.68±3.74ng/ml [p=0.051] respectively for 4, 6, and 18 months after baseline). Although plasma thrombomodulin was lower directly after VLCD (-0.86±0.31ng/ml, p=0.064), it steadily increased during follow-up. There was no additive effect by exercise on shed glycocalyx. In conclusion, a 16-week VLCD in obese T2DM patients improves glycocalyx health, which precedes the anti-inflammatory phenotype and this effect is sustained up to 14 months after cessation of the diet while on a regular eu-caloric diet aimed at weight maintenance.

324

OP 018Detection of Prediabetes and Its Progression to Diabetes: A Population Based Study

Ramona S. DeJesus - USA

Abstract:

Purpose: Thirty seven percent of US adults 20 years and older has pre-diabetes. Our primary care clinics serve over 6000 diabetic patients but the prevalence of pre-diabetes is unknown and time of progression to diabetes is unclear. It is imperative to identify both so interventions can be proactively initiated to prevent diabetes and optimize risk reduction.

Aims: In this retrospective cohort study, we determined the prevalence of pre-diabetes among primary care empanelled patients and estimated rate of progression to diabetes at 1, 5 and 10 years.

Methods: Records of adult community dwelling patients 20 years or older empanelled in a primary care practice in Jan.2005, who met criteria for pre-diabetes based on either hemoglobin A1c or fasting blood sugar, were reviewed to identify prevalence. Incidence rates at 1, 5 and 10 years were determined. Modified population attributable risk (PAR) statistics to estimate the impact of reducing fasting glucose on incidence (progression) of diabetes was applied.

Results: Of 66,510 paneled patients who had at least one appropriate lab test (FBS or A1C), 16.2 % (n=10,786) had pre-diabetes. Forty percent were 65 years and older; 80% were either overweight or obese. At one year, number of new diabetics was 404 (3.7%); at 5 years, it jumped to 17% and at 10 years, 25.5% of the cohort had diabetes. The prevalence of patients with baseline glucose of 110-119 is 2743 (25.8%) vs. 633 (6.0%) of patients with baseline glucose >=120: 633 (6.0%).

PAR for a 10 unit reduction in the 110-119 group with 50% treatment adherence was ~15%; if 50% of this group is able to lower FBS by 10 units, it is estimated that diabetes incidence would be reduced by 15%. In contrast, PAR for a 10 unit reduction in the =>120 group with 50% adherence was ~6%; if 50% of this group is able to lower FBS by 10 units, it is estimated that diabetes incidence would be reduced by only 6%. Figure 1

• Conclusion: In this cohort, the likelihood of progression from prediabetes to diabetes appears to increase over time; at 5 years, 17.1% had diabetes. PAR statistics suggest that the greatest reduction in new cases of diabetes may be achieved by targeting interventions among those with fasting glucose between 100-119.

Keywords: Prevalence, incidence, pre-diabetes, PAR

325

OP 044The Role of Metformin in Improving Endothelial Dysfunction in Prediabetes

Fatimah Eliana*, Pradana Suwondo**Faculty of Medicine, Yarsi UniversityFaculty of Medicine, University of Indonesia

Aim: This study aims to determine the benefits of metformin in improving endothelial function in prediabetes patients. Asymmetric dimethylarginine (ADMA) is a major endogenos nitic oxide synthase inhibitor, thus leading to abnormalities in endothelial function.

Methods: The method used in the study was a case control comparing prediabetes patients who used metformin for 6 months (case) and prediabetes patients who are not using metformin (control). Subjets with fasting blood glucose less than 126 mg/dL and 2-hours blood glucose less than 200 mg/dL met the criteria. The distribution of age, gender, body mass index, HbA1c and cholesterol in both groups were about the same. In both groups we also examined ADMA in serum. All patients are given education, medical nutrition therapy and appropriate physical exercise.

Results: Research is done for 3 years, at 123 prediabetes patients taking metformin and 125 prediabetes patients who are not using metformin. In this study proved that prediabetes patient who received metformin decreased HbA1c (5.8±1.2 vs 6.2±1.4, p 0.05) and serum ADMA levels (0.45 ± 0.34 vs 0.63 ±0.38, p < 0.01) than prediabetic patient who did not receive metformin.

Conclusion: Metformin can lower HbA1c level and ADMA in prediabetes patients, so that metformin may improve endothelial function ini prediabetes patient.

Key words: prediabetes, HbA1c, ADMA, Metformin

326

OP 113Evaluation of a Newly Synthesized Ligand as Peptide Radionuclide Therapy on Neuro-Endocrine Tumor

SunJu Choi*, YoungDon Hong, SoYoung Lee and SungHee Jung

Radioisotope Research Division, Korea Atomic Energy Research Institute, Daedukdaero #989-111, Deajon, Korea

Among the modalities in the treatment of malignant tumor, chemotherapy is the 1st line of the tumor therapy due to its efficient and effective way, but a lack of specificity often causes an indiscriminate toxicity to a normal cells. There have been a many attempts to reduce its unwanted toxicities. Small molecules like monoclonal antibodies and receptor targeting agents get the attention for the new modalities. Recently radiopeptide therapies has got the worlds’ attraction for the tumor targeting modalities due to its beneficial effect on less side effect compared to cytotoxic chemotherapies including pain palliation. In nuclear medicine, 177Lu-DOTATATE is known to be a new modality as an effective one invented so far in treating neuroendocrine tumor (NET) and it has been in clinical trials in globally due to many beneficial effects. Study still should have been extended to overcome the its less effective in large solid tumor. To improve the effectiveness of radiopeptide therapy. potent small molecules were selected to target the tumor site selectively and its labeling with radioisotope of emitting high energy were confirmed through present study. Also, present study was focus to increase a biological half-life of radio somatostatin peptide which targets the somatostatin receptor by altering the bifunctional chelator (BFCA) and at the same time introducing moiety to increase its lipophilicity. Present study will introduce new concept of radio-peptide therapy in neuro-endocrine tumor.

327

OP 105DEPRESSION IN PATIENTS WITH DIABETES MELLITUS- AN ANALYTICAL STUDY IN BANGLADESH

Rahman Abu Shahin MM 1, Hasan Aminul2, Haque Azizul3, Hossain Mamun4

Introduction: Depression is one of the most common co-morbid psychiatric disorders associated with diabetes mellitus (DM) and impacts upon glycaemic control. Optimal management of depression may lead to better control of blood glucose levels in DM.

Objectives: To assess depression in patients with DM and to compare it with healthy control and to determine the association of depression with glycaemic control and socio-demographic profile in patients with DM.

Methods: A cross sectional comparative study was conducted among 140 patients with DM attending Rajshahi Medical College Hospital & Diabetic Association Hospital, Rajshahi, bangladesh from July 2014 to Dec 2015. Subsequently 140 age matched healthy controls were also included in this study. The DSM-V criteria were used to diagnose depression and the severity of depression was assessed by “The Hamilton rating Scale for Depression”. Blood glucose control was assessed by measuring HbA1C levels and categorized as: good glycaemic control <7%, fair glycaemic control 7-8%, and > 8% considered as poor glycaemic control.

Result: The proportion of depression was significantly higher in the patient 51(36.4%) than in the control 20(14.3%) (x2 = 18.256, df = 2, p < 0.001). Among patient 13 (9.28%) were mild depression, 23 (16.42%) were moderate depression & 15 (10.70%) were severe depression. But among control 11(7.87%) were mild depression. Depression was more in patients aged 40-60 years 45(42.1%) than in those aged 18-39 years 6 (18.2%) which was statistically significant (t = - 3.947, p< 0.001). Both mild, moderate and severe depression were more common in females, among singles, obese, Type 2 DM & Patients who were taking both insulin & OHA. Statistically significant depression was observed in poorly control DM (HbA1C > 8%) compared to fair control (HbA1c 7-8%) (p < 0.001, 95% CI = 2.29 to 3.82) and good control ( HbA1c <7%) (p< 0.001, 95% CI = 4.25 to 5.98). Both poor and fair glycaemic control were associated with any level of depression. Significant positive correlation was observed between DSM-V score and age (r = 0.295, p<0.001), BMI (r = 0.473, p<0.001), duration of DM (r = 0.287, p<0.01) and HbA1C (r = 0.734, p<0.001) in patient with DM.

328

Conclusion: Our findings demonstrate that there is a higher proportion of depression in patients with DM, which is almost thrice than healthy control. Since patients with DM are at higher risk of developing depression, assessment of depression should be part of initial and ongoing evaluation of these patients to improve their quality of life. Key words: DM, Depression, DSM-V, HbA1C.

Correspondence to:

Dr. Abu Shahin Mohammed Mahbubur Rahman

Assistant Professor, Department of Medicine,

Rajshahi Medical College, Rajshahi, Bangladesh.


Cell: 8801763248448.

329

OP 007Controlled Attenuation Parameter (CAP) have close relationship with the Prevalence and the severity of NAFLD in a T2DM population

By : jaehyuk lee

Background:Insulin-like growth factor-1 (IGF-1) is known to be closely related to the growth of thyroid cells and thyroid diseases. However, the association between IGF-1, thyroid nodule, and thyroid cancer has not been clearly established yet. Therefore, this study investigated the association between IGF-1 and thyroid nodule size.

Methods:A total of 346 patients with thyroid nodules confirmed by ultrasonography were included. For all participants, the levels of serum T3, free T4, TSH and IGF-1, were determined by radioimmunoassay. Among the participants, the risk group was defined as those with nodule size greater than 10mm or those with suspicious features on ultrasonography even for nodule size smaller than 10mm, and they underwent fine needle aspiration biopsy. The measurement data were expressed as the mean ± standard deviation (SD). The analysis of variance was performed by t-test, and the correlation analysis was performed by linear regression.

Results:The proportion of patients with large nodule size and suspicious sonographic features was significantly higher in risk group. In non-risk group, IGF-1 and nodule size did not show a significant association. Subgroup analysis for the risk groupfound IGF-1 to be significantly elevated in subjects whose cytology returned as thyroid cancer. (173.3 ng/ml vs 213.1ng/ml, p-value <0.05) In this group, IGF-1 and nodule size demonstrated a positive association(r=0.195, p-value <0.05), and multiple linear regressions found IGF-1 to be independently associated with nodule size.(ß = 5.579, p-value <0.05)

Conclusions:A positive association between IGF-1 and nodule size was observed only in risk group, and IGF-1 was elevated in thyroid cancer group. Measuring serum IGF-1 in patients with large thyroid nodule on ultrasonography and with suspicious sonographic features may be clinically significant.

330

OP 017Relation of serum paraoxonase-1 activity with biochemical variables and in obese versus non-obese diabetic patients

Pınar Karakaya1, Meral Mert1, Yildiz Okuturlar2, Asuman Gedikbasi3, 1Department of Endocrinology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, 2Department of Internal Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, 3Department of Biochemistry, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul,

Objective: To evaluate the relation of serum paraoxonase and arylesterase activities with biochemical variables and in obese versus non-obese diabetic patients.

Methods: A total of 201 diabetic patients (mean(SD) age: 52.4(13.4) years, 73.6% were females) were included in this study and divided into two groups based on body mass index (kg/m2) as obese (n=89, patients with BMI>30kg/m2, mean(SD) age: 52.8(11.7) years, 83.1% were females) and non-obese (n=82, BMI<29.99 kg/m2, mean(SD) age: 52.2(14.6) years, 65.5% were females) diabetic patients. Data on patient characteristics, blood biochemistry, HOMA-IR and brachial artery diameter and IMT were evaluated with respect to serum PON and ARE activities.

Results: No significant difference was noted in mean(SD) paraoxonase (119.5(35.6) U/L in the obese group and 120(39.1) U/L in the non-obese group) and arylesterase values (150.4(39.0) U/L in the obese group and 147.9(40.7) U/L in the non-obese group) with respect to obesity. Similarly, no significant difference was noted in paraoxonase and arylesterase values with respect to age (119.6(43.8) vs. 120.3(32.4) U/L for paraoxonase and 149.4(42.7) vs. 148.4(37.9) U/L for arylesterase in patients aged ≤50 vs. >50 years, respectively) and gender (120.8(38.5) vs. 115(33.0) U/L for paraoxonase and 152.5(41.8) vs. 139.8(32.9) U/L for arylesterase in females vs. males, respectively). Paraoxonase and arylesterase activities were negatively correlated with HbA1c (r=-0.533, p=0.000 and r=-0.544, p=0.000, respectively) and plasma glucose (r=-0.457, p=0.000 and r=-0.584, p=0.000, respectively) in the overall study population as were in obese and non-obese groups. There was a negative correlation of HOMA-IR to paraoxonase (r=-0.263, p=0.039 in obese and r=-0.281, p=0.007 in non-obese patients) and arylesterase (r=-0.269, p=0.035 in obese and r=-0.334, p=0.001 in non-obese patients) levels in both obese and non-obese patients. ( Table 1)

Conclusion: In conclusion, our findings among diabetic patients revealed no difference in serum paraoxonase and arylesterase activities with respect to obesity, negative correlation of both serum paraoxonase and arylesterase activities to glycemic parameters regardless of obesity, only in obese diabetic patients. In this regard, our findings emphasize the

331

possible role of low serum paraoxonase and arylesterase activities in predicting poor glycemic control among diabetics regardless of obesity, whereas early atherosclerosis only in obese diabetic patients.

Table 1. Correlation of paraoxonase and arylesterase activities with glycemic and atherosclerosis related parameters

Paraoxonase Arylesterase Obese Non-obese Obese Non-obese

HbA1c r -0.331 -0.684 -0.456 -0.596p 0.002 0.000 0.000 0.000

Plasma glucose r -0.340 -0.527 -0.586 -0.577p 0.001 0.000 0.000 0.000

HOMA-IR r -0.263 -0.281 -0.269 -0.334p 0.039 0.007 0.035 0.001

332

OP 079Plasma fetuin-A levels and its relation with cardiovascular risk factors in patients with hypothyroidism

Okan Bakiner*, Emre Bozkirli*, Derun Ertugrul**, Nurzen Sezgin*, Eda Ertorer*

*Baskent University,Faculty of Medicine, Turkey

**Kecioren Hospital, Turkey

Background: Fetuin-A is a carrier plasma glycoprotein synthesized by the liver with multiple functions. Its most famous function is on mineralization biology. Various studies have demonstrated an association between reduced plasma fetuin-A levels and increased vascular calcification and cardiovascular mortality.In this study we aimed to determine fetuin-A levels and plasma changes with L-thyroxine replacement and also compare with other cardiovascular risk factors in hypothyroid patients.

Methods: Forty-four treatment naive patients diagnosed with hypothyroidism and 39 age and sex matched control subjects were enrolled. Anthropometric measurements, blood pressure, plasmaThyroidStimulatingHormone, fetuin-A, free-T4, LDL-cholesterol, triglyceride, C-reactive protein, fibrinogen levels, and brachial artery flowmediated dilatation were measured in admission. All measurements were repeated at 3 months in the control group and at 3 months after the attainment of euthyroidism with L-thyroxine replacement in the hypothyroid group.

Baseline data were compared between the twogroups. Post-treatment plasmafetuin-A levels of hypothyroid patients were compared with baseline levels of both groups. The relationship between plasma fetuin-A, TSH levels and other cardiovascular risk factors were evaluated.

Results: Plasmafetuin-A levels were significantly lower in hypothyroid patients compared to the controls (p=0.0001). Fetuin-A levels were similar in two groups after L-thyroxine replacement (p=0.38). Significant increase was determined in fetuin-A levels following the replacement in patients with hypothyroidism (p=0.0001). A significant negative correlation was determined between plasma TSH and fetuin-A levels in all cases (r=-0.79; p=0.001). No significant correlation was determined between other cardiovascular risk factors and plasma fetuin-A levels in entire-group and patient-group analysis. Linear regression analysis revealed that parameters affecting the fetuin-A levels were only hypothyroidism and TSH levels (p=0.024 andp=0.021, respectively).

Conclusion: Reduced plasma fetuin-A levels have been determined in hypothyroid patients independently from other cardiovascular risk factors.

333

OP 086RADIOFREQUENCY ABLATION OF BENIGN SYMPTOMATIC THYROID NODULES: EFFICACY AND SAFETY PROFILES

Hendra Zufry, Krishna W Sucipto

Division of Endocrinology, Metabolism & Diabetes- Thyroid CenterDepartment of Internal Medicine, School of Medicine Syiah Kuala University/Dr. Zainoel Abidin General Teaching Hospital, Banda Aceh- Indonesia

Back ground:Benign thyroid nodules are an extremely common occurrence. Radiofrequency ablation (RFA) is gaining ground as an effective technique for their treatment, in case they become symptomatic. This study was conducted to evaluate the safety and efficacy of RFA for benign symptomatic thyroid nodules

Material and Methods: Prospective cohort study of 68 benign symptomatic thyroid nodules from November 2013 - March 2015. RFA procedure were performed with RF Medical Generator, internal cooling electrode of thyroid; Gauge-18, 7 cm length, 0.5-1.0 cm active tip, power 30 – 60 watt, with trans-isthmic and moving shot approach. Thyroid Ultrasonography (US) were performed at, 1, 6 and months after the RFA to evaluate volume reduction. Symptoms score using a 10-cm visual analogue scale (0 – 10), cosmetic score (1,no palpable mass; 2, a palpable mass but no cosmetic problem; 3, cosmetic problems on swallowing only; 4, readily detected cosmetic problems) and complications were evaluated up to 1year follow-up. A paired T-test and Wilcoxon test analysis were performed to compare change in nodule volume, symptom score and cosmetic score from before RFA until 1year after RFA.

Results : Mean volume reduction at 1, 6 and 12 months follow-up were 42.1 %, 72.1 % and 82 .1 %. RFA effective decrease symptoms score (6.47 ± 0.559) to (1.19 ± 0.396) and cosmetic score (3.79 ± 0.407) to (1.09 ± 0.286) (P <0.005). The incident of complication during RFA were mild pain 0.147 %, mild skin burn 0.073 and carbonization 0.04 %.

Conclusion : Our study shows that RFA of benign symptomatic thyroid nodules is safe and give excellent short-term result as shown by significant reduction of volume, nodules-related symptoms and cosmetic problems

334

OP 096METABOLIC ADAPTATION TO A 5-DAYS HIGH-FAT HIGH-CALORIE DIET :RURAL AND URBAN COMPARISONDicky L. Tahapary*1,2, Farid Kurniawan*1, Karin de Ruiter*2, Erliyani Sartono2, Yenny Djuardi3, Taniawati Supali3, Em Yunir1, Maria Yazdanbakhsh2, Johanes WA Smit4,

Pradana Soewondo#1, Dante S. Harbuwono#1,5

1. Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

2. Department of Parasitology, Leiden University Medical Centre, Leiden, The Netherlands

3. Department of Parasitology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

4. Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands

5. Diagnostic and Research Centre, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

*These authors have contributed equally, #These authors have contributed equally

Urbanization, which is characterized by sedentary lifestyle and westernized diet, contributes to the increase of adiposity, insulin resistance (IR) and type 2 diabetes (DMT2). We aim to study (1) the effect of urbanization on adiposity and IR, as well as (2) the impact of short term high-fat high-calorie (HFHC) diet among healthy young Indonesians and how it differs in urban and rural setting.

Methods: (1) We conducted a cross-sectional study involving rural and urban subjects (n=135) with same ethnicity. We measured BMI, WC, WHR, 4-sites skinfold, body fat composition, leptin, adiponectin, resistin, FBG, insulin, HOMA-IR, HbA1c, lipid levels and hsCRP. (2) We recruited subset of young healthy male subjects (n=36) and gave them 5-days HFHC diet. Additional measurements of FFA, CETP, IL-4, IL-6, IL-10 and TNF-alpha were performed before and after the diet.

Results: (1) Urban group had higher adiposity, which was positively correlated with the living duration in the urban area. Urban group was also associated with having higher leptin, resistin and FFA level. (2) A 5-days HFHC diet was able to induce a significant increase in FBG [5.1 (0.4) to 5.4 (0.6), p=0.012], insulin [4.6 (3.4-5.7) to 6.5 (4.5-9.4), p=0.001] and HOMA-IR [0.91 (0.75-1.33) to 1.38 (1.01-2.37), p=0.002], as well as CETP level [2.26 (0.67) to 2.42 (0.67), p=0.029]. Surprisingly, this increase was more pronounced in the rural group, except for the CETP level.

Conclusion: Living in rural area was associated with having better adiposity and adipokines

335

profile. However, a short-term HFHC diet could already induced a more pronounced increase in IR suggesting that their metabolism profile might have not adapted to this type of diet. Further study would be needed to unravel the cellular mechanism of these findings.

Acknowledgement: This work was supported by Directorate of Higher Education Republic of Indonesia, Directorate Research and Community Services Universitas Indonesia and The Royal Netherlands Academy of Arts and Science (KNAW)

Abbreviations : BMI=Body Mass Index, WC=Waist Circumference, WHR=Waist Hip Ratio, FBG=Fasting Blood Glucose, FFA=Free Fatty Acid, CETP=Cholesterol Ester Transfer Protein

336

OP 102Autores: M. Paula Russo; M. Florencia Grande Ratti; Maria A. Yuma; Luciana A. Rovegno; Paloma Rojas Saunero; Carolina Antonietti; Gabriel D Waisman; Cristina M Elizondo; Diego H Giunta

PREVALENCE OF HYPERGLYCEMIA AND INCIDENCE OF STRESS HYPERGLYCEMIA IN HOSPITALIZED PATIENTS: A RETROSPECTIVE COHORT.

Background: Patients who develop in hospital hyperglycemia may be included in four clinical situations: (1) previous diabetes (2) unknown diabetes (3) stress hyperglycemia or (4) indeterminate hyperglycemia. Previous studies demonstrated an increase in mortality, morbidity, length of stay, and higher rates of rehospitalization in patients with hyperglycemia during hospitalization. The objective of this study was to evaluate the prevalence of in-hospital hyperglycemia and incidence of stress hyperglycemia (SH).

Methods: Retrospective cohort. We included all hospitalized adults patients between June/2014 and May/2015 in Hospital Italiano de Buenos Aires. We excluded pregnant women. Hyperglycemia was defined as glucose >140mg/dl. Incident cases of SH were defined as not diabetic patients, with hyperglycemia and HbGl <6.5. Each person was followed from admission to discharge, contributing time at risk to the denominator. Incidence density (ID) for SH was calculated per 1,000 person–days. Rates with 95%CI were adjusted using direct standardization with the age and gender distribution of the 2010 Argentinean population.

Results: During the study period 21,397 patients were admitted: 10.99% (95%CI10.58-11.41) had a previous diagnosis of diabetes and 0.2% (95%CI0.12-0.23) had a new diagnosis of diabetes. A total of 13,017 remained at risk, followed for a total of 100,454 person-days, of whom 1,579 developed SH. The overall ID of HS was 0.3 per 1,000 person–7days (CI95%0.29-0.32). Adjusted incidence data to the 2010 Buenos Aires population for age and sex was 0.18 (CI95%6.95-9.19) per 1,000 person–7days. The prevalence of hyperglycemia was 40% (6,035/14,938) because 6,459 had no glucemia.

Conclusion: This is the first report of prevalence of in-hospital hyperglycemia and incidence of SH in Latin America, relevant for developing guides for management.

337

OP 002Diabetes Mellitus as A Risk Factor of Surgical Site Infection and Perioperative Antibiotic Use Following Major Surgical Procedure

Radityo Bagus Wicaksono[1], Ricardo Adrian Nugraha[1], Lukman Raya Praja[1], Yogi Agung Prima Wardhana[1], Rina Judiwati[2]

1. Faculty of Medicine, University of Airlangga, Surabaya – Indonesia2. Department of Biomedics, Faculty of Medicine, University of Airlangga

Introduction. Little is known about the association between diabetes mellitus and surgical site infection and perioperative antibiotic use in patients undergoing major surgery. However, we found that although many of the common complications and deleterious effects of diabetes mellitus on surgical patients had been well documented, the aspect of microbial colonization seemingly had been overlooked

Objectives. To understanding the association between diabetes mellitus, and its relation to the risk of developing a surgical site infection and perioperative antibiotic use in major surgical procedure.

Methods. PubMed and Science Citation Index were searched for relevant randomized controlled trials (RCTs) and reference list up to December 2015. Three independent reviewers screened the records from the electronic databases, selected relevant studies, assessed the methodological quality, and extracted the data from included articles. Stata 12.0 was used to conduct a pooled analysis for main outcomes.

Results. After controlling for potentially relevant confounding variables noted earlier, we found heterogeneity from 15 trials which Forrest plot shows that Diabetes Mellitus had increased risk of surgical site infection compared with nondiabetic (mean, 32,6% vs 22,3%; OR 2,56 [1,84-3,67], 95% CI, p < 0.001). We also found that again correcting for confounders, diabetes mellitus had increased perioperative antibiotic use compared with nondiabetic (odds ratio 3.8; 95% CI, 2.59-4.52).

Discussion. There is a vicious circle in patients with Diabetes Mellitus: hyperglycemia leads to increase of incidence risk and severity of surgical site infection. Normalization of blood glucose levels promotes prompt relief of symptoms of infection and bacterial eradication, rational treatment of infection contributes to rapid correction of glucose level.

Conclusion. Diabetes mellitus is associated with increased risk of estimated surgical site infection and perioperative antibiotic use in patients undergoing major surgical procedures. Our data indicate that preoperative blood glucose levels may be useful in risk stratification. Further study is needed to determine whether preoperative insulin therapy

338

may reduce the risk of surgical site infection. Diabetic patients should be counseled regarding these risks and on blood glucose controlled before undergoing major surgery.

Keywords: Diabetes mellitus, Major Surgery, Microbial Colonization, Perioperative Antibiotic Use, Surgical Site Infection

339

OP 040Para Grass Beta-Expansins with IgE-Reactivity Against Sera of Thai Atopic Donors

Siriyaporn DHAMMACHAT 1* and Wisuwat SONGNUAN 2

1 Department of Biotechnology, 2 Department of Plant Science, Faculty of Science, Mahidol University, Bangkok, Thailand.

*Presenting author

Airborne allergy has been an important problem and increasing in Thailand. Several grass species have been abundantly distributed and often detected in the airborne pollen surveys. Nevertheless, little information of grass pollen sensitization has been the major problem in Thailand. Therefore, aims of the present study were to identify and clone IgE-binding protein from para grass pollen, one of the major allergen sources in Thailand. The immunoblots using sera of grass atopic donors showed that two 30 kD proteins were potential the major IgE-binding compounds of para grass pollen. The peptide matching results from ESI-LC-MS/MS analysis indicated that both of them highly matched to beta-expansins but different isoforms, beta-expansin 9 and beta-expansin 11. Beta-expansin 9 and beta-expansin 11 were cloned and analyzed their sequences compared with beta-expansin allergens. Beta-expansin 9 was highly similar to Panicoideae allergens such as Pas n 1, Sor h 1, and Zea m 1, whereas beta-expansin 11 was closely related to different isoforms of Sor h 1 and Zea m 1. Two beta-expansins share only 60% sequence identity at both nucleotide and amino acid levels. The recombinants of two proteins were produced and confirmed their IgE-binding properties using immunoblots and immunoblot inhibition assays. The results from this study ensured IgE-binding properties of two beta-expansins and they showed the different IgE-binding profiles. It can be concluded that beta-expansins were an important IgE-binding compounds in para grass pollen. Moreover, two subgroups of allergenic beta-expansins might be the specific character of para grass and other Panicoidea grasses. The knowledge gained from this study will provide the better understanding in grass pollen allergy among Thai population and also provided more information of allergenic compounds of subtropical grass.

Keywords:recombinant allergen, beta-expansin, para grass pollen, Urochloa mutica, grass allergy

340

OP 055ASSOCIATION BETWEEN INSERTION/DELETION OF PROMOTER DNA VEGF (rs699947) WITH VEGF/sVEGFR-2 RATIO IN CHRONIC LIVER DISEASE

Neneng Ratnasari1, Siti Nurdjanah1, Ahmad Hamim Sadewa2, Mohammad Hakimi3, Yoshihiko Yano4

1. Department of Internal Medicine, Faculty of Medicine Gadjah Mada University/ Dr. Sardjito Hospital, Yogyakarta, Indonesia.

2. Department of Biochemistry, Faculty of Medicine Gadjah Mada University, Yogyakarta, Indonesia.

3. Department of Public Health, Faculty of Medicine Gadjah Mada University, Yogyakarta, Indonesia.

4. Center for Infectious Diseases, Kobe University Graduate School of Medicine, Kobe, Japan.

AbstractBackground. Polymorphisms of DNA vascular endothelial growth factor (VEGF) gene located in promoter region may influence expression of VEGF and its receptor. Insertion/deletion (I/D) located in rs699947 are presented in hepatocellular carcinoma (HCC). Ratio VEGF/sVEGFR-2 is most influenced in clinical expression of neo-angiogenesis process. Aims of study are to explore association between occurring of promoter I/D with ratio VEGF/sVEGFR-2 serum in chronic liver disease (CLD).Methods. The prospective study with cross sectional design and consecutive sampling was performed in 59 CLD patients [20 chronic hepatitis (CH), 19 liver cirrhotic (LC) and 20 hepatocellular carcinoma (HCC)] and 17 healthy controls. The study was performed at Dr. Sardjito General Hospital Yogyakarta, Indonesia. Promoter I/D were examined using specific primer for rs699947, and DNA was sequenced using Applied Bio systems. Level of VEGF and sVEGFR-2 serum was examined by ELISA. All data were analyzed by STATA version 11.0, with significant p<0.05.Results. There were no significant difference on gender (49/64.47% male; 27/ 35.53% female) and age (52.08±13.18 year) between subjects. There were deletion 18 base-pair (bp) located at -2549 and insertion+deletion located at -2547 until -2526 with various bp. There were no significant difference occurring deletion, insertion+deletion and normal sequence in all subjects (normal 5/6.58%, deletion 37/48.68%, insertion+deletion 34/44.74%; p=0.959). Median VEGF/sVEGFR-2 ratio in HCC [0.090 (0.010;0.258)] was significant difference compare with LC [0.027 (0.008;0.096); (p=0.005], CH [0.027 (0.016;0.070); p=0.002] and healthy control [0.029 (0.01;0.08); p=0.005]. Median of VEGF/sVEGFR-2 in deletion subjects was higher than insertion+deletion subjects [0.042 (0.008;0.258) vs. 0.026 (0.008;0.220); p=0.017] and not showed significant different in subjects without I/D [0.040 (0.019;0.057)].Conclusion. The VEGF/sVEGFR-2 ratio in CLD and HCC subjects who occurring of deletion (-2549; 18 bp.) higher than subject with insertion+deletion (-2547 until -2526), significantly.

341

OP 078The influence of cumin extract (Nigella Sativa) for inflammation marker sTREM-1 and eosinophil count at asthma bronchial patientsRaveinal, Deni Arisanti

Sub division allergy and immunology of internal medicine, faculty of medicine Andalas University Padang Indonesia

Background: WHO data show in the world, approximately 300 million people suffer from asthma bronchial and will be increase until 400 million at 2025. Astma bronchial is inflammatory disease of respiratory tract. sTREM-1 (soluble Triggering Receptor Expressed on Myeloid Cells) is the new of inflammatory marker at respiratory tract. Maria B et al (2012) show the sTREM-1 release from the surface of neutrophile, monocyte dan macrophage.

El Gazar et al (2006) show thymoquinon the main content of cumin extract can decreased sitokine of T hellper2, mucous and eosinophyle count at lung of mice. sTREM -1 at blood plasma from asthma bronchial patients can reflect the grade of severe, exacerbation and obstruction of respiratory tract at asthma bronchial patients.

Aim of the study to look the influence of giving extract cumin (Nigella Sativa) to sTREM-1 and eosinophil count at asthma bronchial patients.

Method: Design of study is clinical study with double blind control. The first group take the standard treatment plus extract cumin and the second group take the standard treatment plus placebo for 4 weeks. Study was done for out patients at M Jamil Hospital Padang.

Results: This study found decrease of sTREM-1 level after 4 week treatment is significant different between case and control patients ( 103.85 ± 0,35 pg/ml to 95.52 ± 30.63 pg/ml at case patients compare 117.66 ± 0.92 pg/ml to 128.56 ± 0.98 pg/ml at control patients ). The study also found decrease of eosinophil count significant different between case and control patients ( 0.39 x 103 ± 0.11 u/l to 0.19 x 103 ± 0.13 u/l at case patient compare 0.39 x 103 u/l ± 0.53 to 0.49 x 103 ± 0.55 u/l at control patients ). Asthma control test increase significant between case and control patients ( 12.23 ± 4.1 to 19.58 ± 3.6 at case patients compare 19.72 ± 2.1 to 14.05 ± 2.1 at control patients )

Conclusion: Giving the cumin extract (Nigella Sativa) to the asthma bronchiale patients can decrease inflammation marker sTREM-1, eosinophile count and increase the asthma control test.

342

OP 109SINGLE NUCLEOTIDE POLYMORPHISMS VARIANTS OF TRANSCRIPTION FACTOR 7- LIKE 2 GENE EXPRESSED DIFFERENT mRNA ISOFORMS IN THE PERIPHERAL BLOOD

Made Ratna Saraswati1), Ketut Suastika1), AAG Budhiarta1), Herawati Sudoyo2), Safarina G. Malik2) I Gusti Ngurah Kade Mahardika3)

1)Endocrinology and Metabolism Division, Department of Internal Medicine Faculty of Medicine Udayana University/Sanglah Hospital2)Eijkman Institute for Molecular Biology, Jl. Diponegoro 69 Jakarta 104303) Faculty of Veterinary Medicine Udayana University

Background: Single Nucleotide Polymorphisms (SNPs) of the Transcription Factor 7-Like 2 (TCF7L2) diabetes susceptibility gene were located in the non coding region. Intronic SNP may play a role in the mRNA splicing. This study aimed to elucidate whether SNP variants of the TCF7L2 gene express different mRNA isoforms in the peripheral blood.

Methods: A cross sectional analytic, observational study was conducted in Legian Bali study population which has known variants SNPs of TCF7L2 gene, 28 subjects in each group, age and sex were matched, age between 30-74 years, male:female 36:20. Heterozygote or mutant of rs12255372 SNP (GT or TT), rs7903146 (CT or TT), and rs10885406 (AG or GG), were grouped into subject carrying diabetes risk allele and the second group were wild type of rs12255372 (GG), rs7903146 (CC), and rs10885406 (AA). SNPs of the TCF7L2 gene were identified using polymerase chain reaction restricted fragment length polymorphism (PCR-RFLP) method. The mRNA isolation was done using LS Trizol reagent (Invitrogen®) and variants of the mRNA isoform in the TCF7L2 gene was identified by reverse transcriptase-polymerase chain reaction (RT-PCR) method, using two overlapping primer sets.

Results: We identified Group-A (positive band 300bp), Group-B (400bp), Group-C (300 and 400bp), and Group-D (negative band) using primer set 1. The primer 2 PCR products were grouped into Group-a (600bp), Group-b (900bp), Group-c (600 and 900bp), and Group-d (negative band). There were 7 pairs of the group combination based on this classification, including: Group-A-a, Group-A-c, Group-A-d, Group-C-a, Group-C-c, Group-C-d, and Group-D-c. The mRNA variants of Group-C-c expressed by subject with diabetes risk allele was 2.66 time more likely than subjects without diabetes risk allele of SNPs in the TCF7L2 gene (95%CI 1.24–5.72 p=0.011)

343

Conclusions: This study revealed that SNPs variants of TCF7L2 gene express different mRNA isoforms in the peripheral blood.

Keywords: Diabetes, SNP TCF7L2, mRNA isoforms

Giving the cumin extract (Nigella Sativa) to the asthma bronchiale patients can decrease inflammation marker sTREM-1, eosinophile count and increase the asthma control test.

344

OP 035Effect of Secretome Messenchymal Stem Cell to HsCRP levels and TNF α in Mice Model of Lupus Nephritis

Nurudhin A1, Agung RA2, Maharani IP2, Wulandari EL2, Adnan ZA2

Rheumatology Department of Internal Medicine Moewardi Hospital/medical Faculty Sebelas Maret University

Resident of Internal Medicine Moewardi Hospital/ Medical Faculty Sebelas Maret University

Backgroumd : Lupus nephritis is a common and serious complication in SLE with deposition of autoanti-bodies in the glomerulus. HsCRP is an acute-phase reactant serum which usually parallel with disease activity in inflammatory states. TNF α was reported to be increased in Lupus Nephritis and correlated with disease activity and it has been proposed to contribute to the immunopathogenesis of SLE. Injection Pristan intraperitoneal can induce lupus Nephritis in mice. Secretome mesenchymal stem cells act as anti-apoptotic agents, suppress B cells and autoreactive T cells, and have anti-inflammatory properties

Aim : This study aimed to determine the effect of secretome mesenchymal stem cells on the HsCRP levels and expression of TNF α in mice model of Lupus Nephritis.

Methods : An experimental study with randomization, with post test only control group design, the sample of 21 female mice Mus musculus strain Balb / C, divided into 3 groups: control group (intraperitoneal injection of 0.5 ml of 0.9% NaCl), the group Pristan (injection Pristan intraperitoneal 0.5 ml) and Pristan + secretome group (intraperitoneal injection of 0.5 ml Pristan and secretome 0.45 ml). Research carried out for 24 days, secretome given on the day 21st of the study. After treatment, we performed measurements of HsCRP levels and TNF expression. Statistical analysis using SPSS 22 for windows with ANOVA and post hoc LSD. p significant if p <0.05.

Result : There are statistically significant differences in all groups in HsCRP levels (p=0,003 ) and TNF α expressions (p=0,005). There is a difference in hsCRP levels between the control (387.05 pg/mL +157pg/mL) with Pristan, (2152.92pg/mL+1440.93pg/mL) (p=0,002), Pristan with Pristan+sekcetome (686.33pg/mL+524.91pg/mL) (p=0,006), and there is no difference between the control group with Pristan+secretome (p=0,537). There is a difference in TNF α expressions between the control (6.86/100 limfosit+1.95/100 limfosit) with Pristan, (11.71/100 limfosit+ 3.40/100 limfosit) (p=0,002), Pristan with Pristan+sekcetome (7.86/100 limfosit+2.04/100 limfosit) (p=0,011), and there is no difference between the control group with Pristan+secretome (p=0,473).

Conclusion : Secretome mesenchymal stem cells can decrease HsCRP levels and

345

expression of TNF α in mice model of Lupus Nephritis.

Keyword : Secretome mesenchymal stem cells, HsCRP, TNF α, Lupus Nephritis

Effect of Secretome Messenchymal Stem Cell to IL 17 expressions and Microalbuminuria in Mice Model of Lupus NephritisNurudhin A1, Agung RA2, Maharani IP2, Wulandari EL2, Adnan ZA2

1. Rheumatology Department of Internal Medicine Moewardi Hospital/medical Faculty Sebelas Maret University

2. Resident of Internal Medicine Moewardi Hospital/medical Faculty Sebelas Maret University

Backgroumd : Lupus nephritis is a common and serious complication in SLE with deposition of autoanti-bodies in the glomerulus. IL-17 production increased in patients with SLE can amplify the immune response by increasing target organ inflammation and damage and by augmenting the production of antibodies by B cell.. Microalbuminuria has been defined as a urinary albumin excretion of 20–200 μg/min (30–300 mg/24 h), endothelial dysfunction has been implicated in the pathogenic mechanism, and microalbuminuria may be a marker of susceptibility to increased permeability of the vascular wall. Injection Pristan intraperitoneal can induce lupus Nephritis in mice. Secretome mesenchymal stem cells act as anti-apoptotic agents, suppress B cells and autoreactive T cells, and have anti-inflammatory properties

Aim : This study aimed to determine the effect of secretome mesenchymal stem cells on the IL 17 expressions and Microalbuminuria in mice model of Lupus Nephritis.

Methods : An experimental study with randomization, with post test only control group design, the sample of 21 female mice Mus musculus strain Balb / C, divided into 3 groups: control group (intraperitoneal injection of 0.5 ml of 0.9% NaCl), the group Pristan (injection Pristan intraperitoneal 0.5 ml) and Pristan + secretome group (intraperitoneal injection of 0.5 ml Pristan and secretome 0.45 ml). Research carried out for 24 days, secretome given on the day 21st of the study. After treatment, we performed measurements of IL 17 expressions and microalbuminuria. Statistical analysis using SPSS 22 for windows with ANOVA and post hoc LSD. p significant if p <0.05.

Result : There are statistically significant differences in all groups in IL 17 expressions (p=0,016) and Microalbuminuria (p=0,0001). There is a difference in IL 17 expressions between the control (7.29/100 limfosit +2.36/100 limfosit ) with Pristan, 9.86/100 limfosit +2.27/100 limfosit) (p=0,42), Pristan with Pristan+sekcetome (6.14/100 limfosit+1.95/100 limfosit ) (p=0,005), and there is no difference between the control group with Pristan+secretome (p=0,344). There is a difference in Microalbuminuria between the

346

control (27.53μg/mL+3.03μg/mL) with Pristan, (60.85μg/mL +19.27μg/mL ) (p=0,0001), Pristan with Pristan+sekcetome (30.02μg/mL+3.13 μg/mL ) (p=0,001), and there is no difference between the control group with Pristan+secretome (p=0,688).

Conclusion : Secretome mesenchymal stem cells can decrease IL 17 expressions and Microalbuminuria in mice model of Lupus Nephritis.

Keyword : Secretome mesenchymal stem cells, IL 17, microalbuminuria, Lupus Nephritis

Effect of Secretome Messenchymal Stem Cell to IL 6 and IL 10 expressions in Mice Model of Lupus Nephritis

Nurudhin A1, Agung RA2, Maharani IP2, Wulandari EL2, Adnan ZA2

1. Rheumatology Department of Internal Medicine Moewardi Hospital/medical Faculty Sebelas Maret University

2. Resident of Internal Medicine Moewardi Hospital/medical Faculty Sebelas Maret University

3. Backgroumd : Lupus nephritis is a common and serious complication in SLE with deposition of autoanti-bodies in the glomerulus. IL-6 is a multifunctional cytokine produced by leukocytes and intrinsic kidney cells that affects inflammation, increases mesangial cell proliferation, and also contributes to autoimmunity by stimulating terminal B-cell differentiation, autoantibody secretion, and T-cell differentiation. IL10, a cytokine produced by monocytes and to a lesser extent lymphocytes, has pleiotropic effects in immune regulation and inflammation. It enhances B cell survival, proliferation, differentiation, and antibody production, and these effects play a role in autoimmune diseases. Injection Pristan intraperitoneal can induce lupus Nephritis in mice. Secretome mesenchymal stem cells act as anti-apoptotic agents, suppress B cells and autoreactive T cells, and have anti-inflammatory properties

Aim : This study aimed to determine the effect of secretome mesenchymal stem cells on the IL 6 and IL 10 expression in mice model of Lupus Nephritis.

Methods : An experimental study with randomization, with post test only control group design, the sample of 21 female mice Mus musculus strain Balb / C, divided into 3 groups: control group (intraperitoneal injection of 0.5 ml of 0.9% NaCl), the group Pristan (injection Pristan intraperitoneal 0.5 ml) and Pristan + secretome group (intraperitoneal injection of 0.5 ml Pristan and secretome 0.45 ml). Research carried out for 24 days, secretome given on the day 21st of the study. After treatment, we performed measurements of IL 6 and IL 10 expressions. Statistical analysis using SPSS 22 for windows with ANOVA and post hoc LSD. p significant if p <0.05.

347

Result : There are statistically significant differences in all groups in IL 6 expressions(p=0,002) and IL 10 expressions (p=0,012). There is a difference in IL 6 expressionsbetween the control (7.57/100 limfosit+1.51/100 limfosit) with Pristan, (15.00/100 limfosit + 5.42/100 limfosit) (p=0,001), Pristan with Pristan+sekcetome (9.14/100 limfosit + 1.77/100 limfosit ) (p=0,001), andthere is no difference between the control group with Pristan+secretome (p=0,399). There is a difference in IL 10 expressions between the control (17.14/100 limfosit+2.61/100 limfosit) with Pristan, (21.57/100 limfosit +3.10/100 limfosit) (p=0,006), Pristan with Pristan+sekcetome (17.57/100 limfosit+ 2.30/100 limfosit) (p=0,012), and there is no difference between the control group with Pristan+secretome (p=0,769).

Conclusion : Secretome mesenchymal stem cells can decrease IL 6 expressions and IL 10 expression in mice model of Lupus Nephritis.

Keyword : Secretome mesenchymal stem cells, IL 6, IL 10, Lupus Nephritis

Judul lain :

study model of lupus mice with Pristan induction on HsCRP levels and TNF α expressionsstudy model of lupus mice with Pristan induction on IL 6 and IL 10 expressionsstudy model of lupus mice with Pristan induction on complement C3 and antibody dsDNAstudy model of lupus mice with Pristan induction on microalbuminuria and HsCRPstudy model of lupus mice with Pristan induction on complement C3 and histopatology kidneystudy model of lupus mice with Pristan induction on antibody dsDNA and TNF αAssociation TNF α levels with kidney histological features of mice model lupus nephritis with pristan inductionAssociation HsCRP levels with kidney histological features of mice model lupus nephritis with pristan inductionAssociation complement C3 with kidney histological features of mice model lupus nephritis with pristan inductionAssociation IL 6 expression with kidney histological features of mice model lupus nephritis with pristan inductionAssociation IL 10 expression with kidney histological features of mice model lupus nephritis with pristan inductionAssociation IL 17 expression with kidney histological features of mice model lupus nephritis with pristan inductionAssociation microalbuminuria with kidney histological features of mice model lupus nephritis with pristan inductionAssociation antibody dsDNA with kidney histological features of mice model lupus nephritis with pristan induction

348

OP 056Clinical risk factors profile for intradialytic hypertension in End Stage Renal Disease at hospital dialysis units in Bandung

Afrianti. R, Afiatin, Roesli. RMADepartement Internal Medicine, Padjadjaran University

Intradialytic hypertension is one of serious complication in haemodialysis. Compared to previous studies in other countries, this complication is the most common in Indonesia. Pathophysiology of intradialytic hypertension is still poorly understood and results from many studies are contradictory. Several factors contributing in intradialytic hypertension events are age, volume overload, renin angiotensin aldosterone system activity, sympathetic nerve system over-activity, serum sodium level, increased blood viscosity, excess ultrafiltration and arterial stiffness. The aim of this study is to describe intradialytic hypertension risk factors characteristics in haemodialysis population.

This was a descriptive cross-sectional study. Data were collected from dialysis units in Hasan Sadikin General Hospital, Santosa Hospital, and Habibie Hospital from May 2015 to June 2015. The unpaired t-method test was used to show difference between intradialytic hypertension group and non-intradialytic hypertension group.

Three hundred and nine subjects had intradialytic hypertension by 35% prevalence. There were significant difference between pulse pressure and intradialytic hypertension (p=0.02). There were no significant differences between age, intradialytic weight gain (IDWG), ultrafiltration, pulse rate, haematocrit, and serum sodium level prior to haemodialysis in either intradialytic hypertension group or non-intradialytic hypertension group (p>0.05).

This study conclude that pulse pressure, as an indication of arterial stiffness, is a significant risk factor in intradialytic hypertension in hospital dialysis units in Bandung.

Keywords : Intradialytic hypertension, risk factors

349

OP 060RELATIONSHIP BETWEEN INTRADIALYTIC BLOOD PRESSURE VARIABILITY (BVP) AND ULTRAFILTRATION REMOVED (UFR) DURING HEMODIALYSIS (HD) SESSION IN BADUNG DISTRICT HOSPITALMahendra IBN, Widiana IGR, Suwitra K, Sudhana W, Loekman JS, Kandarini YDivision of Nephrology and Hypertension, Departement of Internal MedicineMedical Faculty of Udayana University, Sanglah General Hospital-Denpasar

Background: Recent observational data demonstrated an association between short-term blood pressure variability (BPV) and adverse outcomes among chronic hemodialysis (HD) patients. However, there is no report regarding paterrns of intradialytic BPV and wether this condition related to hemodialysis procedure.

Objective: The aims of study is to observe paterrns of intradialytic BPV and to determine wether ultrafiltration removed (UFR) related to intradialyitc BPV during HD session.

Method: A cohort observational study was done among 34 chronic hemodialysis (HD) patients at the HD unit of Badung district hospital. BP (systolic blood pressure-SBP, diastolic blood pressure-DBP, mean arterial blood pressure-MAP) was meassured hourly during HD session (hours-0=initial HD, hours-1, hours-2, hours-3, hours-4) by the standardized automatic BP device which is integrated on the Bellco’s machine dialytic software. Whereas, UFR obstained based on delivery dose during HD session.

Results: Subject characteristics: n = 34 (male 29, female 5), age (48,29 ± 14,81 yo), HD length (34,36 ± 21,30 months), cut-off UFR based on median value (2.950 mL). Generally, we found U-shaped patterns of BPV among HD patients with upper median UFR against SBP (SBP-0: 158,94 ± 31,85 ; SBP-1: 147,76 ± 22,16 ; SBP-2: 147,82 ± 27,44 ; SBP-3: 151,94 ± 27,56 ; SBP-4: 151,94 ± 27,66), DBP (DBP-0: 89,47 ± 15,00 ; DBP-1: 87,94 ± 12,98 ; DBP-2: 87,35 ± 11,07 ; DBP-3: 86,29 ± 12,25 ; DBP-4: 89,29 ± 13,55) and certainly MAP (MAP-0: 112,65 ± 18,99 ; MAP-1: 107,82 ± 13,57 ; MAP-2: 107,59 ± 15,28 ; MAP-3: 108,18 ± 15,17 ; MAP-4: 110,35 ± 16,92). Whereas, the other side of lower median UFR we found more linier-shaped against SBP (SBP-0: 145,65 ± 29,53 ; SBP-1: 141,94 ± 23,83 ; SBP-2: 145,71 ± 24,54 ; SBP-3: 147,59 ± 26,71 ; SBP-4: 147,00 ± 28,56), DBP (DBP-0: 86,53 ± 17,31 ; DBP-1: 85,29 ± 14,00 ; DBP-2: 85,47 ± 12,12 ; DBP-3: 85,59 ± 13,92 ; DBP-4: 85,18 ± 13,93) and certainly MAP (MAP-0: 106,29 ± 19,30 ; MAP-1: 104,35 ± 16,00 ; MAP-2: 105,65 ± 13,89 ; MAP-3: 106,18 ± 15,63 ; MAP-4: 105,88 ± 16,90).In Conclusion: In this study, among chronic HD patients accompanied by UFR upper than median value tends relate to higher intradialytic BPV (SBP, DBP and MAP). Paterrns of intradialytic BPV shows U-shaped BP fluctuations, while UFR lower than median value shows more linier-shaped.

Keyword: Intradialytic blood pressure variability (BPV), ultrafiltration removed (UFR), hemodialysis (HD).

350

OP 106Registry data show that hypertension combined with comorbid disorders is a risk factor for adverse perinatal outcomes in pregnant women1Martynov A.I., .1Stryuk R.I., 1Berns S.A., 1Filipova M.P., 1Borisov I.V., 1Barkova E.L., 1Gomova T.A., 2Kozina E.A.

Medical University of Higher Professional Education «Moscow State University of Medicine and Dentistry named after A.I. Evdokimov of the Ministry of Health of Russia, Moscow, Russia

Tula Regional Perinatal Center, Russia

Objective: to analyze the frequency and structure of arterial hypertension its relationship with comorbid conditions and their role in development of adverse perinatal outcomes in pregnant women in routine clinical practice

Materials and methods: the analysis of birth histories and medical charts data of 3216 pregnant women who delivered their babies in the Tula regional perinatal center. Enrollment to the Registry started on the 01.01.2014 and terminated on the 31.12.2014. Inclusion criteria for enrollment in the Registry were: 1) Pregnancy at any stage during registration of a women in the antenatal clinic or hospitalization to the perinatal center ; 2) the informed consent signed 3) the willingness to comply with all the requirements of the Registry protocol.

Results: The mean age of pregnant women was 28 (25; 33) years. Arterial hypertension (AH) was observed in 451 (14.0%) women. Out of this group hypertension before pregnancy (chronic hypertension - (CAH) took place in 177 (39.3%) women, pre-eclampsia (PE) was diagnosed in 158 (35.0%), gestational hypertension (GAH) in 116 (25.7%) patients. Women with CAH and GAH were significantly (p <0.0001) older compared with women without hypertension: 31 (27; 36) and 30 (27; 36) to 28 (25; 32), respectively.

Obesity was detected in 789 (24.7%) of all the pregnant women. In all cases of hypertension obesity occurred significantly more often when compared to normal weight before pregnancy (p <0.0001): with CAH - 110 (62.1%), with GAH - 67 (57.8%), with PE - 87 (55.1%) compared to pregnant women without AH - 525 (19.0%), respectively. The similar trend and the combination of hypertension with diabetes mellitus (DM) type 2: patients with CAH compared to pregnant women without hypertension (30.3% versus 5.8%; p <0.0001), with GAGs (30.3% vs 13.8%; p = 0.0012), with PE (30.3% vs. 14.5%; p = 0.0006) has been noticed.

Women with CAH, GAH and PE had significantly more often history of cardiovascular disease when compared with women without AH: the CAH from 46.9% (p = 0.019), GAH at 22.4% (p = 0.03) and PE at 40.9% (p <0.0001) patients.

351

Premature baby delivery (in term of <38 weeks) were observed significantly more frequently in women with CAH (17.1%; p = 0.0028) and PE (35.2%; p <0.0001) when compared with women without hypertension (10.0%). Cesarean sections have been applied significantly more often (p <0.001) in AH women including those with CAH – 85 (48.0%) and with PE - 105 (66.5%) in comparison with the pregnant women without AH where Cesarean section took place in 894 (32.3%) cases. The deaths of newborn were observed in 44 cases (0.46%) in total and in 27.3% of pregnant women of this subgroup AH was observed.

Conclusions:

1. Any type of AH in pregnant women including CAH, GAH and PE is associated with older age, obesity, diabetes mellitus type 2 and cardiovascular burdened history.

2. Hypertension leads to a significantly greater number of patients with premature childbirths and surgery for baby delivery.

352

OP 111EVALUATION OF THE EFFECT OF FGF-23, IL-1 BETA AND KIM-1 ON DISEASE PROGRESSION AND MORTALITY IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Emel S. GOKMEN1, Hasan KAYABASI2, Dede SIT3,Bennur ESEN4, Ahmet E. ATAY2, Mustafa H. DINCKAL5, Saadet P. GUZEL6, Elif YORULMAZ7

1. Eyup State Hospital, Internal Medicine, Istanbul, Turkey2. Bagcilar Education and Research Hospital, Internal Medicine and Nephrology,

Istanbul, Turkey3. Istinye University Medicalpark Hospital, Internal Medicine and Nephrology, Istanbul,

Turkey4. Acibadem Taksim Hospital, Internal Medicine and Nephrology, Istanbul, Turkey5. Bakırkoy Dr. S. Konuk Education and Research Hospital, Cardiology, Istanbul,

Turkey6. Bagcilar Education and Research Hospital, Biochemistry, Istanbul, Turkey7. Bagcilar Education and Research Hospital, Internal Medicine and Gastroenterology,

Istanbul, Turkey

Aim: Because of increasing frequency and treatment costs, chronic kidney disease (CKD) is a major public health problem worldwide an in our country. Hence prevention of disease, early diagnosis, delaying the progression and prediction of mortality is impotant. In this study it was aimed to investigate the relationship between progression – mortality and serum FGF-23, IL-1 beta and KIM-1 levels among predialysis CKD patients.

Materials and Metods: A total of 147 patients with CKD admitted to Intenal Medicine Department of Bagcilar Training and Research Hospital between January and May 2012 were enrolled into the study. Demographic and etiological data were recorded, and blood samples including hemogram analysis, biochemical parameters and serum FGF-23, IL-1 beta and KIM-1 levels were examined. Patients were followed for 48 months. Demographical and laboratory data of survivors and nonsurvivors were compared.

Results: In our study, diabetes mellitus (DM) and hypertension (HT) were major causes of CKD. During the 48 month follow-up period, 51 patients (34.6%) died. Statistically significant relationship was observed between mortality rates and stage of disease, age, high levels of serum CRP and ferritin and decreased serum albumin levels, however the effects of gender and the presence of DM on mortality were statistically nonsignificant. There was no statistically significant difference between survivors and nonsurvivors with regard to serum levels of FGF-23, IL-1 beta and KIM-1 (Table-1). Relationship of serum FGF-23, IL-1 beta and KIM-1 with magnesium as well as serum FGF-23 and IL-1 beta with uric acid and IL-1 beta with CRP were statistically significant.

Conclusion: Both initial serum levels and variations during 48 months follow-up period of

353

FGF-23, IL-1 beta and KIM-1 have nonsignificant impact on mortality of CKD patients. Further studies with large number of participants and longer duration of follow-up are required to determine predictors of prognosis and mortality in patients with CKD.

Keywords: Chronic kidney disease, progression, mortality, serum FGF-23, IL-1 beta, KIM-1

Table-1. The mean FGF-23, IL-1 beta and KIM-1 levels of survivors and nonsurvivors in the baseline evaluation (p=0.170, p=0.221 and p=0.829; respectively)

354

OP 011Modified body mass index predicts poor outcome of patients with biopsy-proven AA amyloidosis with renal involvement.

Ekrem Kara1,Teslime Ayaz1, Tuncay Sahutoglu, Elbis Ahbap2, Tamer Sakaci2, Yener Koc2, Taner Basturk2, Abdulkadir Unsal2.

1. Recep Tayyip Erdogan University, Faculty of Medicine, Department of Internal Medicine, Rize, Turkey.

2. Sisli Etfal Educational and Research Hospital, Department of Nephrology, Istanbul, Turkey.

Abstract

Introduction: AA amyloidosis is a multisystemic, progressive and fatal disease.Malnutrition is a prominent clinical feature and a predictor of increased mortality in this population. Body mass index (BMI) is a suboptimal measure to assess the clinical status of patients.Modified BMI corrects for the effect of hypoalbuminemia and is a better reflection of overall nutritional health.The aim of this study was to investigate the effects of mBMI on the outcome of patients with biopsy-proven AA amyloidosis with renal involvement.

Methods: A total of 121 (Male/Female:84/37,were analyzed.Demographic,clinical and laboratory features and outcomes data were obtained from follow up charts.Patients were divided into 2groups according to their median mBMI levels;group1(n: 60)=mBMI<57.3 and group2(n:61)=mBMI≥57.3.

Results:FMF(37.2%) and tuberculosis(24.8%) were the most frequent causes of amyloidosis.Median(IQR)serum creatinine and proteinuria at diagnosis were 1.3(2.2)mg/dl and 5.3(7) g/day, respectively. There were no significant difference between groups regarding age, gender, weight, BMI, etiology of amyloidosis and laboratory features.Compared to the group 2, group 1 had significantly lower follow-up time, mBMI, serum albumin and calcium and higher lipids, ferritin and proteinuria levels. Sixty-eight(56.2%) of 121 patients were started dialysis treatment during the follow-up period and there were no difference between groups35(58%)vs 33(54%), respectively,p:0.639). Time to dialysis(13.9±20.8vs25.7±28.1months,respectively,p:0.040)and renal survival time(49.2±7.4vs75.1±8.9,respectively,p:0.027)wereshorter in group 1.Fifty patients(%41.3) died during the follow-up period(30(50%) vs20(32.7%), respectively, p:0.041).The mean patient survival time were shorter in group1. (58.9±9.1vs106.9±10.4months, respectively,p:0.003).One, two and five year survival rates of group 1 and 2 patients were 74.4% vs 90%,55.8% vs 80.3% and41.4% vs 65.4%, respectively. Short time to dialysis and low mBMI levels were found as independent predictors of mortality in multivariate Coxproportional hazard model analysis.

355

Conclusions:The outcome of patients with AA amyloidosis and renal involvement is poor, particularly in those who had low mBMI and dialysis requirement at the outset.Low mBMI as a reflection of malnutrition is an independent predictor of mortality.

Table 1. Characteristics of all patients and mBMI groups.

All patients

(n= 121)

Group 1

(n=60)

Group 2

(n= 61)P- value

Demographics

Age (y) 43 (19) 42 (18) 44 (22) 0.654

Gender (F/M) 37/84 15/45 22/39 0.187

Follow- up time (months) 26 (56) 15 (33) 35 (59) 0.001

Weight (kg) 62 (15) 60.4 (16) 62 (14) 0.323

Body mass index (kg/m²) 21.9 (3.2) 21.4 (3.9) 22.2 (2.5) 0.065

mBMI 57.3 (32.9) 41.5 (15.6) 74.2 (21.8) <0.001

Etiology of amyloidosis (n)

FMF 45 19 26Tuberculosis

30 19 11

Bronchiectasis 8 3 5 0.402Inflammatory bowel

disease4 1 3

Rheumatologic 10 6 4

Undetermined 24 12 12U

Laboratory

Urea (mg/dL) 44 (60) 40.5 (46) 55 (72) 0.420

Creatinine (mg/dL) 1.3 (2.2) 1.28 (2.7) 1.56 (2) 0.699

eGFR (ml/min) 60.3 (79.7) 66.7 (87.9) 57.9 (77.3) 0.701

Hemoglobin (g/dl) 12 (3) 12.2 (3) 12 (3) 0.215

Uric acid (mmol/L) 5.9 (2.2) 5.5 (2.3) 6.2 (2.3) <0.001

Sodium (mmol/l) 139 (4) 139 (3.9) 139 (4) 0.416

356

Potassium (meq/L) 4.5 (1) 4.4 (1) 4.5 (1) 0.099

Albumin (g/dl) 2.6 (1.5) 1.9 (0.7) 3.4 (1.1) <0.001

Calcium (mg/dL) 8.5 (1.3) 8.2 (1.3) 8.8 (1.1) <0.001

Phosphorus (mg/dL) 4.5 (1.5) 4.6 (1.4) 4.4 (1.7) 0.324

intact PTH (pg/ml) 75 (101) 73.5 (81) 78 (141) 0.866

Total cholesterol (mmol/L) 233 (146) 295.5 (162) 200 (100) <0.001

LDL (mmol/L) 145 (117) 179 (150) 124 (76) <0.001

Triglyceride (mmol/L) 180 (170) 250 (216) 136 (105) <0.001

Ferritin (ng/ml) 105 (180) 151 (234) 63 (130) 0.003

Proteinuria (gr/24 h) 5.3 (7) 7.1 (8) 3.7 (6) <0.001

Data were presented as median ± interquartilerange (IQR); mBMI: Modified body mass index; FMF: Familial mediterranean fever; eGFR: Estimated glomerular filtration rate; PTH: Parathormone, LDL: Low density lipoprotein

Table 2. Comparison of patientandrenalsurvivalbetweenmBMIgroups.

Group 1

(n=60)

Group 2

(n= 61)P- value

Dialysisrequirement (n,%) 35 (58%) 33 (54%) 0.639

Time todialysis (months) 13.9±20.8 25.7±28.1 0.040

Renalsurvival time (months) 49.2±7.4 75.1±8.9 0.027

Exitus (n,%) 30 (50%) 20 (32.7%) 0.041

Patientsurvivaltime (months) 58.9±9.1 106.9±10.4 0.003Data were presented as mean ± SD; mBMI: Modified body mass index

357

Table 3.Multivariatesurvivalanalysis (Coxproportionalhazard model) of thefactorsthatpre-dictsmortality.

Predictor of death Beta ODDS% 95 Confiden-

ceInterval P- value

LowerUpper

Age (years) 0.004 1.004 0.980 1.028 0.757Time todialysis (mont-

hs) -0.027 0.974 0.958 0.990 0.002

Serum albumin (g/dl) 0.324 1.382 0.458 4.171 0.566

eGFR (ml/min) -0.009 0.991 0.973 1.009 0.308Serum creatinine (mg/

dl) -0.098 0.907 0.775 1.060 0.220

Proteinuria (g/24 h) -0.027 0.974 0.918 1.033 0.381

mBMI -0.018 0.983 0.966 0.999 0.040mBMI: Modified body mass indexFigure 1. Renalsurvival of mBMIgroups.

Figure 2.Patientsurvival of mBMIgroups.

358

OP 030Decline of estimated glomerular filtration rate is a risk of poor outcome for HIV-infected patients

Masaki Hara1 Naoki Yanagisawa2 Minoru Ando3

1Division of Nephrology and 2Infectious Diseases, Department of Medicine, Tokyo Metropolitan, Komagome Hospital, Bunkyo-Ku, Tokyo, Japan, 3Department of Medicine, Tokyo Metropolitan Fu-chu Medical and Welfare Center for the Disabled, Fu-Chu-Shi, Tokyo, Japan

Background: The effect of decreased kidney function on poor outcomes including, cardiovascular disease, cerebral vascular disease, and all-cause mortality has not been fully understood. This study examined a long-term impact of incident decreased estimated glomerular filtration rate (eGFR) on a future develop these outcomes among HIV-infected individuals.

Methods: Consecutive data of eGFR were obtained during 6 years from 2008 to 2014 in 636 HIV-infected patients on combination antiretroviral therapy. Incident decreased eGFR was defined as a new decline in eGFR more than ≥30% that occurred between 2008 and 2009. New onset of cardiovascular disease, cerebral vascular disease, and all-cause mortality that occurred between 2009 and 2014 were defined as a composite outcome. Composite outcome was analyzed by the Kaplan-Meier method, stratified by presence or absence of incident decreased eGFR. Multivariate Cox proportional hazards regression analysis was used to calculate hazard ratio (HR) with its 95% confidence interval (CI) for composite outcome, adjusted for age, gender, presence or absence of hypertension, diabetes mellitus, hepatitis C, and eGFR, HIV-RNA levels and CD4 cell counts at baseline.

Results: Patients age was 46±11 years [mean ± standard deviation (SD)]. The mean (SD) of the follow-up period was 4.78±0.71 years. Incident decreased eGFR was 2.2% (14 out of 636 patients), and totally 46 patients occurred composite outcome (cardiovascular disease, 15 patients; cerebral vascular disease, 9 patients; all-cause mortality, 22 patients). The cumulative incidence of composite outcome over time was significantly higher in the presence than absence of incident decreased eGFR (35.7% versus 6.8%; p<0.0001). In addition, the HR (95% CI) of incident decreased eGFR for composite outcome was 6.96 (2.05-19.6; p=0.0006).

Conclusion: Decline of eGFR may be a harbinger of cardiovascular disease, cerebral vascular disease, and all-cause mortality for HIV-infected patients.

359

OP 067Effectiveness grant of zinc to nutritional status and inflammation in chronic kidney disease patients those undergoing haemodialysis regular in Mohammad Hoesin Hospital Palembang

Adhi Permana1, Suprapti1, Novadian1, Zulkhair Ali1, Ian Effendi1, Theodorus T2, Arbangi Kadarusman1

1. Department of Internal Medicine Mohammad Hoesin Hospital Palembang, Kidney and hypertension, Indonesia

2. University of Sriwijaya, Medical faculty, Indonesia

Objective: This study to prove whether zinc supplementation improve nutrional status and inflammation, seen from changes in nutritional status and CRP levels before and after administration of zinc or placebo for 12 weeks in patients with CKD-HD regular

Design and Method: a single-blind study randomized clinical trials, research in Hemodialysis Installation RSMH Palembang March to June 2015. Subject made history, physical examination, assessment of appetite, laboratory tests and CRP levels later divided randomly assigned (randomized) into the group received zinc and placebo. At the end of the study there were 36 subjects (18 subjects who received zinc and 18 subjects received placebo ), which conducted the analysis.

Results: The mean levels of CRP in the zinc before the study was 4.10 ± 1.40 mg / L and after 12 weeks 2.54 ± 1.75 mg / L. Contrary to the placebo group. Paired t-test showed a mean reduction in CRP levels in the zinc group were statistically significant (p = 0.003).There is changes in appetite levels. Total of 12 (66.7%) subjects in the zinc expressed his appetite increased, while 16 (88.9%) subjects in the placebo group states settled their appetite. The difference was statistically significant (Kolmogorov-Smirnov test, p = 0.002). After research, found no significant changes in nutrional status.

Conclusions: The provision of zinc effectively lowers CRP levels in patients with CKD-HD. Zinc supplementation can be used as an adjunctive therapy to reduce the incidence of chronic inflammation in patients with CKD-HD and improve appetite.

360

OP 070Effects of Anemia and Renal Failure on the Survival in Elderly Patients

Seyit Ahmet Uslu1, Yaşar Küçükardalı2, Mehmet Akif Öztürk2, Yasemin Gül Aydemir2, Betül Küçükardalı3, Zehra Eren4, Nihat Alpay5, Özlem Çakır6, Çiğdem E Kaspar7

1. GATA Haydarpasa Training Hospital, Dept. of Internal Medicine, Istanbul, Turkey2. Yeditepe University Medical Faculty, Dept. of Internal Medicine, Istanbul, Turkey3. Yeditepe University Science and Literature Faculty, Dept. of Psychology, Istanbul,

Turkey 4. Yeditepe University Medical Faculty, Dept. of Nephrology, Istanbul, Turkey 5. bakirköy Ruh ve Sinir Hastalıkları Hastanesi, Dept. of Psychiatry, Istanbul, Turkey6. Avicenna Atasehir Hospital, Dept. of Neurology, Istanbul, Turkey 7. Yeditepe University Medical Faculty, Dept. of Biostastics and Medical İnformatics,

Istanbul, Turkey8. Introduction

In this study elderly nursing home residents with anemia were evaluated. Relationship of anemia and demographic features, co-morbidities, renal functions and also survival were analyzed.

Material and Methods:

Six hundred twelve elderly patients who registered for the residency at nursing home during the period of January 2005 to 2013 were consecutively enrolled to the study. Glomerular filtration rate was estimated by the Cockcroft-Gault Formula. Persistence of eGFR<60 ml/min was assigned as the diagnosis of chronic renal failure (CRF).

Results: Anemia was detected in 276 (54%) of 612 patients. Age (78.1±10.9 vs 75.1±11.5, p0.001), mortality (46% vs 34%, p=0.004) was significantly higher and follow up period was shorter in duration (15±21 months vs 21 ±24, p=0.002) in patients with anemia. Gender, BMI, and mini mental test results were not different between groups. Physical dependency during daily activities was significantly higher in anemia group. Comorbidities >6 illnesses was higher, hemoglobin was lower, eGFR was lower, frequency of eGFR < 60 ml/dk was higher in patients with anemia. Frequency of anemia was significantly higher (60% vs 34%, p<0.001) in CRF compared with non-CRF group. Average Hb levels measured at the initiation and the end of the follow up period was as 11,9±1,7 vs 11,9 ± 1,7 in non-CRF group and as 11,5 ±1,6 vs 11,1±1,5 in CRF group (p=0.008). Survival duration was significantly shorter (24±4 vs 57±9 months, p<0.001) in anemia groups compared to patients without anemia. Additionally, survival was shorter (22±5 vs 59 ±9 months, p<0.001) in patients with eGFR <60 ml/min.

Conclusion: Presence of anemia is significantly associated with the reduced survival rates

361

among elderly nursing home residents. Co-morbidity of chronic renal failure additively reduces the survival. Hematological supplement therapy and renal protection is clinically important. Detection of abnormalities and preventive measures should be performed earlier.

362

OP 085CLINICAL CORRELATES OF HEMOGLOBIN LEVEL AND PATHOGENESIS OF ANEMIA IN PATIENTS WITH EARLY DIABETIC NEPHROPATHY

Pchelin I.Y., Shishkin A.N., Hudiakova N.V.

Saint Petersburg State University, Department of Faculty Therapy, Saint Petersburg, Russia

Background. Anemia is associated with increased mortality and impaired quality of life in patients with diabetic nephropathy (DN). In this study we assessed clinical correlates of hemoglobin (Hb) level and the contribution of different pathogenic factors to anemia development in early DN.

Methods. We investigated 95 anemic and 77 non-anemic patients with type 2 diabetes mellitus and CKD stages 1-3. In addition to routine tests we measured serum levels of erythropoietin (EPO), ferritin, vitamin B12, folate, asymmetric dimethylarginine (ADMA), interleukin-1beta (IL-1beta), interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor alpha (TNFalpha) using immunoassay. Correlations were assessed by Spearmen’s correlation coefficients (rs).

Results. Hb level had no significant correlations with age, glycemic control, urinary albumin excretion, serum levels of insulin, C-peptide, leptin, C-reactive protein, homocysteine, ADMA and IL-10. Hb level correlated negatively with serum levels of IL-1beta (rs=-0.273, p=0.007), IL-6 (rs=-0.500, p<0.001) and TNFalpha (rs=-0.311, p=0.001). Elevated level of proinflammatory cytokines were observed in most patients with anemia (IL-1beta – 86.3%, IL-6 – 70.5%, TNFalpha – 21.1%). Anemic patients had EPO deficiency in 46.3%, low ferritin – in 11.6%, vitamin B12 deficiency – in 1.1% and folate deficiency – in 2.1% cases. The prevalence of EPO deficiency was progressing with the decline in GFR. Normochromic type of anemia was the most frequent (61%).

Conclusion. The results of the study suggest that anemia in patients with early DN is often related to EPO deficiency and systemic inflammation. Given this evidence for complex pathogenesis of anemia in DN, comprehensive investigation is essential for effective treatment.

The study was supported by the President Grant for Government Support of Young Russian Scientists MK-5632.2015.7.

363

OP 020Impact of Nutritional Status on Length of Hospital Stay

AuthorsKoichi Miyakoshi, Takaaki Katsurai, Yurie ImaiDepartment of Rehabilitation Medicine, Kameda Medical Center

BackgroundPrediction of length of hospital stay is important to provide effective treatment and hospital discharge plan. But it is sometimes difficult to predict the length of hospital stay, because various factors can affect length of hospital stay. Malnutrition is considered to be one of important factors affecting length of hospital stay. In this study, we report the relationship between the nutritional status and length of hospital stay.

MethodsThe subjects were consecutive patients who admitted to the internal medicine ward of our hospital, from April 2014 to march 2015. Our hospital is an 857-bed acute care community hospital accredited by Joint Commission International. We collected the following variables from the medical records retrospectively. The candidates for prognostic factors were, age, gender, mini nutritional assessment short-form (MNA-SF) on admission. The MNA-SF is comprised of six items (food intake decline, weight loss, mobility, psychological stress or acute disease, neuropsychological problems and body mass index). The outcome indicator was length of hospital stay. Multivariate analysis was done using stepwise regression analysis. SPSS19 Japanese edition was used to complete the analysis.

ResultsThe participants were 5217 patients. The mean age was 69.5 years, mean MNA was 9.94 and mean length of hospital stay was17.6 days. Significant predictive factors of length of hospital stay elucidated by multivariate regression analysis were MNA-SF. Among assessment items of the MNA-SF, mobility had the highest impact, followed by food intake decline and weight loss.

ConclusionStatistically significant correlation exists between MNA-SF and length of hospital stay. Nutritional status should be taken into consideration in order to provide an effective treatment plan. We intend to develop the prediction tool for length of hospital stay through continuation of the survey in our subsequent prospective study.

364

OP 032DIFFERECES OF POLYUNSATURATED FATTY ACID IN HEALTHY JAPANESE LIVING IN INLAND AND SEACOAST AREA AT WAKAYAMA PREFECTURE

Hiroto Tanaka, Hideyuki Sasaki, Mikio Arita

Department of Internal Medicine, Wakayama Medical University, Kihoku Hospital, Wakayama, Japan

Introduction: It has been revealed that the ratio of eicosapentaenoic acid (EPA) to arachidonic acid (AA) is important for the prevention cardiovascular disease by some studies. However, Neither EPA, nor AA can be synthesized in the human body, and thus only dietary intake can increase the concentration of these molecules in blood. The aim of this study was to investigate the differences of polyunsaturated fatty acid (PUFA) levels of serum between inland area and seacoast area at Wakayama prefecture. Subjects and methods: We enrolled 527 healthy subjects (mean age 61.8±9.1 years) living in inland area and 207 health subjects (mean age 61.0±8.2 years) living in seacoast area. Level of PUFA, including EPA, docosahexaenoic acid (DHA), AA in serum were measured. Healthy subjects in both areas were divided into subgroups according to age. Results: LDL-cholesterol and AA in serum were significantly higher and triglyceride, uric acid and EPA/AA ratio in serum were significantly lower in inland area than in seacoast area. Stepwise increase in EPA, DHA and EPA/AA ratio, but not AA were observed in serum of both areas. Especially, AA in serum of 50’s year, 60’s year, and 70’s year was significantly higher in inland area than in seacoast area and EPA/AA ratio in serum of 50’s year and 60’s year was significantly higher in inland area than in seacoast area. Conclusion: The differences of polyunsaturated fatty acid (PUFA) levels of serum between inland area and seacoast area at Wakayama prefecture were shown. Especially, although stepwise increase in EPA, DHA and EPA/AA ratio in serum of both areas was observed in the same way, AA and EPA/AA ratio in serum of 50’s year and 60’s year were significantly higher in inland area than in seacoast area.

365

OP 036Sleep Disturbances and Risk of Stroke in Men Aged 25-64 Years: Who Epidemiological Program Monica -Psychosocial

Gafarov V.1,2, Gromova E.1,2, Gagulin I.1,2, Gafarova A.1,2, Panov D.1,2

1. Collaborative laboratory of Cardiovascular Diseases Epidemiology,2. FSBI Institute of Internal and Preventive Medicine, Novosibirsk, Russia

Objective: We aimed to examine the relationship between sleep disturbances and the risk development of stroke in male population aged 25 to 64 years.

Methods: Within the framework of WHO program «MONICA-psychosocial» representative sample of male inhabitants aged 25-64 years in Novosibirsk was examined in 1994. Total sample was 657 persons. Sleep disturbances were measured at baseline with using the MONICA - psychosocial Interview scale. Incidence of new cases of stroke was revealed over 14-year follow-up. Cox-proportional regression model was used for an estimation of hazard ratio (HR).

Results: During the 5-year follow-up the risk for stroke was 3.9-fold higher (95%CI: 1.1-11; p<0.01) in men assessed their sleep as «poor» or «very bad» compared to those with «good» sleep. Over the 10-years of follow-up the risk of stroke developing was higher in men with «bad» or «poor» sleep and the risk of stroke was 2.72-fold (95%CI: 1.0 -9.5; p<0.05) higher. For 14 years there was a tendency of increasing HR stroke in 1.5-times (p>0.05) in men with sleep disorders compared to those who have pointed out the quality of sleep as «satisfactory» or «good «. Rates of stroke were higher in men with sleep disorders in groups of widowed and divorced with incomplete secondary - primary education as well as in those with heavy and moderate physical work and retired.

Conclusion: The results showed that in male population 25-64 years the risk of stroke significantly associated with sleep disorders. Supported by Grant of Russian Foundation for Humanities №14-06-00227/a.

366

OP 057Javanese Traditional Massage Combined with Extract of Curcuma xanthorrhizaradix, Centella asiatica leaf, and Clarias batrachus, could Improve Dementia inGeriatric PatientsNyoman Kertia*, Suwijiyo Pramono**, Eko Rusmiyati***, Lisa Kurnia Sari****,Tia Yulviantari****

*Rheumatology Division, Internal Medicine Department, Faculty of Medicine, Gadjah Mada University – Sardjito Hospital Yogyakarta, Indonesia, **Faculty of Pharmacy, Gadjah Mada University, Yogyakarta, Indonesia, ***Bethesda Community Development Center, Yogyakarta, Indonesia, ****Internal Medicine Department, Faculty of Medicine, Duta Wacana Christian University – Bethesda Lempuyangwangi Hospital, Yogyakarta, Indonesia, *****Center of Traditional Medicine Development and Application Yogyakarta Special Region, Indonesia

Background: Free radical, vascular disturbance, and malnutrition can cause dementia. Extract of Centella asiatica leaf and Curcuma Xanthorrhiza radix contains antioxidant. Javanese Traditional Massage is believed could make relaxation state and improve blood circulation. Clarias batrachus extract contain poly-unsaturated-fatty-acid and protein that can improve nutritional state. This study aimed to know the effect of Javanese Traditional Massage, combined with extract of Curcuma xanthorrhiza radix, Centella asiatica leaf, and Clarias batrachus, in improving dementia.

Methods: This was a Prospective Open and Blinded Evaluaton Study without control, conducted in Yogyakarta, Indonesia. Thirty subjects with mild to moderate dementia were treat with Javanese Traditional Massage twice weekly, for 4 weeks. Subjects were also consumed three times daily of 250 mg Centella asiatica leaf extract, 50 mg Curcuma Xanthorrhiza radix extract and 10 gr Clarias batrachus extract, concommitantly. Level of dementia was assessed every two weeks (before, during, and after treatment) using Mini Mental State Examination (MMSE) questionnaires. Complete blood count, Aspartate Transaminase (AST), Alanin Transaminase (ALT), Ureum, Creatinin, estimated Glomerular Filtration Rate (eGFR, CKD-Epi equation), Total Antioxidant Status (TAS) and albumin serum, were also measured before and after four weeks of treatment.

Results:There was improvement in MMSE score, before (20.90 ± 4.65), after 2 weeks (22.13 ± 2.45; p=0.072), and after 4 weeks of treatment (24.97 ± 5.35; p=0.000). Total Antioxidant Status was increase (1.33 ± 0.14 vs 1.47 ± 0.11; p=0.000). Platelet count was significantly increase (279.37 ± 84.74 vs 288.97 ± 81.45; p=0.033). Eritrocyte Sedimentation Rate (ESR) was significantly decrease (47.90 ± 26,41 vs 39.23 ± 23,99; p=0.001). Estimated Glomerular Filtration Rate was increase (57.37 ± 17.82 vs 60.08 ± 19.63; p=0.041). There were no significant different in any other parameters.

Conclusions: Javanese Traditional Massage, combined with extract of Curcuma xanthorrhiza radix, Centella asiatica leaf, and Clarias batrachus, could improve dementia in geriatric patients

367

OP 083The Effect of Erdosteine Administration on Neutrophils Sputum in Patients with Stable Chronic Obstructive Pulmonary Disease

Ika Trisnawati, Sumardi, Eko Budiono

Pulmonology Division, Internal Medicine Department, Dr. Sardjito Hospital /Faculty of Medicine Gadjah Mada University Yogyakarta

Background: COPD is the fifth most common disease and the third leading cause of death worldwide. The main mediator inflammatory that is responsible for COPD is protease which is produced by inflammatory cells particularly neutrophil. Degranulated neutrophils will be activated and release neutrophil elastase and other proteinases such as cathepsin G, proteinase 3, and metalloproteinase that will cause tissue damage. Erdosteine is a prodrug which is metabolized in liver to form thiol resulting in metabolite I that produces pharmachological activity as mucolytic, bacterial antiadhesive, antioxidant, and anti-inflammation.

Aim: To understand the effect of Erdosteine 300 mg treatment twice a day for 10 days on neutrophils sputum count in patients with stable COPD compared to placebo

Methods: In this randomized controlled trial study, 32 patients with stable COPD in Dr. Sardjito Hospital were treated either with Erdosteine 300 mg or placebo twice a day as an additional therapy to the standard treatment for 10 days. The difference of the mean of neutrophils sputum count before and after therapy was then analyzed using Mann-Whitney U test and factors which affect neutrophils sputum were analyzed using Fisher Exact test.

Results: Administration of Erdosteine to the standard therapy in this study is able to affect neutrophils sputum by reducing the neutrophils sputum significantly in patients with stable COPD in which the neutrophils sputum count before therapy was 79,19±17,73 compared to 66,25±21,08 after therapy (p=0,043; p<0,05)

Conclusion: The administration of Erdosteine to the standard therapy for 10 days can significantly decrease the neutrophils sputum count in patients with stable COPD compared to placebo.

Keywords: erdosteine, neutrophils sputum, metabolite I, FEV1, COPD

368

OP 110RIFAMPICIN RESISTANCE TUBERCULOSIS IN HIV PATIENTS: A RETROSPECTIVE STUDY

Restuti Hidayani Saragih1, Endang Sembiring1, Franciscus Ginting,1 Tambar Kembaren1, Armon Rahimi1, Yosia Ginting1, Parluhutan Siagian2, R.Lia Kusumawati31Division of Tropical and Infectious Disease, Department of Internal Medicine;2Department of Pulmonology and Respiratoy Medicine; 3Department of Clinical Microbiology; Faculty of Medicine, Universitas Sumatera Utara / Haji Adam Malik General Hospital, Medan, Indonesia

Background : Multidrug-resistant tuberculosis (MDR-TB) remains a challenge to as well as threatens global TB control, with an estimated global disease incidence in 2014 of 480 000 cases. During 2014-2015, of 1068 HIV patients, there were 373 (34.92%) cases of tuberculosis and HIV co-infection in Haji Adam Malik Hospital, Medan. This study was conducted to evaluate the characteristics and treatment response of Rifampicin resistance tuberculosis in HIV patients.

Methods : A retrospective cohort study was conducted in Haji Adam Malik Hospital in Medan, North Sumatera, Indonesia. Samples were gained by total sampling of six HIV-infected patients having positive results to Rifampicin resistance by GeneXpert MTB/RIF, during January 2014-December 2015.

Results : Of the 6 subjects, 5 were males and 1 was female, with the mean age 31.5 years. All subjects had received TB treatment previously, in whom 4 patients (66.7%) had poor adherence to treatment. Pulmonary TB were found in 4 subjects (66.7%), while the rest had both pulmonary TB and extrapulmonary TB (33.3%). Mean absolute CD4 was 201.5 cells/mm3 (range 4-676 cells/mm3). Each subject had at least one or two other opportunistic infection and concomitant disease. Five of them showed improvement with MDR TB therapy, another one had passed away due to sepsis.

Conclusion : Poor adherence to prior TB treatment was the most dominant characteristic that might be correlated with the incidence of Rifampicin resistance TB in HIV-infected patients, besides the HIV infection itself. Thus, strengthening TB control program is mandatory, along with the adherence to Antiretroviral Therapy.

369

OP 043Serum Complement and Anti-dsDNA levels in Relation to Renal and Non-renal Manifestations of Systemic Lupus Erythematosus

Lya Rosita*, B.P.Putra Suryana**, Nur samsu Djais***

*Departement of internal medicine, Brawijaya University-Saiful Anwar General Hospital Malang-Indonesia**Division of Rheumatology, Departement of Internal Medicine, Brawijaya University-Saiful Anwar General Hospital Malang-Indonesia

***Division of Nephrology, Departement of Internal Medicine, Brawijaya University-Saiful Anwar General Hospital Malang-Indonesia

Background: Systemic lupus erythematosus (SLE) has diverse and complex clinical manifestations involving various organs, including renal or non-renal. Renal manifestations are known to be associated with significant morbidity and mortality. SLE is characterized by multiple serological aberrations, including complement C3, C4, and anti-dsDNA, unfortunately the association of C3, C4, and anti-dsDNA with clinical manifestations of renal and non-renal are not clear. The objective of this study is to examine levels of C3, C4, and anti-dsDNA in relation to renal and non-renal manifestations of SLE. Methods: Cross sectional study was conducted in Rheumatology Outpatient Clinic, Saiful Anwar General Hospital Malang. 43 Subjects who met the revised 1997 American College of Rheumatology criteria, which consisted of 11 patients with renal manifestations and 32 patients with non-renal manifestations, participated in this study. Serum C3 and C4 leves were measured using turbidimetry technique and anti-dsDNA levels was measured using enzyme-linked immunosorbent assays (ELISA). T-independent test was used to analyze the comparation of C3 levels, whether Mann-Whitney test was used to analyze the comparation of C4 and anti-dsDNA levels between both groups. Results: Renal manifestations of SLE had significant lower levels of C3 (71.27±32.65 vs 94.47±26.29, p=0.022), C4 (14.55±8.20 vs 25.50±11.05, p=0.002), and higher levels of anti-dsDNA (249.27±240.34 vs 109.91±166.11p=0.014), than those of non-renal manifestations. C3 levels was profoundly more depressed than C4, and anti-dsDNA was elevated in both renal and non-renal manifestation. However, anti-dsDNA in renal manifestation was eleveted higher than that of non-renal manifestation. Conclusions: Renal manifestations of SLE had significant lower levels of C3 and C4 and higher levels of anti-dsDNA than non-renal manifestations of SLE.

Key Words: complement C3, C4, anti-dsDNA, systemic lupus erithematosus, renal manifestation, non-renal manifestation

Correspondence: Lya Rosita. Department of Internal Medicine, Brawijaya University-Saiful Anwar General Hospital, Jl. Jaksa Agung No. 2 Malang Telp. (0341) 366242 Email: [email protected]

370

OP 064CORRELATION BETWEEN DISEASE DURATION, DISEASE ACTIVITY SCORE, DISABILITY SCORE WITH DIASTOLIC DYSFUNCTION IN RHEUMATOID ARTHRITIS WOMEN IN CIPTOMANGUNKUSUMO NATIONAL CENTRAL GENERAL HOSPITAL

Bernard Dakhi, Dono Antono, Harry Isbagio

Background: Cardiovascular is the main cause of mortality in RA, with the rate of 1.5-1.6 times higher than non RA population .The prevalence of HF in RA is 2 times fold of non RA. We conducted a study to asses the correlation between each of the non traditional risk factors including disease duration,disease activity and disability score with the diastolic dysfunction in women with RA.

Methods: A cross-sectional, consecutive sampling study conducted to 52 RA women without any history of cardiovascular disease. All participants underwent an echocardiography to asses the diastolic dysfunction and other findings associated. Duration of disease is assesed by direct interview, while the disease activity by calculating DAS28 and disability score by HAQ-DI.

Results: Diastolic dysfunction was found in 30,8 % of study participants ( 13,5 % for each low and moderate grade, while severe was 3.8% ). Mean of disease duration was 26.5 months (range 2-240), mean DAS28-CRP 2.69±1,11 while mean DAS28-ESR 3,65 (range 1.13-7.5), HAQ-DI score 0,29 (range 0-2,38). LV hypertrophy was found in 34.61% participants. Mean EF 66,7±5,76%. Valve abnormality was found in 34.6% study participants. Correlation between duration of disease, DAS28-CRP, DAS28-ESR and HAQDI score with E/A in sequence was (r= - 0.065; p=0.89), (r=0.393; p=0,38), (r=0.357; p=0.43), (r=0.630; p=0.12) ; while with E/E’ in sequence was (r=0.136; p=0.77), (r= - 0.536; p=0.21), (r= - 0.393; p=0.38), (r=0.374; p=0.41)

Conclusions; Duration of the disease, the disease activity score and disability score in our RA study participants had no correlation with diastolic dysfunction. The most valvular abnormality findings was mild regurgitation. Since there was a big proportion of participants with diastolic dysfunction, it is encouraged to make a stepwise approach of cardiovascular management in patients with RA

Keywords : rheumatoid arthritis, diastolic dysfunction, duration of disease, DAS28, HAQ-DI score

371

OP 039The Relationship of Adequacy and Serum Insulin-like Growth Factor-1 (IGF-1) and Insulin-Like Growth Factor Binding Protein-1 (IGFBP-1) on Peritoneal Dialysis Patient

Herman Trianto1, Atma Gunawan1, Nursamsu1, Putu Arsana1

1Konsultan Nephrology Division, Faculty of Medicine Universitas Brawijaya dr. Saiful Anwar Hospital –Malang – Indonesia

ABSTRACT

Background. Calory protein malnutrition is often found in patients with CAPD but underdiagnosed. 18-56% CAPD patients was reported to diagnosed as malnutrition based on antrophometric and biochemistry examinations. Endocrine insulin like growth factor-1/insulin like growth factor binding protein (IGF-1/IGFBP) axis was allegedly played role as a secondary etiology of malnutrition, and adequacy improvement was hypothesized to ameliorate metabolic and hormonal dearrangement, including IGF-1/IGFBP-1 axis.

Objection. To ascertain correlation of adequacy with IGF-1/IGFBP-1 axis on patients with CAPD.

Method. This study is a survey, held in Malang CAPD Center in May-August 2014. 68 patients participated and performed history taking and physical examinations to determine baseline characteristics. Membran transport characteristics was calculated with PET (Peritoneal Equilibration Test) Twardowski, and adequacy was determined by calculated weekly Kt/V (wKt/V) and weekly creatinine clearance (wCrCl). Serum IGF-1 and IGFBP-1 was measured with Human Quantikinine ELISA. Correlation of adequacy (wKt/V and wCrCl) and IGF-1/IGFBP-1 was analyzed statistically. Data analysis used Pearson, Spearman, Point Biserial and Regresi Multiple Linier tests.

Result. Mean ± SD age of the patients was 47.82 ± 11.17 years old. Membran transport characteristics were low (10.29%), low average (47.05%), high average (33.82%), and high (8.82%), whether adequacy wKt/V was 1.84±0.56 L/week and wCCr 61.51±23.69 L/week/m2. Mean serum IGF-1 was 10.69±4.85 μg/L and median serum IGFBP-1 was 7.16(0.99-56.72) μg/L. Significant correlation was found between serum IGF-1 and plasma fasting glucose (r=-0.516,p=0.00), even after multivariate analysis (r=-0.478,r2=0.228,p=0.00), but correlation of adequacy and serum IGF-1 wasn’t statistically significant. Serum IGFBP-1 was significantly correlated with wKt/V (r=-0.711,p=0.00), wCrCl (r=-0.867,p=0.00), ureum (r=0.244,p=0.045), and creatinine (r=0.329,p=0.006).

Conclusion. Dialysis adequacy (wKt/V and wCrCl) is not correlated with serum IGF-1, but negatively correlated with serum IGFBP-1.

Keywords: CAPD,adequacy,Kt/V,creatinine clearance,IGF-1,IGFBP-1.

372

List

of P

oste

r The

33r

d W

CIM

Bal

i 201

6 Tu

esda

y, 2

3 A

ugus

t 201

6

Post

er

Num

ber

Nam

eC

ount

ryR

emar

ksTi

tle

PO 0

01Pe

lin T

utun

cuog

luTu

rkey

Endo

crin

olog

yC

linic

al a

nd B

ioch

emic

al C

hara

cter

istic

s of

Typ

e 2

Dia

betic

El

derly

Pat

ient

s W

ith N

euro

path

y

PO 0

02Ju

lius

Spic

akC

zech

Rep

ublic

Endo

crin

olog

y

Fina

l Res

ults

of M

ulti-

Cen

ter,

Pros

pect

ive,

Con

trolle

d Tr

ial o

f th

e D

uode

no-J

ejun

al B

ypas

s Li

ner f

or th

e Tr

eatm

ent o

f Typ

e 2

Dia

bete

s M

ellit

us in

Obe

se P

atie

nts:

Effi

cacy

and

Fac

tors

Pr

edic

ting

a Su

bopt

imal

Effe

ct

PO 0

03M

uham

mad

Fai

sal S

oleh

Indo

nesi

aEn

docr

inol

ogy

The

Com

paris

on o

f effi

cacy

bet

wee

n Be

rapr

ost S

odiu

m a

nd

Cilo

staz

ol F

or re

duci

ng p

ain

in P

erip

hera

l Arte

ry D

isea

se

to D

iabe

tes

Mel

litus

Pat

ient

With

Inte

rmitt

en C

laud

icat

io In

M

oham

mad

d H

oesi

n H

ospi

tal P

alem

bang

PO 0

04R

ania

Hao

ues

Alge

riaEn

docr

inol

ogy

Amne

sia

and

Dia

bete

s in

a P

regn

ant W

oman

,Wha

t Dia

gno-

sis?

?

PO 0

05D

wity

a El

vira

Indo

nesi

aEn

docr

inol

ogy

Asso

ciat

ion

Betw

een

Age-

Rel

ated

Dev

elop

men

t with

T-R

egu-

lato

ry F

oxp3

in G

rave

s’ D

isea

se P

atie

nts

PO 0

06H

oChu

n C

hoi

Sout

h Ko

rea

Endo

crin

olog

yD

iabe

tes

and

Thyr

oid

Can

cer R

isk

PO 0

07Fa

timah

Elia

naIn

done

sia

Endo

crin

olog

yC

orre

latio

n of

Gly

cohe

mog

obin

and

the

Valu

e of

Bra

chia

l Ar

tey

Flow

-Med

iate

d D

ilata

tion

(FM

D) i

n Pr

edia

betic

PO 0

08M

arin

a Ep

rilia

wat

iIn

done

sia

Endo

crin

olog

yC

ardi

ogen

ic S

hock

and

Isch

emic

Hep

atiti

s in

Mal

e w

ith A

trial

Fi

brilla

tion

Due

To

Gra

ves

Dis

ease

: A

Cas

e R

epor

t

PO 0

09Al

i Abd

ulna

bi M

oham

edU

KEn

docr

inol

ogy

HbA

1c C

orre

late

s W

eakl

y w

ith F

ruct

osam

ine

in L

ate

Preg

-na

ncy

373

PO 0

10M

oham

mad

Sha

habu

l Hud

a C

how

dhur

yBa

ngla

desh

Endo

crin

olog

yAs

soci

atio

n of

Dep

ress

ion

with

Typ

e 2

Dia

bete

s M

ellit

us

Amon

g Th

e Pa

tient

s At

tend

ing

At T

he T

ertia

ry L

evel

Hos

pita

l in

Ban

glad

esh-

Cas

e C

ontro

l Stu

dy

PO 0

11Ed

dy C

hand

raPh

ilippi

nes

Endo

crin

olog

yIn

cide

nce

of C

in in

Pat

ient

s W

ith T

ype

2 D

iabe

tes

Mel

litus

an

d its

Ass

ocia

tion

with

HBA

1C L

evel

and

Dur

atio

n of

Dia

-be

tes

PO 0

12Sv

etla

na B

erns

Rus

sia

Endo

crin

olog

yLa

bora

tory

Par

amet

ers

in P

atie

nts

with

Acu

te C

oron

ary

Syn-

drom

e an

d Ty

pe 2

Dia

bete

s M

ellit

us

PO 0

13N

atal

ya V

olko

vaR

ussi

aEn

docr

inol

ogy

New

Adv

ance

s in

Insu

lin In

duce

d Li

pohy

pertr

ophy

Dia

gnos

-tic

s in

Dia

betic

Pat

ient

s: E

stim

atio

n R

isk

Mod

el

PO 0

14Ta

srin

a Sh

amna

z Sa

mda

niBa

ngla

desh

Endo

crin

olog

yG

lyce

mic

Sta

tus

of T

ype

2 D

iabe

tic S

ubje

cts

on D

iffer

ent

Anti-

Dia

betic

Man

agem

ent

PO 0

15H

erm

ina

Nov

ida

Indo

nesi

aEn

docr

inol

ogy

Cor

rela

tion

Betw

een

Solu

ble

Cd1

63 a

nd L

ow D

ensi

ty L

ipo-

prot

ein

Cho

lest

erol

, Not

With

Gly

cem

ic C

ontro

l in

Type

2

Dia

bete

s Pa

tient

s

PO 0

16Ed

war

d M

ulia

wan

Put

era

Indo

nesi

aEn

docr

inol

ogy

Mor

talit

y R

ate

of T

hyro

id S

torm

Pat

ient

s at

dr.

Soet

omo

Gen

-er

al H

ospi

tal D

urin

g Pe

riod

of 2

010

- 201

4

PO 0

17So

upar

tBe

lgiu

mEn

docr

inol

ogy

Clin

ical

Eva

luat

ion

of P

atie

nts

with

App

aren

tly Id

iopa

thic

Si

adh

PO 0

18D

zher

ieva

Irin

aR

ussi

aEn

docr

inol

ogy

Inte

rcon

nect

ion

of T

he F

orm

and

Lev

el o

f Gly

cem

ic R

ehab

ili-ta

tion

of P

atie

nts

with

Isch

emic

Stro

ke

PO 0

19H

adia

ti Se

tyor

ini

Indo

nesi

aEn

docr

inol

ogy

Prev

alen

ce o

f Thy

roto

xico

sis

Perio

dic

Para

lysi

s Am

ong

Para

l-ys

is C

ases

and

Thy

roto

xico

sis

Cas

es in

dr.S

oeto

mo

Gen

eral

H

ospi

tal

PO 0

20Le

zzan

Kes

kin

Turk

eyEn

docr

inol

ogy

The

Prev

elan

ce o

f Dia

bete

s M

ellit

us, I

mpa

ired

Fast

ing

Glu

-co

se, I

mpa

red

Glu

cose

Tol

eran

ce a

nd O

besi

ty in

Mal

atya

374

PO 0

21Ve

ny V

icy

Vidy

Man

dang

Indo

nesi

aEn

docr

inol

ogy

Prev

alen

ce o

f Typ

e-2

Dia

bete

s M

ellit

us in

Eld

erly

Min

ahas

a N

orth

Sul

awes

i Ind

ones

ia

PO 0

22H

adia

ti Se

tyor

ini

Indo

nesi

aEn

docr

inol

ogy

Cor

rela

tion

betw

een

Triio

doth

yron

ine,

Thy

roxi

ne, F

ree

Thy-

roxi

ne a

nd T

hyro

tropi

n w

ith T

hyro

toxi

cosi

s Pe

riodi

c Pa

raly

sis

PO 0

23Iy

an M

eyas

di R

icar

do

Tarig

an

Indo

nesi

aEn

docr

inol

ogy

Cor

rela

tion

Betw

eeen

Wai

st C

ircum

fere

nce

And

Ankl

e Br

achi

-al

Inde

x In

Men

opau

se

PO 0

24Pe

trina

Kem

ala

Dew

iIn

done

sia

Endo

crin

olog

yTh

e C

orre

latio

n be

twee

n Si

mva

stat

in U

se w

ith F

astin

g Bl

ood

Glu

cose

and

Tw

o H

our P

ost P

rand

ial G

luco

se L

evel

in D

islip

i-de

mia

Pat

ient

s

PO 0

25Ba

tari

Ret

no M

inan

tiIn

done

sia

Endo

crin

olog

yA

Profi

le o

f Dia

betic

Pat

ient

s in

Dia

betic

Out

patie

nt C

linic

at

Haj

Hos

pita

l Sur

abay

a In

done

sia

Year

201

5PO

026

Mar

gare

th G

raci

aIn

done

sia

Endo

crin

olog

yKe

toac

idos

is in

Phe

ochr

omoc

ytom

a Pa

tient

PO 0

27R

oy P

anus

unan

Sib

aran

iIn

done

sia

Endo

crin

olog

yAs

ian

Spec

ific

Defi

nitio

n fo

r The

Met

abol

ic S

yndr

ome

and

The

Rel

atio

nshi

p w

ith A

lani

ne A

min

otra

nsfe

rase

in a

n In

done

-si

a Po

pula

tion

(The

Jak

hear

t Stu

dy)

PO 0

28Yo

si Ir

awat

i Wib

owo

Indo

nesi

aEn

docr

inol

ogy

Indo

nesi

an P

hysi

cian

-Pha

rmac

ist C

olla

bora

tive

Prac

tice

in

Dia

bete

s C

are:

A Q

ualit

ativ

e St

udy

PO 0

29Ko

mar

iatu

nIn

done

sia

Endo

crin

olog

yTh

e Ef

fect

of A

polip

opro

tein

E G

ene

Poly

mor

phis

m to

Dia

bet-

ic N

ephr

opat

hy In

cide

nce

in T

2DM

at P

alem

bang

PO 0

30R

io W

irone

goro

Indo

nesi

aEn

docr

inol

ogy

A C

ase

of H

ypog

onad

otro

pic

Hyp

ogon

adis

m D

ue to

Mic

road

-en

oma

in G

ynec

omas

tia M

ale

Patie

nt

PO 0

31N

ur A

ini H

anifi

ahIn

done

sia

Endo

crin

olog

ySu

bjec

tive

Glo

bal A

sses

smen

t as

A Sc

reen

ing

for M

alnu

tri-

tion

in E

lder

ly P

atie

nt w

ith T

ype

2 D

iabe

tes

Mel

litus

: A C

ase

Rep

ort

PO 0

32Lu

ddw

i Ach

mad

Riz

kyIn

done

sia

Endo

crin

olog

yTh

e Ef

fect

of N

rf2 A

ctiv

atio

n on

End

othe

lial F

unct

ion

in

Dia

bete

s

375

PO 0

33O

zlem

Sac

anTu

rkey

Endo

crin

olog

yPr

otec

tive

Effe

cts

of Z

inc

Sulfa

te A

gain

st O

xida

tive

Stre

ss in

Th

e G

astri

c Ti

ssue

of S

trept

ozot

ocin

-Indu

ced

Dia

betic

Rat

s

PO 0

34O

mur

Tab

akTu

rkey

Endo

crin

olog

yO

xida

tive

Stre

ss, C

yclo

philin

A A

nd N

ucle

ar F

acto

r Kap

pa

B in

Rel

atio

n w

ith T

he D

evel

opm

ent o

f Com

plic

atio

ns o

f D

iabe

tes

PO 0

35H

afize

Uzu

nTu

rkey

Endo

crin

olog

ySe

rum

Glu

cago

n Li

ke P

eptid

e -1

Lev

els

and

Dip

eptid

yl P

epti-

dase

-4 A

ctiv

ity in

Typ

e 2

Dia

bete

s M

ellit

us w

ith M

icro

vasc

ular

C

ompl

icat

ions

PO 0

36W

ahyu

ni L

ukita

Atm

odjo

Indo

nesi

aEn

docr

inol

ogy

The

Leve

l of I

nsul

in R

esis

tanc

e Su

bstra

te a

nd F

astin

g Bl

ood

Suga

r in

Rat

afte

r Adm

inis

tratio

n of

Hig

h Fa

t Die

t and

Inje

c-tio

n of

Stre

ptoz

otoc

in

PO 0

37Se

hnaz

Bol

kent

Turk

eyEn

docr

inol

ogy

The

Rol

e of

a N

ew V

anad

ium

Com

plex

on

the

Kidn

ey o

f St

rept

ozot

ocin

-Dia

betic

Rat

s

PO 0

38Sa

yuri

Shim

izu

Japa

nEn

docr

inol

ogy

Hos

pita

lizat

ion

of A

dult

Patie

nts

with

Low

-Ris

k C

omm

uni-

ty-A

cqui

red

Pneu

mon

ia:

A R

etro

spec

tive

Obs

erva

tiona

l St

udy

Usi

ng a

Nat

iona

l Inp

atie

nt D

atab

ase

in J

apan

.

PO 0

39H

endr

a G

unaw

anIn

done

sia

Endo

crin

olog

yC

orre

latio

n O

f Phy

sica

l Exa

min

atio

n An

d N

eutro

phil T

o Ly

m-

phoc

yte

Rat

io W

ith C

ortis

ol S

erum

In P

atie

nts

With

Cus

hing

Sy

ndro

me

PO 0

40Şa

kir Ö

zgür

Keş

kek

Turk

eyEn

docr

inol

ogy

Freq

uenc

y of

Hyp

erho

moc

yste

inem

ia in

Pat

ient

s w

ith P

oly-

cyst

ic O

vary

Syn

drom

e

PO 0

41N

ikko

Dar

nind

roIn

done

sia

Endo

crin

olog

yPr

eval

ence

of P

erip

hera

l Arte

rial D

isea

se in

Pat

ient

s w

ith D

ia-

bete

s M

ellit

us in

A P

rimar

y R

effe

ral H

ospi

tal

PO 0

42M

ujga

n G

urle

rTu

rkey

Endo

crin

olog

ySe

rum

Vis

fatin

Lev

els

in P

atie

nts

with

Sub

clin

ical

and

New

ly

Dia

gnos

ed T

ype

2 D

iabe

tes

Mel

litus

376

PO 0

43Su

ng S

oo S

him

Sout

h Ko

rea

Endo

crin

olog

yPr

esen

ce o

f Dia

bete

s an

d Its

Ass

ocia

tion

with

Dep

ress

ive

Sym

ptom

and

Tre

atm

ent:

The

6th

Kore

an N

atio

nal H

ealth

an

d N

utrit

ion

Exam

inat

ion

Surv

ey

PO 0

44Ag

us J

oko

Susa

nto

Indo

nesi

aEn

docr

inol

ogy

Succ

essf

ul M

anag

emen

t of I

nsul

in H

yper

sens

itivi

ty o

n Ty

pe 2

D

iabe

tes

Mel

litus

Pat

ient

: A

Cas

e R

epor

t

PO 0

45D

easy

Ard

iany

Indo

nesi

aEn

docr

inol

ogy

Cor

rela

tion

of H

igh

Mol

ecul

ar W

eigh

t Adi

pone

ctin

with

Fas

t-in

g In

sulin

in T

he T

ype-

2 D

iabe

tes

Mel

litus

PO 0

46Sh

afira

Pus

padi

naIn

done

sia

Endo

crin

olog

ySy

stem

atic

Rev

iew

of T

he E

ffica

cy o

f Int

erle

ukin

-1 R

ecep

tor

Anta

goni

st in

Typ

e 2

Dia

bete

s

PO 0

47Yu

suf A

ulia

Rah

man

Indo

nesi

aEn

docr

inol

ogy

Clin

ical

Fea

ture

s of

Hyp

othy

roid

ism

and

Hel

ath-

Rel

ated

Q

ualit

y of

Life

Afte

r Rad

ioth

erap

y: J

ustif

ying

Thy

roid

Fun

ctio

n Sc

reen

ing

for I

ndon

esia

n N

asop

hary

ngea

l Can

cer S

urvi

vors

PO 0

48N

ugra

heny

Pra

sast

i Pur

-lik

asar

iIn

done

sia

Endo

crin

olog

yC

linic

al P

rofil

e of

Mol

a H

ydat

idos

a Pa

tient

s w

ith H

yper

thyr

oid

PO 0

49R

enny

Ang

grae

nyIn

done

sia

Endo

crin

olog

yC

ortis

ol H

orm

one

Profi

le In

Mac

road

enom

a H

ypop

hisi

s Pa

-tie

nts

Who

Und

ergo

Sur

gery

In D

r. So

etom

o G

ener

al H

ospi

tal

Sura

baya

PO 0

50D

jati

Susi

loIn

done

sia

Endo

crin

olog

yM

orta

lity

Rat

e As

soci

ated

with

Hyp

oalb

umin

emia

in D

iabe

tic

Foot

Pat

ient

s

PO 0

51Ac

hmad

Sya

iful L

udfi

Indo

nesi

aEn

docr

inol

ogy

Asso

ciat

ion

betw

een

Glo

mer

ular

Filt

ratio

n R

ate

and

Inta

ct

Para

thyr

oid

Hor

mon

e Le

vel i

n N

on-D

ialy

tic D

iabe

tic K

idne

y D

isea

se P

atie

nts

PO 0

52H

asna

Fah

mim

a H

aque

Bang

lade

shEn

docr

inol

ogy

Freq

uenc

y an

d R

isk

Fact

ors

of D

iabe

tic C

ompl

icat

ions

Am

ong

Sele

cted

Gro

up o

f Dia

betic

Pat

ient

s: R

eal-L

ife S

ce-

nario

from

A D

evel

opin

g C

ount

ry, B

angl

ades

h

377

PO 0

53Fi

ras

Faris

i Alk

aff

Indo

nesi

aEn

docr

inol

ogy

Det

ectio

n of

Mon

ocyt

e C

hem

oattr

acta

nt P

rote

in-1

in K

idne

ys

of D

iabe

tic M

ice

with

and

with

out F

unct

iona

l End

othe

lial

Hep

aran

Sul

fate

PO 0

54O

livia

Cic

ilia W

alew

angk

oIn

done

sia

Endo

crin

olog

yH

urtle

Cel

l Car

cino

ma

of T

he T

hyro

id G

land

PO 0

55W

asim

MD

Moh

osin

Ul

Haq

ueBa

ngla

desh

Endo

crin

olog

ySe

rum

Inta

ct P

arat

hyro

id H

orm

one

Leve

l is

Inve

rsel

y C

orre

-la

ted

with

Gly

cate

d H

aem

oglo

bin

in D

iabe

tic C

KD S

tage

s 3-

5 Pr

edia

lysi

s Pa

tient

s

PO 0

56Li

sa K

urni

a Sa

riIn

done

sia

Endo

crin

olog

yEf

fect

of P

hysi

cal A

ctiv

ity In

tens

ity to

HBA

1C L

evel

in N

on

Dia

betic

Sm

okin

g M

en

PO 0

57Br

ama

Ihsa

n Sa

zli

Indo

nesi

aEn

docr

inol

ogy

Cor

rela

tion

Betw

een

Gly

cem

ic C

hara

cter

istic

And

Ery

thro

cyte

In

dice

s In

Obe

se S

ubje

cts

With

Diff

eren

t Gly

cem

ic S

tatu

s

PO 0

59R

izky

Sya

wal

uddi

n D

jam

alIn

done

sia

Endo

crin

olog

yTh

yroi

d D

isea

ses

: Cha

ract

eris

tic S

ympt

oms

in A

dult

Wom

an

in U

rban

Citi

es in

Indo

nesi

a

PO 0

60Yu

e Sh

iU

SAH

emat

olog

y /

Onc

olog

yN

ot a

n O

rdin

ary

UTI

: A C

ase

of M

ultip

le M

yelo

ma

Stag

e III

, w

ith N

o Bo

ne P

ain,

Hyp

erca

lcem

ia, o

r Ost

eoly

tic L

esio

ns

PO 0

61D

ae-W

eung

Kim

Sout

h Ko

rea

Hem

atol

ogy

/ O

ncol

ogy

Thyr

oglo

bulin

Mea

sure

men

t in

Nee

dle

Was

hout

s fro

m

Fine

-Nee

dle

Aspi

ratio

n Bi

opsy

: Use

ful T

ool f

or th

e D

iagn

osis

of

Cer

vica

l Lym

ph N

ode

Met

asta

ses

from

Pap

illary

Thy

roid

C

ance

r bef

ore

Thyr

oide

ctom

y

PO 0

62M

arth

a Is

kand

arIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

KIM

UR

A D

ISEA

SE in

You

ng In

done

sian

Mal

e a

Rar

e C

ase

in

Fatm

awat

i Gen

eral

Hos

pita

l

PO 0

63Yu

nju

Nam

Sout

h Ko

rea

Hem

atol

ogy

/ O

ncol

ogy

Prog

nost

ic U

tility

of S

erum

St-2

Lev

el A

s A

Pred

icto

r of C

lini-

cal O

utco

mes

in In

cide

ntal

Dia

lysi

s Pa

tient

s

PO 0

64Ji

nzho

u Zh

uC

hina

Hem

atol

ogy

/ O

ncol

ogy

Epid

emio

logi

cal T

rend

s in

Col

orec

tal C

ance

r in

Chi

na

PO 0

65Ba

har O

zdem

irTu

rkey

Hem

atol

ogy

/ O

ncol

ogy

Asso

siat

ion

of M

ultip

le M

yelo

ma

and

Aden

okar

sino

ma

of

Unk

now

n Pr

imar

y

378

PO 0

66An

dy P

urno

mo

Indo

nesi

aH

emat

olog

y /

Onc

olog

yTy

pe 2

Nor

man

dy V

on W

illebr

and

Dis

ease

A R

are

Cas

e R

epor

t

PO 0

67Je

rry E

anes

San

ches

Si

moe

sPo

rtuga

lH

emat

olog

y /

Onc

olog

yG

astri

c Pl

asm

acyt

oma

and

a Su

gest

ive

Panc

reat

ic P

lasm

a-cy

tom

a

PO 0

68W

ahyu

Dja

tmik

oIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

BCR

-ABL

Mol

ecul

ar D

iagn

ostic

for C

hron

ic M

yelo

id L

euke

mia

in

Ban

yum

as R

egen

cy, I

ndon

esia

PO 0

69D

iana

Jen

i Has

tuti

Indo

nesi

aH

emat

olog

y /

Onc

olog

yR

heum

atoi

d Ar

thrit

is-L

ike

Synd

rom

e Pr

esen

ting

in A

cute

Pr

omye

locy

tic L

euke

mia

PO 0

70Xi

aohu

a Li

Chi

naH

emat

olog

y /

Onc

olog

yTh

e C

hara

cter

izat

ion

of P

hosp

hory

latio

n Le

vel o

f Aut

opha

gy

Skel

eton

Pro

tein

Bec

lin1

in C

linic

al R

ecta

l Can

cer S

ampl

es

PO 0

71Su

-Jin

Koh

Sout

h Ko

rea

Hem

atol

ogy

/ O

ncol

ogy

End-

of-L

ife C

are

Dec

isio

ns U

sing

Kor

ean

Adva

nce

Dire

ctiv

es

amon

g C

ance

r Pat

ient

-Car

egiv

er D

yads

PO 0

73Eu

n Ju

Kim

Sout

h Ko

rea

Hem

atol

ogy

/ O

ncol

ogy

Abno

rmal

DN

A M

ethy

latio

n-in

duce

d ge

ne In

activ

atio

n is

Re-

late

d to

the

T-ce

ll Le

ukem

ias

Dia

gnos

is a

nd/o

r The

rapy

PO 0

74N

or H

eday

anti

Indo

nesi

aH

emat

olog

y /

Onc

olog

yPr

imar

y Se

min

oma

in T

he M

edia

stin

um C

ase

Rep

ort i

n a

26

-Yea

r-Old

Mal

e

PO 0

75D

anan

gIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Cor

rela

tion

Betw

een

Neu

troph

il C

ount

And

Hem

oglo

bin

Achi

evem

ent T

arge

t In

Hem

odia

lysi

s Pa

tient

s At

Hem

odia

ly-

sis

Uni

t Rsu

d D

r Tjit

row

ardo

jo P

urw

orej

o

PO 0

76R

isw

an A

risan

diIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Phle

gmas

ia C

erul

ea D

olen

s an

d R

ecur

rent

Thr

ombo

sis

in

Anti

Phos

phol

ipid

Syn

drom

e an

d Ev

ans

synd

rom

e

PO 0

77Ba

har O

zdem

irTu

rkey

Hem

atol

ogy

/ O

ncol

ogy

Diff

eren

tiatio

n of

Ben

ign

and

Mal

igna

nt B

reas

t Les

ions

Usi

ng

Com

plet

e Bl

ood

Cou

nt P

aram

eter

s

PO 0

78Ag

us S

udar

soIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Mal

igna

nt P

erip

hera

l Ner

ve S

heat

h Tu

mor

in T

he A

nter

ior

Med

iast

inum

in E

lder

ly: A

Cas

e R

epor

t

PO 0

79Pu

tu N

iken

Am

rita

Indo

nesi

aH

emat

olog

y /

Onc

olog

yTh

erap

eutic

Leu

kaph

eres

is E

ffect

iven

ess

in C

hron

ic M

yelo

g-en

ous

Leuk

emia

: A

Sing

le C

ente

r Exp

erie

nce

in In

done

sia

379

PO 0

80M

erly

na S

avitr

i In

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Borte

zom

ib C

ompa

red

to V

AD R

egim

en a

s an

Indu

ctio

n C

hem

othe

rapy

on

CD

34+

Cou

nt in

Mul

tiple

Mye

lom

a Pa

tient

U

nder

wen

t PBS

CT

in S

urab

aya,

Indo

nesi

a

PO 0

81W

idi H

ersa

naIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Stem

Cel

l Mob

ilizat

ion

Usi

ng H

igh

Dos

e C

yclo

phos

pham

ide

and

G-C

SF S

uper

ior t

han

G-C

SF A

lone

in M

ultip

le M

yelo

ma

Patie

nt U

nder

wen

t Aut

olog

ous

Perip

hera

l Blo

od S

tem

Cel

l Tr

ansp

lant

atio

n

PO 0

82H

arta

nto

wija

yaIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Com

paris

on o

f His

tam

ine

Leve

l in

Chr

onic

Mye

loid

Leu

kem

ia

Patie

nts

Rec

eivi

ng Im

atin

ib M

esyl

ate

and

Nilo

tinib

in H

ema-

tolo

gy C

linic

of P

rof D

r. R

.D.K

ando

u G

ener

al H

ospi

tal

PO 0

83N

i Mad

e R

enny

Ang

gren

i R

ena

Indo

nesi

aH

emat

olog

y /

Onc

olog

y

Trea

tmen

t Res

pons

e of

Chr

onic

Pha

se C

hron

ic M

yelo

id

Leuk

emia

Pat

ient

Tre

ated

with

Tyr

osin

e Ki

nase

Inhi

bito

r at

Gen

eral

Hos

pita

l San

glah

Den

pasa

r

PO 0

84Ja

n Kv

asni

cka

Cze

ch R

epub

licH

emat

olog

y /

Onc

olog

yTh

rom

boph

ilia R

isk

Alle

les

and

Thei

r Ass

ocia

tion

with

Ven

ous

Thro

mbo

embo

lism

in C

zech

Rep

ublic

PO 0

85An

dri I

skan

dar M

ardi

a In

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Antit

rom

bin

III In

Pat

ient

s W

ith H

igh

Ris

k Th

rom

bosi

s

PO 0

86Fi

fi Ak

war

ini

Indo

nesi

aH

emat

olog

y /

Onc

olog

yAc

quire

d H

emop

hago

cytic

lym

phoh

istio

cyto

sis:

a C

ase

serie

s re

port

PO 0

87M

eilia

naIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Anem

ia in

Chr

onic

Ren

al F

ailu

re P

atie

nts

at M

oham

mad

H

oesi

n G

ener

al H

ospi

tal (

RSM

H) P

alem

bang

PO 0

88Ad

e Yo

nata

Indo

nesi

aH

emat

olog

y /

Onc

olog

yR

isk

Fact

ors

of A

nem

ia in

HIV

/AID

S Pa

tient

s w

ith Z

idov

udin

e Th

erap

y

PO 0

89M

ulya

di J

oyo

Sant

oso

Indo

nesi

aH

emat

olog

y /

Onc

olog

y

Com

paris

on b

etw

een

M2

Pyru

vate

Kin

ase

and

Imm

unoc

hro-

mat

ogra

phic

Fec

al O

ccul

t Blo

od T

est F

or C

olor

ecta

l Can

cer

Scre

enin

g at

Moe

ham

mad

Hoe

sin

Hos

pita

l Pal

emba

ng

380

PO 0

90D

evid

Erg

anIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Perfo

rman

ce o

f Im

mun

ochr

omat

ogra

phic

Fec

al O

ccul

t Blo

od

Test

as

Scre

enin

g To

ol fo

r Col

orec

tal C

ance

r

PO 0

91Ak

imas

a Ta

naka

Japa

nH

emat

olog

y /

Onc

olog

yA

Cas

e of

Spo

radi

c N

euro

nal I

ntra

nucl

ear I

nclu

sion

Dis

ease

D

iagn

osed

by

MR

I Fin

ding

and

Ski

n Bi

opsy

PO 0

92In

driy

ani H

erm

iyan

aIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Non

agen

aria

n M

an w

ith B

reas

t Can

cer,

Hyp

erco

agul

able

St

ate

and

Dia

betic

Nep

hrop

aty

PO 0

93Ab

d. R

ahm

an U

mar

Indo

nesi

aR

heum

atol

ogy

Obe

sity

Con

tribu

tion

on S

ynth

esis

and

Deg

rada

tion

of C

arti-

lage

Mar

ker T

hrou

gh In

flam

mat

ion

Path

way

in O

steo

arth

ritic

Pa

tient

s: A

nalis

is o

f Adi

pone

ctin

, Lep

tin, Y

KL-4

0, C

artil

age

Olig

omer

ic M

atrix

Pro

tein

(CO

MP)

Syn

ovia

l Flu

ids

PO 0

94Lu

kman

Pur

aIn

done

sia

Rhe

umat

olog

ySt

eroi

d In

duce

d Av

ascu

lar B

one

Nec

rosi

s in

Pat

ient

with

N

ephr

otic

Syn

drom

e

PO 0

95Fi

ras

Faris

i Alk

aff

Indo

nesi

aR

heum

atol

ogy

Seco

ndar

ily G

ener

aliz

ed T

onic

-Clo

nic

Seiz

ures

Man

ifest

a-tio

ns in

Tee

nage

rs w

ith C

ereb

ral S

yste

mic

Lup

us E

ryth

emat

o-su

s: A

Cas

e R

epor

t

PO 0

96Fo

ng K

ok Y

ong

Sing

apor

eR

heum

atol

ogy

Prev

alen

ce o

f Dia

bete

s M

ellit

us, H

yper

tens

ion

and

Dys

lipi-

dem

ia in

Sys

tem

ic L

upus

Ery

them

atos

us P

atie

nts

PO 0

97T.

Dia

n Pe

rmat

asar

iIn

done

sia

Rhe

umat

olog

ySc

lero

derm

a

PO 0

98Fi

ras

Faris

i Alk

aff

Indo

nesi

aR

heum

atol

ogy

Inhi

bitio

n of

Tra

nsm

embr

ane

Activ

ator

and

Cal

cium

-Mod

u-la

ting

Cyc

loph

ilin L

igan

d In

tera

ctor

as

A Ta

rget

ed T

hera

py

for R

emis

sion

and

Pre

vent

Exa

cerb

atio

n in

Sys

tem

ic L

upus

Er

ythe

mat

osus

: A L

itera

ture

Rev

iew

PO 0

99G

usti

Fung

ani H

arti

Indo

nesi

aR

heum

atol

ogy

The

Qua

lity

of L

ife o

f SLE

Pat

ient

s in

Has

an S

adik

in H

ospi

tal

PO 1

00Ku

ghan

Gov

inde

nM

alay

sia

Rhe

umat

olog

yC

ase

Stud

y: H

yper

troph

ic M

enin

gitis

with

Mul

tisys

tem

In-

volv

emen

t as

Initi

al P

rese

ntat

ion

of B

ehce

t’s D

isea

se

381

PO 1

01Fe

rdy

Ferd

ian

Indo

nesi

aR

heum

atol

ogy

The

Cor

rela

tion

Betw

een

Seru

m A

nti-C

lq A

ntib

ody

Leve

ls

and

Dis

ease

Act

ivity

(bas

ed o

n SE

LEN

A-SL

EDAI

sco

re) i

n Pa

tient

s w

ith S

yste

mic

Lup

us E

ryth

emat

osus

at R

SUP

Dr

Has

an S

adik

in B

andu

ng

PO 1

02Be

nny

Budi

man

Indo

nesi

aR

heum

atol

ogy

Bone

Min

eral

Den

sity

Pro

file

of P

atie

nt w

ith A

utoi

mm

une

Dis

ease

in R

heum

atol

ogy

Clin

ic a

t Dr.H

asan

Sad

ikin

Hos

pita

l Ba

ndun

g

PO 1

03D

wi B

udi D

arm

awat

i In

done

sia

Rhe

umat

olog

yPo

st-C

hlor

oqui

ne A

dmin

istra

tion

Dys

kine

sia

to P

atie

nt w

ith

Syst

emic

Lup

us E

ryth

emat

osus

: a C

ase

Rep

ort

PO 1

04Fa

isal

Bas

hir B

utt

Sing

apor

eR

heum

atol

ogy

Seve

re H

ypok

alem

ia S

econ

dary

to T

ype1

(dis

tal)R

TA S

econ

d-ar

y to

Prim

ary

Sjog

ren’

s Sy

ndro

me

PO 1

05M

usa

Salm

anoğ

luTu

rkey

Rhe

umat

olog

yA

Rar

e C

ase

of L

ymph

aden

omeg

aly:

Kim

ura

Dis

ease

PO 1

06R

amez

an A

li Ata

ee

Iran

Rhe

umat

olog

yN

ew In

side

on

Rhe

umat

oid

Arth

ritis

Pat

hoge

nesi

s: G

ene

Anal

ysis

PO 1

07Je

ston

i Ara

nilla

Philip

pine

sR

heum

atol

ogy

Swee

t’s S

yndr

ome

Co-

Exis

ting

with

Leu

kocy

tocl

astic

Vas

culi-

tis in

A 2

8-Ye

ar O

ld F

ilipin

o M

ale

PO 1

08Je

ston

i Ara

nilla

Philip

pine

sR

heum

atol

ogy

A C

ase

of S

yste

mic

Lup

us E

ryth

emat

osus

-Aut

oim

mun

e H

ep-

atiti

s O

verla

p Sy

ndro

me

with

Spo

ntan

eous

Intra

pare

nchy

mal

H

emor

rhag

es a

nd P

ulm

onar

y Tu

berc

ulos

is in

A 2

9-Ye

ar O

ld

Filip

ino

Mal

e

PO 1

09Ak

itake

Suz

uki

Japa

nR

heum

atol

ogy

Succ

essf

ul C

olch

icin

e Th

erap

y fo

r Rec

urre

nt P

eric

ardi

tis in

A

Patie

nt w

ith L

ong-

Stan

ding

Rhe

umat

oid

Arth

ritis

: A C

ase

Rep

ort

PO 1

10C

haris

ma

Dia

n SH

M S

ima-

tupa

ngIn

done

sia

Rhe

umat

olog

yG

out P

robl

ems

in P

atie

nts

with

Chr

onic

Kid

ney

Dis

ease

s

382

PO 1

11An

dri R

eza

Rah

mad

iIn

done

sia

Rhe

umat

olog

y

A Po

pula

tion

Base

d St

udy

Exam

inin

g C

alca

neus

Qua

ntita

tive

Ultr

asou

nd in

Cip

atuj

ah S

ub-D

istri

ct, T

asik

mal

aya

Wes

t Jav

a In

done

sia

in C

onju

nctio

n of

Uni

vers

itas

Padj

adja

ran

Com

mu-

nity

Ser

vice

s Pr

ogra

m 2

015

PO 1

12Li

ta D

iah

Rah

maw

ati

Indo

nesi

aR

heum

atol

ogy

The

Rel

atio

n Be

twee

n Ag

e of

Ons

et a

nd D

isea

se D

urat

ion

With

The

Thi

ckne

ss o

f Car

otid

Intim

a M

edia

In P

atie

nt W

ith

Spon

dylo

arth

ritis

PO 1

13As

tri U

liaIn

done

sia

Rhe

umat

olog

yAs

soci

atio

n of

Hig

hly

Sens

itive

C-R

eact

ive

Prot

ein

Seru

m

Leve

ls w

ith L

eque

sne

Inde

x in

Kne

e O

steo

arth

ritis

PO 1

14C

ahyo

Wib

ison

oIn

done

sia

Rhe

umat

olog

yA

Man

With

SLE

And

Ant

i-Pho

spho

lipid

Syn

drom

e In

Lim

ita-

tion

Of D

iagn

ostic

And

The

rape

utic

Opt

ion

(Cas

e R

epor

t)

PO 1

15Zo

ubid

a Ta

zi M

ezal

ekM

oroc

coR

heum

atol

ogy

Kiku

chi-F

ujim

oto

Dis

ease

: Rep

ort o

f 4 C

ases

and

Rev

iew

of

The

Lite

ratu

re

PO 1

16Zo

ubid

a Ta

zi M

ezal

ekM

oroc

coR

heum

atol

ogy

Late

Ons

et S

yste

mic

Lup

us E

ryth

emat

osus

: Ret

rosp

ectiv

e St

udy

Abou

t 22

Cas

es

PO 1

17Fa

jar S

arin

ings

ihIn

done

sia

Rhe

umat

olog

yR

isk

Fact

ors

Asso

ciat

ed w

ith L

ow B

ack

Pain

in M

alan

g Po

pula

tion

PO 1

18C

amel

ia Q

usnu

l Cho

timah

Indo

nesi

aR

heum

atol

ogy

The

Prev

alen

ce a

nd R

isk

Fact

ors

of S

oft T

issu

e R

heum

atis

m

in M

alan

g, E

ast J

ava

Indo

nesi

a

PO 1

19Li

a Sa

smith

aeIn

done

sia

Rhe

umat

olog

yTh

e R

elat

ions

hip

of R

isk

fact

or F

or M

uscu

losc

elet

al P

ain

With

D

urat

ion,

Inte

nsity

of P

ain

and

Dis

abilit

y in

Mal

ang,

Indo

nesi

a

PO 1

20M

oham

ad A

nant

o C

Indo

nesi

aR

heum

atol

ogy

The

Prev

alen

ce a

nd R

isk

Fact

ors

of K

nee

Ost

eoar

thrit

is in

M

alan

g, In

done

sia

PO 1

21Su

riani

Alim

uddi

nIn

done

sia

Rhe

umat

olog

yFe

mal

e w

ith E

arly

Der

mat

omyo

sitis

: A

Cas

e R

epor

tPO

122

Kun

Salim

ahIn

done

sia

Rhe

umat

olog

yD

erm

atom

yios

itis

: Eva

lutio

n of

a D

iagn

osis

PO 1

23Ac

hmad

Zai

nudi

n Ar

ifIn

done

sia

Rhe

umat

olog

yTh

e R

elat

ions

hip

of R

isk

Fact

or o

f Mus

culo

skel

etal

Pai

n W

ith

Hea

lth S

eeki

ng B

ehav

iour

in M

alan

g, E

ast j

ava,

Indo

nesi

a

383

PO 1

24Su

ryo

Angg

oro

Indo

nesi

aR

heum

atol

ogy

Pred

icto

rs o

f Rhe

umat

oid

Arth

ritis

Dis

ease

Con

trol a

fter S

ix

Mon

th o

f Con

vent

iona

l Dis

ease

Mod

ifyin

g An

ti R

heum

atic

D

rugs

Mon

othe

rapy

PO 1

25Yo

gi A

gung

Prim

a W

ard-

hana

Indo

nesi

aN

ephr

olog

yIn

tera

ctio

n Be

twee

n C

hron

ic N

euro

infla

mm

atio

n an

d Pa

rox-

ysm

al S

ymph

atet

ic H

yper

activ

ity in

Hyp

erte

nsio

n

PO 1

26Be

tul E

rism

isTu

rkey

Nep

hrol

ogy

Seco

ndar

y M

embr

anou

s N

ephr

opat

hy A

ssoc

iate

d W

ith G

uil-

lain

-Bar

ré S

yndr

ome

PO 1

27Yo

orim

Seo

Sout

h Ko

rea

Nep

hrol

ogy

Ora

l Glu

cose

Tol

eran

ce T

est a

nd S

erum

C-p

eptid

e Le

vels

in

Pat

ient

s U

nder

goin

g C

ontin

uous

Am

bula

tory

Per

itone

al

Dia

lysi

s

PO 1

28Eu

njin

Kan

gSo

uth

Kore

aN

ephr

olog

yTh

e As

soci

atio

n of

Vis

cera

l Fat

Are

a w

ith R

enal

and

Car

diac

Fu

nctio

n in

a P

opul

atio

n w

ith N

orm

al o

r Mild

ly Im

paire

d R

enal

Fu

nctio

n

PO 1

29H

ugo

You-

Hsi

en L

inTa

iwan

Nep

hrol

ogy

Eval

uatio

n of

Com

bina

tion

of P

erito

neal

Dia

lysi

s an

d H

emod

i-al

ysis

in K

aohs

iung

, Tai

wan

PO 1

30Ka

nika

Tya

giSi

ngap

ore

Nep

hrol

ogy

Des

crib

ing

Azot

emia

as

a R

are

Asso

ciat

ion

with

Pur

ple

Urin

e Ba

g Sy

ndro

me

PO 1

31Li

nda

Arm

elia

Indo

nesi

aN

ephr

olog

yTh

e As

soci

atio

n Be

twee

n Le

vels

of E

ryth

ropo

ietin

and

Lev

els

of A

sym

etric

Dim

ethy

larg

inin

e in

Ren

al F

ailu

re P

atie

nts

Trhe

e M

onth

s Af

ter K

idne

y Tr

ansp

lant

atio

n

PO 1

32Eu

i Dal

Jun

gSo

uth

Kore

aN

ephr

olog

yA

Nov

el R

ET M

utat

ion

Iden

tified

in a

Pat

ient

With

Phe

ochr

o-m

ocyt

oma

and

Ren

al C

ell C

arci

nom

a

PO 1

33N

ata

Prat

ama

Har

djo

Lugi

toIn

done

sia

Nep

hrol

ogy

Epid

emio

logi

cal,

Clin

ical

Pro

file

and

Man

agem

ent o

f Hy-

perte

nsiv

e C

risis

in G

ener

al H

ospi

tal i

n Ta

nger

ang,

Ban

ten,

In

done

sia

384

PO 1

34Iri

na K

imR

ussi

aN

ephr

olog

yTh

e Ef

fect

iven

ess

of T

he Q

uest

ionn

aire

for C

ereb

rova

scu-

lar D

isea

ses

Det

ectio

n in

Hyp

erte

nsiv

e Pa

tient

s in

Prim

ary

Hea

lth C

are

PO 1

35Vi

ka W

irdha

niIn

done

sia

Nep

hrol

ogy

Cor

rela

tion

betw

een

Fibr

obla

st G

row

th F

acto

r-23

Seru

m

and

Frac

tiona

l Exc

retio

n of

Pho

spha

te U

rine

in P

redi

alys

is

Chr

onic

Kid

ney

Dis

ease

PO 1

36Bo

bby

Pres

ley

Indo

nesi

aN

ephr

olog

yD

irect

Med

ical

Cos

t Bur

den

Amon

g H

yper

tens

ive

Patie

nts

at

A Pu

blic

Hos

pita

l in

East

Jav

a Pr

ovin

ce

PO 1

37Fa

tih M

ehm

et C

ilingi

rTu

rkey

Nep

hrol

ogy

Freq

uenc

y of

Hyp

erte

nsio

n in

Our

Dis

trict

, Erb

aa, a

Bla

ck

Sea

Dis

trict

PO 1

38N

ata

Prat

ama

Har

djo

Lugi

toIn

done

sia

Nep

hrol

ogy

Qua

lity

of L

ife o

f End

Sta

te R

enal

Dis

ease

Pat

ient

s R

ecei

v-in

g H

emod

ialy

sis

in G

ener

al H

ospi

tal i

n Ta

nger

ang,

Ban

ten,

In

done

sia

PO 1

39Ku

ang-

Chi

h H

siao

Taiw

anN

ephr

olog

yD

iffer

ent I

mpa

ct o

f Asp

irin

on R

enal

Pro

gres

sion

in P

redi

-al

ysis

Adv

ance

d C

hron

ic K

idne

y D

isea

se P

atie

nts

with

or

With

out P

revi

ous

Stro

ke

PO 1

40G

odfre

y M

utas

ham

bara

R

weg

erer

aBo

tsw

ana

Nep

hrol

ogy

Car

dio-

Met

abol

ic R

isk

Fact

ors

Amon

g C

hron

ic K

idne

y D

is-

ease

Pat

ient

s Ad

mitt

ed a

t Prin

cess

Mar

ina

Hos

pita

l, G

abor

o-ne

, Bot

swan

a: C

ross

-Sec

tiona

l Cas

e M

atch

ed S

tudy

PO 1

41Ze

ynep

Alti

nTu

rkey

Nep

hrol

ogy

A C

ase

of A

utos

omal

Dom

inan

t Pol

ycys

tic K

idne

y D

isea

se

Pres

ente

d w

ith A

cute

Pan

crea

titis

PO 1

42H

asan

Bas

riIn

done

sia

Nep

hrol

ogy

Nor

mal

izat

ion

of B

lood

Pre

ssur

e C

ircad

ian

Rhy

thm

in K

idne

y D

onor

s w

ithin

12

Wee

k Po

st N

ephr

ecto

my

PO 1

43Fa

tnan

Set

yo H

ariw

ibow

oIn

done

sia

Nep

hrol

ogy

Impa

ct o

f Acu

te K

idne

y In

jury

on

Mor

talit

y R

ate

of P

atie

nts

with

Sep

sis

in In

tens

ive

Car

e U

nit

PO 1

44Te

guh

Thaj

ebTa

iwan

Nep

hrol

ogy

H-P

roto

n M

agne

tic R

eson

ance

Spe

ctro

scop

y (1

H-M

RS)

of

Osm

otic

dem

yelin

atio

n sy

ndro

me

in a

Ure

mic

Pat

ient

385

PO 1

45Lu

kman

Pur

aIn

done

sia

Nep

hrol

ogy

Pleu

rope

riton

eal L

eak

in P

atie

nt w

ith C

ontin

uous

Am

bula

tory

Pe

riton

eal D

ialy

sis

(CAP

D) (

Cas

e Se

ries)

PO 1

46H

erm

an B

agus

Tria

nto

Indo

nesi

aN

ephr

olog

yTh

e R

elat

ions

hip

of S

erum

Insu

lin-li

ke G

row

th F

acto

r-1 (I

GF-

1) a

nd In

sulin

-Lik

e G

row

th F

acto

r Bin

ding

Pro

tein

-1 (I

GF-

BP-1

) with

Nut

ritio

nal S

tatu

s of

Per

itone

al D

ialy

sis

Patie

nt

PO 1

47N

uri S

usan

tiIn

done

sia

Nep

hrol

ogy

Asso

ciat

ion

Betw

een

Phos

phat

e An

d Fi

brob

last

Gro

wth

Fac

-to

r 23

Leve

l In

Pre-

Dia

lysi

s C

hron

ic K

idne

y D

isea

se P

atie

nts

PO 1

48Ar

taria

Tje

mpa

kasa

riIn

done

sia

Nep

hrol

ogy

Asso

ciat

on o

f Neu

trofil

to L

ymph

ocyt

e R

atio

with

Lef

t Ven

tri-

cle

Hyp

ertro

phy

in H

emod

ialy

sis

Patie

nts

PO 1

49Tr

i Asi

h Im

ro’a

tiIn

done

sia

Nep

hrol

ogy

Com

paris

on o

f H

igh

Sens

itivi

ty-C

-Rea

ctiv

e Pr

otei

n Le

vel

betw

een

Chr

onic

Kid

ney

Dis

ease

Sta

ges

PO 1

50Ar

dity

o R

ahm

at A

rdha

nyIn

done

sia

Nep

hrol

ogy

Asso

ciat

ion

betw

een

MTH

FR g

ene

Poly

mor

phis

m a

nd H

yper

-ho

moc

yste

inem

ia in

Hae

mod

ialy

sis

Patie

nts

in In

done

sia

PO 1

51G

onul

Sim

sek

Turk

eyN

ephr

olog

yLe

ctin

-Lik

e O

xidi

zed

Low

-Den

sity

Lip

opro

tein

-1 R

elat

ed

Endo

thel

ial D

ysfu

nctio

n in

Pat

ient

s w

ith W

hite

Coa

t Hyp

er-

tens

ion

PO 1

52Et

ik M

ertia

nti

Indo

nesi

aN

ephr

olog

yTh

e N

utrit

iona

l Sta

tus

of C

ontin

ous

Ambu

lato

ry P

erito

neal

D

ialy

sis

(CAP

D) P

atie

nts

at C

APD

Cen

tre o

f Sai

ful A

nwar

G

ener

al H

ospi

tal M

alan

g Ea

st J

ava

PO 1

53D

ani R

osdi

ana

Indo

nesi

aN

ephr

olog

yTh

e Ef

fect

of D

hikr

Met

hod

Maj

elis

Zik

ir Al

-Hid

ayah

Pek

an-

baru

tow

ards

the

Dec

reas

e of

Sys

tolic

Blo

od P

ress

ure

and

Dia

stol

ic B

lood

Pre

ssur

e

PO 1

54Fi

tri Im

elda

Indo

nesi

aN

ephr

olog

yC

linic

al F

eatu

res

And

Qua

lity

Of L

ife In

End

Sta

ge R

enal

D

isea

se P

atie

nts

Und

ergo

ing

Hem

odia

lysi

s Tw

ice

A W

eek

Com

pare

d To

Thr

ice

A W

eek

PO 1

55Pr

ahla

d Ka

rki

Nep

alC

ardi

olog

yC

linic

o-Ep

idem

iolo

gica

l Pro

file

of P

atie

nts

with

Atri

al F

ibril

la-

tion

: A H

ospi

tal B

ased

Stu

dy fr

om E

aste

rn N

epal

386

PO 1

56Ta

tsuo

Mis

awa

Japa

nC

ardi

olog

yEf

ficac

y O

f Hig

h R

ight

Ven

tricu

lar S

epta

l Lea

d Pl

acem

ent F

or

Prev

entio

n O

f Sub

clin

ical

Atri

al F

ibril

latio

n

PO 1

57Yu

dist

ira P

anji

Sant

osa

Indo

nesi

aC

ardi

olog

yPe

ricar

dial

Dra

inag

e W

ithou

t Cat

hete

r Lab

orat

ory

and

Echo

-ca

rdio

gram

, Is

It Po

ssib

le?

PO 1

58Sa

ugi A

bduh

In

done

sia

Car

diol

ogy

Cor

rela

tion

betw

een

Asym

ptom

atic

Per

iphe

ral A

rteria

l Dis

-ea

se a

nd S

ever

ity o

f Sta

ble

Cor

onar

y H

eart

Dis

ease

PO 1

59M

unad

iIn

done

sia

Car

diol

ogy

Cor

rela

tion

betw

een

FEV1

% P

redi

ctio

n an

d M

ean

Pulm

o-na

ry A

rteria

l Pre

ssur

e by

Ech

ocar

diog

raph

y in

Sta

ble

Chr

onic

O

bstru

ctiv

e Pu

lmon

ary

Dis

ease

pat

ient

s

PO 1

60D

ongh

an K

imSo

uth

Kore

aC

ardi

olog

y P

rogn

ostic

Val

ue o

f Lef

t Atri

al V

olum

e In

dex

Cha

nge

afte

r Pr

imar

y C

oron

ary

Inte

rven

tion

in P

atie

nt w

ith S

T-El

evat

ion

Myo

card

ial I

nfar

ctio

n

PO 1

61Fa

rhan

a Ah

med

Bang

lade

shC

ardi

olog

yPr

edic

tors

of S

hort

Term

Out

com

es o

f Prim

ary

Perc

utan

eous

C

oron

ary

Inte

rven

tion

(PC

I)

PO 1

62An

dree

va L

yais

anR

ussi

aC

ardi

olog

yAr

teria

l Hyp

erte

nsio

n an

d M

etab

olic

Syn

drom

e: F

ocus

on

Cir-

cadi

an P

rofil

e of

Cen

tral A

ortic

Pre

ssur

e an

d Ar

teria

l Stif

fnes

s

PO 1

63In

grid

Prk

acin

Cro

atia

Car

diol

ogy

The

Sign

ifica

nce

of H

igh

Sens

itivi

ty C

ardi

ac T

ropo

nin

I in

Em

erge

ncy

Dep

artm

ent a

nd P

oten

tial I

mpl

icat

ions

of

Sex-

Spec

ific

Cut

Poi

nts

for C

ardi

ac T

ropo

nin

Assa

ys

PO 1

64R

ober

t Nol

dy N

gant

ung

Indo

nesi

aC

ardi

olog

yC

orre

latio

n of

Epi

card

ial A

dipo

se T

hick

ness

with

the

Seve

rity

of C

oron

ary

Arte

ry S

teno

sis

in S

tabl

e C

oron

ary

Hea

rt D

is-

ease

Pat

ient

PO 1

65Yo

shito

Nis

him

ura

Japa

nC

ardi

olog

ySt

anfo

rd T

ype

A Ao

rtic

Dis

sect

ion

May

Pre

sent

with

Tra

nsie

nt

Loss

of C

onsc

ious

ness

PO 1

66Pi

eter

Nee

fAu

stra

liaC

ardi

olog

yBe

ta-B

lock

ers

are

Und

er-P

resc

rıbed

in P

atıe

nts

wıth

Chr

onıc

O

bstru

ctıv

e Pu

lmon

ary

Dıs

ease

and

Com

orbı

d C

ardı

ovas

cu-

lar D

ısea

se

387

PO 1

67Al

ev M

elte

m E

rcan

Turk

eyC

ardi

olog

y T

he E

valu

atio

n of

Pla

sma

Visc

osity

and

End

othe

lial D

ysfu

nc-

tion

in S

mok

ing

Indi

vidu

als

PO 1

68Sa

ngw

ook

Kang

Sout

h Ko

rea

Car

diol

ogy

Com

paris

on o

f Ang

iogr

aphi

c Pa

ttern

s an

d C

linic

al O

utco

mes

of

In-S

tent

Res

teno

sis

betw

een

1st a

nd 2

nd G

ener

atio

n D

rug

Elut

ing

Sten

ts in

Rea

l Wor

ld C

linic

al P

ract

ice

PO 1

69N

gaka

n Ke

tut W

ira S

uas-

tika

Indo

nesi

aC

ardi

olog

ySo

dium

Lev

el A

s A

Pred

icto

r To

Det

erm

inin

g Le

ngth

Of H

os-

pita

lizat

ion

In A

cute

Dec

ompe

nsat

ed H

eart

Failu

re

PO 1

70Sa

lly A

man

Nas

utio

nIn

done

sia

Car

diol

ogy

Cur

rent

Pro

file

and

Ris

k Fa

ctor

s of

You

ng P

atie

nts

with

Acu

te

Cor

onar

y Sy

ndro

me

in In

done

sia

PO 1

71Er

ic J

ohn

A. M

aray

agPh

ilippi

nes

Car

diol

ogy

Clin

ical

Pro

files

, Tre

atm

ents

Rec

eive

d, a

nd O

utco

mes

of

Elde

rly a

nd N

on-E

lder

ly P

atie

nts

with

Acu

te C

oron

ary

Syn-

drom

e Ad

mitt

ed a

t The

Inte

nsiv

e C

are

Uni

ts o

f Uni

vers

ity o

f Sa

nto

Tom

as H

ospi

tal

PO 1

72Ed

war

d M

ulia

wan

Put

era

Indo

nesi

aC

ardi

olog

yA

Cas

e O

f Thy

roid

Cris

is P

atie

nts

with

Hea

rt Fa

ilure

and

At

rial F

ibril

atio

n

PO 1

73C

ho H

yun

Ok

Sout

h Ko

rea

Car

diol

ogy

Cat

hete

r Abl

atio

n fo

r Atri

al F

ibril

latio

n w

ith C

onta

ct F

orce

C

athe

ters

Usi

ng A

utom

ated

Ann

otat

ion

Syst

em (V

isiT

ag™

) : A

blat

ion

Lesi

on C

hara

cter

istic

s an

d Sh

ort-T

erm

Clin

ical

O

utco

me

PO 1

74Zi

sim

ange

los

Solo

mos

Gre

ece

Car

diol

ogy

The

Impa

ct o

f The

Eco

nom

ic R

eces

sion

on

The

Surv

ival

of

Out

-Of-H

ospi

tal C

ardi

ac A

rrest

Vic

tims

in A

Gen

eral

Hos

pita

l

PO 1

75M

aria

Joã

o Ba

ldo

Portu

gal

Car

diol

ogy

Shor

t and

Lon

g-Te

rm Im

pact

of a

n H

eart

Failu

re M

ultid

isci

pli-

nary

Man

agem

ent P

rogr

am in

Rea

dmis

sion

and

Cos

ts o

f The

Sy

ndro

me

PO 1

76Ez

ekie

l Won

g To

h Yo

onJa

pan

Car

diol

ogy

Cor

rela

tion

betw

een

Seru

m C

once

ntra

tions

of B

-Typ

e N

atriu

-re

tic P

eptid

e an

d Al

bum

in in

A J

apan

ese

Hos

pita

l Pop

ulat

ion

388

PO 1

77Irm

a W

ahyu

niIn

done

sia

Car

diol

ogy

Dag

nost

ic T

est o

f Pla

tele

t Lym

phoc

yte

Rat

io fo

r Scr

eeni

ng

of C

ompl

ex C

oron

ary

Lesi

on in

Diff

eren

t Age

Gro

up o

f Acu

te

Cor

onar

y Sy

ndro

me

PO 1

78Jo

ko B

udim

an J

ong

Indo

nesi

aC

ardi

olog

yPr

ogno

stic

Val

ue o

f Int

erle

ukin

-10

for C

ardi

ac M

orta

lity

in

Acut

e C

oron

ary

Synd

rom

es

PO 1

79D

airio

n G

atot

Indo

nesi

aC

ardi

olog

yC

orre

latio

n Be

twee

n Se

rum

Fer

ritin

With

Sev

erity

Of H

eart

Failu

re P

atie

nts

Hos

pita

lized

In R

sup

Haj

i Ada

m M

alik

PO 1

80R

inal

di B

atub

ara

Indo

nesi

aC

ardi

olog

yTh

orac

ic E

ndov

ascu

lar A

neur

ysm

Rep

air a

nd D

ebra

nchi

ng

Surg

ery

in A

ortic

Asc

endi

ng D

isse

ctio

n w

ith P

leur

al E

ffusi

on :

A C

ase

Rep

ort

PO 1

81Ah

mad

Res

tu Im

anIn

done

sia

Car

diol

ogy

The

Cor

rela

tion

of A

myl

oid

A Se

rum

Lev

els

with

the

Deg

ree

of C

oron

ary

Arte

ry O

cclu

sion

in C

oron

ary

Hea

rt D

esea

se a

t C

ardi

ac C

athe

teriz

atio

n La

bora

tory

RSM

H P

alem

bang

PO 1

82Ku

ghan

Gov

inde

nM

alay

sia

Infe

ctio

us

Dis

ease

Impo

rtanc

e of

Ear

ly D

iagn

osis

of T

uber

culo

us M

enin

gitis

U

sing

Gen

expe

rt M

tb/R

if

PO 1

83I M

ade

Ngu

rah

Sury

a Ad

i In

done

sia

Infe

ctio

us

Dis

ease

Com

bina

tion

of U

rine

Lipo

arab

inom

anna

n (L

AM) R

apid

Tes

t an

d Xp

ert M

TB/R

IF fo

r Dia

gnos

ing

Tube

rcul

osis

in P

atie

nt

with

Hum

an Im

mun

odefi

cien

cy V

irus

Infe

ctio

n: A

n Ev

i-de

nce-

Base

d C

ase

Rep

ort

PO 1

84Ar

end

L. M

apan

awan

gIn

done

sia

Infe

ctio

us

Dis

ease

Abo

Bloo

d G

roup

s Pr

ofile

with

Pha

rmac

okin

etic

of D

ihy-

droa

rtem

isin

in-P

iper

aqui

ne, P

rimaq

uine

to P

atie

nts

Unc

om-

plic

ated

falc

ipar

um M

alar

ia w

ith A

bo B

lood

Gro

ups

Mal

ay in

H

alm

aher

a In

done

sian

PO 1

85Ye

o Li

Fan

gSi

ngap

ore

Infe

ctio

us

Dis

ease

Dis

sem

inat

ed C

rypt

ococ

cus

Gat

tii w

ith P

ulm

onar

y an

d C

ere-

bral

Invo

lvem

ent M

imic

king

Mal

igna

ncy

PO 1

86M

aria

Aul

ia S

andj

aja

Indo

nesi

aIn

fect

ious

D

isea

seU

rine

Lipo

arab

inom

anna

n As

A D

iagn

ostic

Too

l For

Lun

g Tu

berc

ulos

is in

Hum

an Im

mun

e D

efici

ency

Pat

ient

s

389

PO 1

87Jo

onho

An

Sout

h Ko

rea

Infe

ctio

us

Dis

ease

The

Effe

ct o

f Prim

aqui

ne D

osag

e on

the

Rec

urre

nce

of V

ivax

M

alar

ia

PO 1

88Ph

ilip C

hua

Aust

ralia

Infe

ctio

us

Dis

ease

The

Inve

stig

atio

n an

d M

anag

emen

t of S

uspe

cted

Urin

ary

Trac

t Inf

ectio

ns a

t A G

ener

al H

ospi

tal

PO 1

89Fa

thur

Nur

Kho

lisIn

done

sia

Infe

ctio

us

Dis

ease

Cha

ract

eris

tics

of M

ultid

rug-

Res

ista

nt T

uber

culo

sis

in S

ema-

rang

PO 1

90Jo

nath

an C

hia

Aust

ralia

Infe

ctio

us

Dis

ease

Clin

ical

Aud

it: A

naly

sis

of le

vels

of a

dher

ence

to tr

eatm

ent

guid

elin

es a

nd a

ssoc

iate

d ou

tcom

es in

the

man

agem

ent o

f C

ellu

litis

and

Urin

ary

tract

infe

ctio

ns in

a M

etro

polit

an H

ospi

-ta

l in

Wes

tern

Aus

tralia

PO 1

91Ak

mar

alKa

zakh

stan

Infe

ctio

us

Dis

ease

Asse

ssm

ent o

f Par

ents

’ Aw

aren

ess

Leve

l abo

ut A

ntib

iotic

R

esis

tanc

e

PO 1

92Ek

o Se

tiaw

anIn

done

sia

Infe

ctio

us

Dis

ease

Con

tinuo

us In

fusi

on D

osag

e R

egim

en o

f Van

com

ycin

for

Empi

rical

Tre

atm

ent A

mon

g C

ritic

ally

Ill T

hai P

opul

atio

n in

the

Era

“MIC

Cre

ep” M

ethi

cillin

-Res

ista

nt S

taph

yloc

occu

s au

reus

PO 1

93D

ani F

arid

Abd

ulla

hIn

done

sia

Infe

ctio

us

Dis

ease

The

Agre

emen

t Bet

wee

n M

alnu

tritio

n Pa

ram

eter

s In

Tub

ercu

-lo

sis

with

Dia

bete

s M

ellit

us

PO 1

94D

inar

Far

icy

Yadd

inIn

done

sia

Infe

ctio

us

Dis

ease

Asso

ciat

ion

betw

een

Posi

tivity

Deg

ree

of A

cid

Baci

lli,C

avi-

ty,M

alnu

tritio

n,D

m,S

mok

ing

Stat

us w

ith S

putu

m C

ultu

re C

on-

vers

ion

in T

he T

wo

Mon

th T

reat

men

t of M

DR

Tub

ercu

losi

s

PO 1

95C

hevi

e W

iraw

anIn

done

sia

Infe

ctio

us

Dis

ease

The

Man

agem

ent O

f Sev

ere

Seps

is A

nd S

eptic

Sho

ck In

The

Fi

rst S

ix H

ours

In H

asan

Sad

ikin

Gen

eral

Hos

pita

l Ban

dung

PO 1

96Su

silo

Prih

rant

oIn

done

sia

Infe

ctio

us

Dis

ease

Dis

sem

inat

ed T

uber

culo

sis

Pres

entin

g As

Spl

enic

and

Lym

-ph

aden

itis

Tube

rcul

osis

in A

n Im

mun

ocom

pete

nt P

atie

nt

PO 1

97Fa

dria

nIn

done

sia

Infe

ctio

us

Dis

ease

Effe

ct o

f Meg

estro

l Ace

tate

Aga

inst

Dec

reas

ed L

evel

s of

TN

F-α

in P

atie

nts

with

Aid

s W

astin

g Sy

ndro

me

390

PO 1

98Ag

us J

ati S

ungg

oro

Indo

nesi

aIn

fect

ious

D

isea

seC

o-m

orbi

dity

Pro

file

and

Mor

talit

y Am

ong

Hos

pita

lized

Tub

er-

culo

sis

Patie

nts

: A R

etro

spec

tive

Coh

ort S

tudy

PO 1

99Jo

yce

Brat

anat

aIn

done

sia

Infe

ctio

us

Dis

ease

The

Diffi

culti

es o

f Dia

gnos

ing

Cyt

omeg

alov

irus

Pneu

mon

ia in

H

IV P

atie

nts

: Cas

e R

epor

ts

PO 2

00En

amul

Kar

imBa

ngla

desh

Infe

ctio

us

Dis

ease

New

er V

iral I

nfec

tion.

. Ban

glad

esh

Scen

ario

PO 2

01Li

gat P

ribad

i Sem

birin

gIn

done

sia

Infe

ctio

us

Dis

ease

Cha

ract

eris

tics

of P

atie

nt w

ith D

ecub

itus

Ulc

er, B

acte

ria a

nd

Res

iste

nce

of A

nti-B

acte

ria a

t Arifi

n Ac

hmad

Gen

eral

Hos

pita

l R

iau

Prov

ince

PO 2

02Fa

isal

Par

lindu

ngan

Indo

nesi

aIn

fect

ious

D

isea

seA

Cas

e of

Pos

sibl

e Ar

tem

isin

in-B

ased

Com

bina

tion

Ther

a-py

—R

esis

tant

Mal

aria

with

Loe

ffler

’s Sy

ndro

me

PO 2

03Lu

tfie

Indo

nesi

aIn

fect

ious

D

isea

se

Anti-

Rab

ies

Vacc

ine

Com

plia

nce

afte

r Ani

mal

Bite

: Les

sons

Le

arnt

from

Rab

ies

Cen

ter i

n M

aum

ere,

Eas

t Nus

a Te

ngga

ra,

Indo

nesi

a

PO 2

04R

icar

do A

dria

n N

ugra

haIn

done

sia

Ger

iatri

cLo

ng-T

erm

Ste

roid

Abu

sers

as

Pred

ictiv

e Fa

ctor

for F

railt

y an

d Su

bseq

uent

Clin

ical

Det

erio

ratio

n in

Ger

iatri

c Po

pula

tion

PO 2

05Irm

a Sa

vitri

Mad

jidIn

done

sia

Ger

iatri

cIn

trodu

ctio

n O

f Com

preh

ensi

ve G

eria

tric

Asse

ssm

ent I

n A

Com

mun

ity-B

ased

, Prim

ary

Car

e Se

tting

: Exp

erie

nce

From

R

orot

an, N

orth

Jak

arta

PO 2

06Ba

jrakt

arev

ic A

dnan

Bosn

iaG

eria

tric

Mar

fan

Synd

rom

e as

Gen

etic

Dis

orde

r in

Adul

ts a

nd C

hild

ren

PO 2

07D

wi S

eptia

n W

ijaya

Indo

nesi

aG

eria

tric

The

Effe

ct o

f The

rapy

Spi

ritua

l Em

otio

nal F

reed

om T

hec-

niqu

e (S

EFT)

Cha

nges

on

Bloo

d Pr

essu

re in

Eld

erly

Hyp

er-

tens

ion

Expe

rienc

e in

Rej

osar

i Kar

anga

n Tr

engg

alek

201

5

PO 2

08Ed

war

dus

Setia

wan

Indo

nesi

aG

eria

tric

Cas

e R

epor

t : F

railt

y Sy

ndro

mes

of E

lder

ly w

ith F

unga

l Pne

u-m

onia

as

One

of I

t’s D

ebilit

atin

g C

ompl

icat

ions

PO 2

09Si

ti Se

tiati

Indo

nesi

aG

eria

tric

Tran

sitio

n be

twee

n Fr

ailty

Sta

tes

and

Its P

rogn

ostic

Fac

tors

am

ong

Indo

nesi

an E

lder

ly

391

PO 2

10Si

ti Se

tiati

Indo

nesi

aG

eria

tric

Cut

- Off

Poin

t of H

andg

rip S

treng

th a

s A

Dia

gnos

tic T

est F

or

Frai

lty S

yndr

ome

amon

g El

derly

Peo

ple

in In

done

sia

PO 2

11Pr

iyo

Panj

i Uto

mo

Indo

nesi

aG

eria

tric

Valid

atio

n Q

uest

ionn

aire

Fra

ilty

Synd

rom

e

PO 2

12N

adhi

ra A

nind

ita R

alen

aIn

done

sia

Ger

iatri

cAs

soci

atio

n Be

twee

n D

iabe

tes

and

Dem

entia

in G

eria

tric

Patie

nts

PO 2

13In

dra

Kurn

iaw

anIn

done

sia

Ger

iatri

cN

on-P

hysi

cal F

acto

rs A

ssoc

iate

d w

ith M

alnu

tritio

n in

Eld

erly

Pa

tient

s

PO 2

14Li

sa K

urni

a Sa

riIn

done

sia

Ger

iatri

cTh

e Be

nefic

ial E

ffect

of J

avan

ese

Trad

ition

al M

assa

ge in

Im

prov

ing

Dem

entia

, Qua

lity

of S

leep

, and

Qua

lity

of L

ife, i

n G

eria

tric

Patie

nts

PO 2

15N

ur R

ivia

tiIn

done

sia

Ger

iatri

cFa

ctor

s As

soci

ated

with

Han

d G

rip S

treng

th in

Indo

nesi

an

Elde

rly P

atie

nts

PO 2

16W

iwit

Agun

g Sr

i Nur

Cah

y-aw

ati

Indo

nesi

aG

eria

tric

Asso

ciat

ion

betw

een

Mus

cle

Mas

s w

ith H

ands

Grip

Stre

ngth

an

d Ti

me

Up

Go

(Tug

) in

Elde

rly P

opul

atio

n at

Ban

jarm

asin

C

ity, A

Pre

limin

ary

Stud

y

PO 2

17Er

ika

Mar

fiani

Indo

nesi

aG

eria

tric

Profi

le o

f Adi

pone

ctin

Ser

um a

nd F

railt

y in

Eld

erly

Pat

ient

s w

ith C

hron

ic O

bstru

ctiv

e Pu

lmon

ary

Dis

ease

PO 2

18N

ovira

Wid

ajan

tiIn

done

sia

Ger

iatri

cTh

e In

flam

mat

ory

Cyt

okin

e (In

terle

ukin

-6 S

erum

) and

Fra

ilty

in O

lder

Men

Rec

ruite

d fro

m V

eter

an C

omm

unity

in S

ura-

baya

-Indo

nesi

a

PO 2

19Eu

n H

yo J

inSo

uth

Kore

aG

astro

ente

r-ol

ogy

Endo

scop

y Pr

oced

ure

Rel

ated

Fac

tors

for S

edat

ion

Satis

fac-

tion

in G

astro

inte

stin

al E

ndos

copy

PO 2

20Yu

n D

uk J

ung

Sout

h Ko

rea

Gas

troen

ter-

olog

yC

linic

al O

utco

mes

of N

on-V

aric

eal U

pper

Gas

troin

test

inal

Bl

eedi

ng in

Pat

ient

s w

ith W

arfa

rin

PO 2

21Jo

ng J

in H

yun

Sout

h Ko

rea

Gas

troen

ter-

olog

y

Endo

scop

ic B

iliary

Ste

nt In

serti

on th

roug

h D

uode

nal S

tent

in

Pat

ient

s w

ith C

ombi

ned

Mal

igna

nt B

iliary

and

Duo

dena

l O

bstru

ctio

n un

der S

tent

/PTB

D G

uida

nce

392

PO 2

22Jo

o Su

ng K

imSo

uth

Kore

aG

astro

ente

r-ol

ogy

Early

vs

Late

Bed

side

End

osco

py fo

r Gas

troin

test

inal

Ble

ed-

ing

in C

ritic

ally

Ill P

atie

nts

PO 2

23M

icha

el J

onat

anIn

done

sia

Gas

troen

ter-

olog

yTh

e R

ole

of G

astri

c M

icro

biot

a ot

her t

han

Hel

icob

acte

r pyl

ori

in N

ext G

ener

atio

n M

edic

ine

Pers

pect

ive

PO 2

24Fa

uzi Y

usuf

Indo

nesi

aG

astro

ente

r-ol

ogy

Stru

ctur

al A

ltera

tion

of G

ut M

icro

biot

a in

Col

orec

tal C

ance

r Pa

tient

s

PO 2

25Ku

rnia

wan

Indo

nesi

aG

astro

ente

r-ol

ogy

Prev

alen

ce a

nd S

osio

-dem

ogra

phic

Fac

tors

of H

elic

obac

ter

pylo

ri In

fect

ion

amon

g Pa

tient

s w

ith D

yspe

psia

in S

anto

Ant

o-ni

us H

ospi

tal,

Pont

iana

k

PO 2

26Al

ida

Avis

iena

Indo

nesi

aG

astro

ente

r-ol

ogy

Rap

id Im

mun

ochr

omat

ogra

phy

Stoo

l Ant

igen

Tes

t is

Insu

ffi-

cien

t for

Det

ectin

g H

elic

obac

ter P

ylor

i Inf

ectio

n in

Sur

abay

a In

done

sia

PO 2

27H

esti

Ism

arin

iIn

done

sia

Gas

troen

ter-

olog

yC

orre

latio

n Be

twee

n H

elic

obac

ter P

ylor

i Den

sity

And

Inte

rleu-

kin-

8 Ex

pres

sion

Of G

astri

c M

ucos

a In

Dyp

esps

ia P

atie

nts

PO 2

28H

arun

a N

akam

ura

Japa

nG

astro

ente

r-ol

ogy

Sem

i-Sol

idifi

ed E

lem

enta

l Die

t to

Prev

ent R

ecur

rent

Asp

ira-

tion

Pneu

mon

ia D

urin

g Pe

rcut

aneo

us E

ndos

copi

c G

astro

sto-

my

(PEG

) Fee

ding

PO 2

29Zu

lkha

iriIn

done

sia

Gas

troen

ter-

olog

y

The

Asso

ciat

ion

of A

BO B

lood

Gro

up a

nd H

elic

obac

ter p

ylor

i In

fect

ion

In B

atak

Tob

a Tr

ibe

patie

nts,

Sam

osir

Isla

nd, N

orth

Su

mat

ra, I

ndon

esia

PO 2

30Th

amin

da L

iyan

age

Aust

ralia

Pulm

onol

ogy

Use

of D

-dim

er A

ssay

as

an In

itial

Inve

stig

atio

n fo

r Dia

gnos

is

of P

ulm

onar

y Em

bolis

m in

a M

etro

polit

an G

ener

al H

ospi

tal i

n Pe

rth, W

este

rn A

ustra

lia

PO 2

31Ji

won

Hw

ang

Sout

h Ko

rea

Pulm

onol

ogy

Seru

m U

ric A

cid

is P

ositi

vely

Ass

ocia

ted

with

Pul

mo-

nary

Fun

ctio

n in

Kor

ean

Hea

lth S

cree

ning

Exa

min

ees:

A

Cro

ss-S

ectio

nal S

tudy

393

PO 2

32Ek

o Bu

dion

oIn

done

sia

Pulm

onol

ogy

Diff

eren

ces

in L

ung

Func

tion

in V

ario

us D

egre

es o

f Pul

mo-

nary

Tub

ercu

losi

s Se

quel

aePO

233

Sri S

huju

anIn

done

sia

Pulm

onol

ogy

Pulm

onar

y Em

bolis

m in

You

ng A

dult

: A c

ase

repo

rt

PO 2

34H

ae Y

eon

Kang

Sout

h Ko

rea

Pulm

onol

ogy

The

Long

itudi

nal A

ssoc

iatio

n be

twee

n C

hang

es in

Lun

g Fu

nctio

n an

d C

hang

es o

f Abd

omin

al V

isce

ral O

besi

ty in

Ko

rean

Non

smok

ers

PO 2

35N

erm

in Y

elm

enTu

rkey

Pulm

onol

ogy

Influ

ence

s of

Gam

ma-

Amin

obut

yric

Aci

d on

The

Res

pira

tory

R

espo

nses

to H

ypox

ia

PO 2

36Ad

i Kur

niaw

anIn

done

sia

Pulm

onol

ogy

Cor

rela

tion

betw

een

Seru

m L

eptin

Lev

el a

nd T

he S

ever

ity

of P

ulm

onar

y Tu

berc

ulos

is In

Moh

amm

ad H

oesi

n H

ospi

tal,

Pale

mba

ng

PO 2

37Ar

i Sis

wor

oIn

done

sia

Pulm

onol

ogy

Asso

ciat

ion

betw

een

Seru

m L

eptin

Lev

el a

nd M

ultid

rug

Res

ista

nt T

uber

culo

sis

in M

oham

mad

Hoe

sin

Hos

pita

l Pa

lem

bang

PO 2

38W

achy

oe H

adi S

aput

raIn

done

sia

Pulm

onol

ogy

Proc

alci

toni

n as

a B

iom

arke

r of S

ever

ity D

egre

e in

Sep

sis

Due

to P

neum

onia

PO 2

39I D

ewa

Putu

Ged

e W

edha

As

mar

aIn

done

sia

Pulm

onol

ogy

Dia

gnos

tic T

est U

sing

Inte

rferro

n G

amm

a fo

r Ant

i Tub

ercu

lo-

sis

Dru

g In

tens

ive

Phas

e Tr

eatm

ent E

valu

atio

n in

Pat

ient

with

Pu

lmon

ary

Tube

rcul

osis

PO 2

40R

emis

e G

elis

gen

Turk

eyPu

lmon

olog

yAd

ipon

utrin

and

Pho

spho

lipas

e A2

Lev

els

in P

atie

nts

with

Pu

lmon

ary

Tube

rcul

osis

Bef

ore

and

Afte

r Tre

atm

ent

PO 2

41Sa

eed

Sole

iman

-Mei

goon

iIra

nH

epat

olog

yAs

soci

atio

n be

twee

n H

epat

itis

G a

nd U

nkno

wn

Chr

onic

H

epat

itis

PO 2

42Su

ryad

i Sya

mIn

done

sia

Hep

atol

ogy

Cha

ract

eriz

atio

n of

Nuc

leos

(T)Id

e An

alog

ue R

esis

tanc

e M

utat

ions

Am

ong

Trea

tmen

t-Naï

ve C

hron

ic H

epat

itis

B M

i-na

ngka

bau

Ethn

ic P

atie

nts

394

PO 2

43An

dree

Kur

niaw

anIn

done

sia

Hep

atol

ogy

Porta

l Vei

n Tu

mor

Thr

ombo

sis

in H

epat

ocel

lula

r Car

cino

ma

Patie

nts

in S

econ

dary

Ref

erra

l Gen

eral

Hos

pita

l at K

araw

aci,

Tang

eran

g, B

ante

n, In

done

sia

PO 2

44N

uriy

e Ak

evTu

rkey

Hep

atol

ogy

Prot

ectiv

e Ef

fect

of Z

inc

on H

yper

glyc

emia

-Med

iate

d O

xida

-tiv

e D

amag

e in

The

Hep

atic

Tis

sues

of E

xper

imen

tal D

iabe

tic

Rat

s

PO 2

45R

efiye

Yan

arda

gTu

rkey

Hep

atol

ogy

Hep

atop

rote

ctiv

e Ac

tivity

of V

itam

in U

Aga

inst

D-G

alac

-to

sam

ine

Indu

ced

Hep

atic

Inju

ry in

Rat

s

PO 2

46H

endr

a Ko

ncor

oIn

done

sia

Hep

atol

ogy

Acut

e Ph

ase

Prot

eins

for t

he D

iagn

osis

of B

acte

rial I

nfec

tions

in

Cirr

hosi

s

PO 2

47En

dang

Indo

nesi

aH

epat

olog

yTh

e R

ole

of T

radi

tiona

l Alc

ohol

ism

in L

iver

Abs

cess

in N

orth

Su

mat

ra, I

ndon

esia

PO 2

48Yo

ung-

Chu

l Kim

Sout

h Ko

rea

Imm

unol

ogy

Rev

iew

of S

arco

idos

is in

in a

pro

vinc

e of

Kor

ea fr

om 1

996

to

2014

PO 2

49W

ita K

artik

a N

uran

iIn

done

sia

Imm

unol

ogy

Stev

ens-

John

son

Synd

rom

e (S

JS) a

nd T

oxic

Epi

derm

al

Nec

roly

sis

(TEN

) in

dr. S

oeto

mo

Hos

pita

l Sur

abay

a, In

done

-si

a : A

Fou

r Yea

r’s R

evie

w

PO 2

50Su

riani

Alim

uddi

nIn

done

sia

Imm

unol

ogy

A Su

cces

sful

Hyd

roxy

chlo

roqu

ine

Trea

tmen

t for

Urti

caria

and

C

hron

ic A

ngio

edem

a Pa

tient

: A

case

Rep

ort

PO 2

51M

uham

mad

Ali A

pria

nsya

hIn

done

sia

Psyc

hoso

-m

atic

Cor

rela

tion

Dep

ress

ion

and

Tum

or N

ecro

sis

Fact

or-A

lpha

(T

NF-

α) L

evel

in U

ncon

trolle

d Br

onch

ial A

sthm

a Pa

tient

s

PO 2

52To

shih

iko

Hat

aJa

pan

Oth

ers

The

Com

preh

ensi

ve G

ener

al P

hysi

cian

s in

Chr

onic

Pha

se

of D

isas

ter i

s ve

ry im

porta

nt. B

eyon

d th

e G

reat

Eas

t Jap

an

Earth

quak

e

PO 2

53Al

fons

o M

igue

l Gar

rido

Cas

troSp

ain

Oth

ers

Dim

inis

hing

Ave

rage

Hos

pita

l Sta

y in

Orth

oped

ic S

urge

ry

Area

. A 6

Yea

rs F

ollo

w U

p.

395

PO 2

54Fe

i-Wan

Nga

iH

ong

Kong

Oth

ers

Fath

ers’

Perc

eptio

ns o

f Cou

ple-

Base

d C

ogni

tive-

Beha

vior

al

Inte

rven

tion

PO 2

55N

abil

Mtir

aoui

Saud

i Ara

bia

Oth

ers

Hap

loty

pes

Anal

ysis

of A

dipo

nect

in S

NPs

Am

ong

PCO

S Sa

udi A

rabi

an W

omen

PO 2

56In

tissa

r Ezz

idi

Saud

i Ara

bia

Oth

ers

Asso

ciat

ion

of T

CF7

L2 G

ene

Poly

mor

phis

ms

With

an

Elev

at-

ed R

isk

of P

CO

S in

Sau

di A

rabi

an W

omen

PO 2

57M

asaf

umi N

agan

oJa

pan

Oth

ers

Dai

ly V

itam

in D

Inta

ke a

nd S

erum

Vita

min

D C

once

ntra

tions

of

Mal

e Pr

ofes

sion

al B

aseb

all P

laye

rs in

Jap

an

PO 2

59Ze

n Ah

mad

Indo

nesi

aO

ther

sPe

rform

ance

of R

apid

Em

erge

ncy

Med

icin

e Sc

ore

in P

redi

ct-

ing

Mor

talit

y of

Inte

rnal

Med

icin

e Em

erge

ncy

Patie

nts

at M

oh

Hoe

sin

Hos

pita

l Pal

emba

ng

PO 2

60Fa

him

eh M

oham

mad

gha-

sem

iIra

nO

ther

sIm

pact

of A

cety

lsal

icyl

ic A

cid

on S

perm

Chr

omat

in D

ispe

rsio

n Te

st, T

esto

ster

one

and

LH L

evel

s in

Adu

lt M

ouse

PO 2

61Pe

teru

s Th

ajeb

Taiw

anO

ther

sPl

asm

a Le

vel o

f SC

UBE

-1 Is

Ele

vate

d In

Pat

ient

s W

ith

Stro

ke-li

ke E

piso

des

Due

To

Mito

chon

dria

l Dis

orde

rs

PO 2

62Ta

e-Yo

on P

ark

Sout

h Ko

rea

Oth

ers

RO

Rγt

-spe

cific

tran

scrip

tiona

l int

erac

tom

ic in

hibi

tion

sup-

pres

ses

infla

mm

ator

y di

seas

es a

ssoc

iate

d w

ith T

H17

cel

ls

PO 2

63M

oy W

ai L

unSi

ngap

ore

Oth

ers

Phys

icia

ns’ P

ersp

ectiv

es o

n D

o-N

ot-R

esus

cita

te (D

NR

) O

rder

s –

A Si

ngle

Cen

tre S

urve

y in

Sin

gapo

re

PO 2

64An

toni

us A

dji P

rayi

tno

Setia

diIn

done

sia

Oth

ers

Anal

gesi

c Ef

fect

iven

ess

Tow

ard

Patie

nts

With

Cer

vica

l Can

-ce

r In

X H

ospi

tal S

amar

inda

PO 5

30Sa

rbro

op D

hillo

nAu

stra

liaO

ther

sTh

e W

ard

Phar

mac

ist a

s C

ham

pion

Of V

TE R

isk

Asse

ss-

men

t, A

Nov

el A

ttem

pt to

Incr

ease

Pro

phyl

axis

Upt

ake

396

List

of P

oste

r The

33r

d W

CIM

Bal

i 201

6 W

edne

sday

, 24

Aug

ust 2

016

Post

er

Num

ber

Nam

eC

ount

ryR

emar

ksTi

tle

PO 2

65Lu

sian

iIn

done

sia

Car

diol

ogy

Cas

e R

epor

t: Eb

stei

n’s

Anom

aly

In P

regn

ancy

PO 2

66Fi

lsi E

lsa

Nov

enda

Indo

nesi

aC

ardi

olog

yR

elat

ion

betw

een

Hyp

onal

bum

inem

ia a

nd C

linic

al O

utco

mes

in

Pat

ient

s H

ospi

taliz

ed fo

r Hea

rt Fa

ilure

PO 2

67Pr

aman

taIn

done

sia

Car

diol

ogy

Neu

troph

il to

Lym

phoc

yte

Rat

io a

s An

othe

r Cha

ngin

g Fa

ctor

bes

ides

Incr

easi

ng T

ropo

nin

T in

Pat

ient

with

Acu

te

Myo

card

ial I

nfar

ctio

n

PO 2

68Sa

lly A

man

Nas

utio

nIn

done

sia

Car

diol

ogy

Cur

rent

Ris

k Fa

ctor

s, E

choc

ardi

ogra

phic

, Ang

iogr

aphi

c Pr

ofile

s an

d M

ace

Occ

uren

ce in

Dia

betic

and

Non

diab

etic

AC

S Pa

tient

s

PO 2

69Li

ly H

asug

ian

Indo

nesi

aC

ardi

olog

yR

elat

ion

betw

een

Seru

m U

ric A

cid

on A

dmis

sion

and

Clin

ical

O

utco

mes

in P

atie

nts

Hos

pita

lized

for H

eart

Failu

re

PO 2

70An

atol

y M

arty

nov

Rus

sia

Car

diol

ogy

Rel

atio

nshi

p of

Isch

emic

Stro

ke w

ithTt

rans

ient

«H

idde

n»

Atria

l Fib

rilla

tion

PO 2

71Kr

istin

awat

iIn

done

sia

Car

diol

ogy

Seve

re M

itral

Ste

nosi

s w

ith O

rtner

’s Sy

ndro

me

and

Oth

er

Seve

re C

ompl

icat

ions

PO 2

72Va

sist

a Pa

lnat

iIn

dia

Car

diol

ogy

Ebst

ein’

s An

omal

y w

ith C

hron

ic R

heum

atic

Hea

rt D

isea

se

PO 2

73D

endy

Hen

dria

nsya

hIn

done

sia

Car

diol

ogy

Rhe

umat

ic H

eart

Dis

ease

Inw

ard

Patie

nt’s

Profi

le in

RS.

H

asan

Sad

ikin

On

2010

-201

5

PO 2

74Ag

oes

Koos

harto

roIn

done

sia

Car

diol

ogy

The

Leve

l of H

igh

Sens

itivi

ty C

-Rea

ctiv

e Pr

otei

n (H

s-C

rp),

Trop

onin

I, C

kmb

and

Myo

glob

in B

efor

e an

d Af

ter

Perc

utan

eous

Cor

onar

y In

terv

entio

n (P

CI)

Proc

edur

e on

C

oron

ary

Hea

rt D

isea

se

397

PO 2

75H

aera

ni R

asyi

dIn

done

sia

Car

diol

ogy

Clu

ster

of M

ajor

Tra

ditio

nal R

isk

Fact

ors

of C

ardi

ovas

cula

r in

Hyp

erte

nsiv

e Su

bjec

ts in

Sou

th S

ulaw

esi

PO 2

76Lu

sian

i In

done

sia

Car

diol

ogy

Pred

icto

r Fac

tor o

f 12

Lead

s El

ectro

card

iogr

aphy

in

Atyp

ical

Che

st P

ain

Patie

nts

Und

erw

ent D

obut

amin

e St

ress

Ec

hoca

rdio

grap

hy In

Dr.

Cip

to M

angu

nkus

umo

Hos

pita

l

PO 2

77M

uhad

iIn

done

sia

Car

diol

ogy

Cor

rela

tion

of C

oron

ary

Arte

ry D

isea

se’s

Ris

k Fa

ctor

with

D

obut

amin

e St

ress

Ech

ocar

diog

raph

y in

Aty

pica

l Che

st P

ain

Patie

nts

in D

r. C

ipto

Man

gunk

usum

o H

ospi

tal

PO 2

78Er

win

Suk

andi

Indo

nesi

aC

ardi

olog

yC

orre

latio

n be

twee

n Se

rum

Uric

Aci

d Le

vels

and

Sev

erity

C

oron

ary

Hea

rt D

isea

se (C

HD

)

PO 2

79M

oham

ad S

yahr

ir Az

izi

Indo

nesi

aC

ardi

olog

yPr

ogno

stic

Fac

tor O

f Com

plic

atio

n D

urin

g D

obut

amin

e St

ress

Ec

hoca

rdio

grap

hy In

Inte

grat

ed H

eart

Cen

ter,

Dr.

Cip

to

Man

gunk

usum

o H

ospi

tal

PO 2

80M

erry

Indo

nesi

aC

ardi

olog

y

Com

paris

on o

f Ser

um A

ldos

tero

ne L

evel

Uns

tabl

e An

gina

Pe

ctor

is (U

AP) P

atie

nts

and

Non

ST

Elev

atio

n of

Myo

card

ial

Infa

rct w

ith N

on C

ardi

ac C

hest

Pai

n at

Moh

amm

ad H

oesi

n H

ospi

tal P

alem

bang

PO 2

81So

nya

Fara

h D

iba

Indo

nesi

aC

ardi

olog

yEv

iden

ce B

ased

Cas

e R

epor

t: N

on-A

lcoh

olic

Fat

ty L

iver

D

isea

se In

crea

ses

Car

otid

Intim

a M

edia

Thi

ckne

ss a

s A

Ris

k Fa

ctor

of C

oron

ary

Arte

ry D

isea

sePO

282

Mih

aela

Cris

tina

Ola

ruR

oman

iaC

ardi

olog

y C

ardi

ac ta

mpo

nade

: A re

ality

in h

ypot

hyro

idis

m

PO 2

83Yu

di F

adila

hIn

done

sia

Car

diol

ogy

Cor

rela

tion

Poly

mor

phis

ms

Gen

Cha

in

Fib

rinog

en a

nd

Fibr

inog

en L

evel

s w

ith S

teno

sis

Seve

rity

Cor

onar

y Ar

tery

on

Cor

onar

y H

eart

Dis

ease

Pat

ient

s at

Pal

emba

ng M

uham

mad

H

oesi

n H

ospi

tal

PO 2

84Sa

ri H

arah

apIn

done

sia

Car

diol

ogy

Rel

atio

n of

Blo

od U

rea

Nitr

ogen

to In

-Hos

pita

l Mor

talit

y in

H

eart

Failu

re G

eria

tric

Patie

nts

398

PO 2

85D

jalla

lludd

in

Indo

nesi

aC

ardi

olog

yPe

rcut

aneo

us T

rans

lum

inal

Ang

iopl

asty

Pat

ient

with

Su

bcla

vian

-Inno

min

ate

Veno

us T

otal

Occ

lusi

on P

leas

e

PO 2

86To

dung

DA

Sila

lahi

Indo

nesi

aC

ardi

olog

yTh

e Pr

eval

ence

of C

oron

ary

Hea

rt D

isea

se P

atie

nt w

ith

Hyp

erte

nsio

n an

d D

iabe

tes

Mel

litus

His

tory

in J

akar

ta H

eart

Cen

ter H

ospi

tal

PO 2

87To

dung

DA

Sila

lahi

Indo

nesi

aC

ardi

olog

yTh

e D

istri

butio

n of

Cor

onar

y Ar

tery

Les

sion

in P

atie

nt W

ith

Hyp

erte

ntio

n an

d D

iabe

tes

Mel

litus

His

tory

in J

akar

ta H

eart

Cen

ter H

ospi

tal

PO 2

88An

gela

Fel

icia

Sun

jaya

Indo

nesi

aC

ardi

olog

yC

omba

ting

Don

or O

rgan

Sho

rtage

: Org

an C

are

Syst

em

Prol

ongi

ng O

rgan

Sto

rage

Tim

e An

d Im

prov

ing

The

Out

com

e O

f Hea

rt Tr

ansp

lant

atio

ns

PO 2

89Ik

a Pr

aset

ya W

ijaya

Indo

nesi

aC

ardi

olog

yPr

imar

y Pe

rcut

anou

s C

oron

ary

Inte

rven

tion:

Pat

ient

C

hara

cter

istic

In 1

Yea

r Obs

erva

tiona

l Stu

dy In

Cip

to

Man

gunk

usum

o H

ospi

tal

PO 2

90R

achm

at H

amon

anga

nIn

done

sia

Car

diol

ogy

Clin

ical

and

Ang

iogr

aphi

c Pr

ofile

in P

atie

nts

Ove

r 60

Year

s of

Ag

e W

ho U

nder

wen

t Inv

asiv

e C

oron

ary

Proc

edur

e

PO 2

91R

achm

at H

amon

anga

nIn

done

sia

Car

diol

ogy

Impa

ct o

f Fra

ilty

On

30-D

ays

Maj

or C

ardi

ac V

ents

in E

lder

ly

Patie

nts

with

Cor

onar

y Ar

tery

Dis

ease

Und

erw

ent E

lect

ive

Perc

utan

eous

Cor

onar

y In

terv

entio

n

PO 2

92H

alin

a Ku

szU

SAC

ardi

olog

yA

Rar

e C

ase

of C

ompl

ex R

egio

nal P

ain

Synd

rom

e (C

RPS

) be

fore

Myo

card

ial I

nfar

ctio

n

PO 2

93M

uham

mad

Ikhs

anIn

done

sia

Car

diol

ogy

The

Rol

e of

Duk

e Tr

eadm

ill Sc

ore

As A

Pre

dict

or o

f Cor

onar

y Ar

tery

Dis

ease

in P

atie

nts

With

Pos

itive

Tre

adm

ill Te

st

PO 2

94Si

mon

Sal

imIn

done

sia

Car

diol

ogy

Aorti

c D

isse

ctio

n As

soci

ated

with

Myo

card

ial I

nfar

ctio

n: A

C

ase

Rep

ort

399

PO 2

95Ab

dul R

azak

Indo

nesi

aC

ardi

olog

yC

orre

latio

n Be

twee

n Se

rum

Asy

mm

etric

Dim

ethy

larg

inin

e (A

dma)

Lev

el A

nd G

ensi

ni S

core

In C

oron

ary

Arte

ry D

isea

se

Patie

nts

At M

oham

mad

Hoe

sin

Hos

pita

l Pal

emba

ng

PO 2

96Ah

mad

Far

iz M

alvi

Zam

zam

Ze

inIn

done

sia

Car

diol

ogy

The

In-H

ospi

tal M

ajor

Adv

erse

Car

diov

ascu

lar E

vent

s In

Pa

tient

s W

ith A

cute

Cor

onar

y Sy

ndro

me

In In

tern

al M

edic

ine

War

d

PO 2

97Fr

ans

Wan

tani

aIn

done

sia

Car

diol

ogy

Dec

reas

e of

Uric

Aci

d Le

vel i

s As

soci

ated

with

Low

Lev

el

of T

rans

form

ing

Gro

wth

Fac

tor-β

1and

Lef

t Vet

ricul

ar M

ass

Inde

x in

Hea

rt Fa

ilure

Pat

ient

s

PO 2

98R

ibka

Wow

orIn

done

sia

Car

diol

ogy

Ris

k Fa

ctor

s of

Lef

t Ven

tricu

lar H

yper

troph

y in

Mal

e St

uden

ts

at M

edic

al F

acul

ty, S

am R

atul

angi

Uni

vers

ity

PO 2

99Ag

oes

Koos

harto

roIn

done

sia

Car

diol

ogy

The

Succ

ess

of P

ercu

tane

ous

Tran

scat

hete

r Ang

iogr

aphy

(P

TA) O

ne S

tent

in P

atie

nt w

ith E

nd S

tage

Ren

al D

isea

se

(ESR

D) o

n H

emod

ialy

sis

(HD

)

PO 3

00W

ira P

rihat

in S

irega

rIn

done

sia

Car

diol

ogy

Impa

ct o

f Pre

serv

ed v

ersu

s R

educ

ed E

ject

ion

Frac

tion

on

Clin

ical

Out

com

es in

Fem

ale

Patie

nts

Hos

pita

lized

for H

eart

Failu

re

PO 3

01M

atth

ew B

illyIn

done

sia

Car

diol

ogy

The

Appl

icat

ion

Of R

isk

Scor

es A

s Pr

edic

tor O

f In-

Hos

pita

l M

orta

lity

Post

Per

cuta

neou

s C

oron

ary

Inte

rven

tion

In

Indo

nesi

an P

opul

atio

n

PO 3

02Ed

uard

o J

Car

vaja

lPo

rtuga

lC

ardi

olog

yAo

rtic

bloo

d pr

essu

re in

pat

ient

s ha

ving

Acu

te C

oron

ary

Synd

rom

e (A

CS)

ass

esse

d in

a lo

cal h

ospi

tal

PO 3

03Le

slie

Bol

itho

Aust

ralia

Car

diol

ogy

The

Hum

e Al

gorit

hm: a

n ai

d to

ski

lled

asse

ssm

ent o

f che

st

pain

s in

rura

l com

mun

ities

PO 3

04Yu

suf H

unin

gkor

Indo

nesi

aC

ardi

olog

yTh

e R

ole

of M

ollu

cas

Trad

ition

al F

ood

on T

he Im

prov

emen

t of

Ris

k Fa

ctor

s of

Cor

onar

y H

eart

Dis

ease

400

PO 3

05O

mur

Tab

akTu

rkey

Car

diol

ogy

Prog

nost

ic V

alue

Of G

luca

gon

Like

Pep

tide-

1, S

ecre

ted

Friz

zled

-Rel

ated

Pro

tein

-4, D

ipep

tidyl

Pep

tidas

e-4

In

Cor

onar

y Ar

tery

Dis

ease

: Rol

e O

f Dia

bete

s An

d In

tima

Med

ia

Thic

knes

s

PO 3

06O

mur

Tab

akTu

rkey

Car

diol

ogy

The

Asso

ciat

ion

Of P

oten

tial M

edia

tors

And

Bio

mar

kers

With

C

onve

ntio

nal R

isk

Fact

ors

In T

he M

etab

olic

Syn

drom

e

PO 3

07R

ukia

h C

hodi

law

ati

Indo

nesi

aC

ardi

olog

y

Cor

rela

tion

Betw

een

Leve

ls O

f Mat

rix M

etal

lopr

otei

nase

-9

(Mm

p-9)

Ser

um W

ith L

eft V

entri

cula

r Car

diac

Rem

odel

ing

In P

atie

nts

With

Hyp

erte

nsio

n At

Dr.

Moh

. Hoe

sin

Hos

pita

l Pa

lem

bang

PO 3

08Sy

amsu

Indr

aIn

done

sia

Car

diol

ogy

The

Cor

rela

tion

Betw

een

Seru

m A

dipo

nect

in L

evel

s An

d Sl

ow

Cor

onar

y Fl

ow In

Isch

emic

Hea

rt D

isea

se

PO 3

09M

arsi

ta A

yu L

esta

riIn

done

sia

Endo

crin

olog

yTh

e R

isk

Fact

ors

of F

oot U

lcer

atio

n an

d its

Cor

rela

tes

in

Type

2 D

iabe

tic P

atie

nts

at In

tern

al M

edic

ine

War

d of

Arifi

n Ac

hmad

Gen

eral

Hos

pita

l Pek

anba

ru

PO 3

10Em

re B

ozki

rliTu

rkey

Endo

crin

olog

yIm

mun

oglo

bulin

G4

leve

ls a

re e

leva

ted

in p

atie

nts

with

G

rave

s’ di

seas

e an

d G

rave

s’ op

htha

lmop

athy

PO 3

11D

inda

Apr

iliaIn

done

sia

Endo

crin

olog

yC

orre

latio

n be

twee

n So

lubl

e Th

rom

bom

odul

in w

ith In

sulin

R

esis

tanc

e in

Typ

e 2

Dia

bete

s M

ellit

usPO

312

Rio

Wiro

nego

roIn

done

sia

Endo

crin

olog

yFi

ssur

e To

ngue

in T

ype

2 D

iabe

tes

Mel

litus

PO 3

13N

enfia

tiIn

done

sia

Endo

crin

olog

yC

aber

golin

e Th

erap

y O

n Pr

olac

tinom

a Pa

tient

: A

Cas

e R

epor

t

PO 3

14D

enad

a Ai

syah

Sya

lini

Indo

nesi

aEn

docr

inol

ogy

Asso

ciat

ion

of A

1C a

nd C

reat

inin

e Se

rum

in P

atie

nts

with

D

iabe

tic F

oot U

lcer

in D

r.Soe

tom

o G

ener

al H

ospi

tal

PO 3

15Ib

rahi

m C

ETIN

DAG

LITu

rkey

Endo

crin

olog

yA

Cas

e R

epor

t of L

ada

Pres

entin

g w

ith D

iabe

tic K

etoa

cido

sis

at O

lder

Age

PO 3

16Ib

rahi

m C

ETIN

DAG

LITu

rkey

Endo

crin

olog

yA

Com

pellin

g C

ase

of T

hyro

id C

ance

r: Is

It ‘S

ettle

’ or N

ot?

401

PO 3

17Ib

rahi

m C

ETIN

DAG

LITu

rkey

Endo

crin

olog

yW

hat i

s Th

e H

ighe

st V

alue

Of H

BA1C

You

Rem

embe

red

in

The

Dia

gnos

is o

f Dia

bete

s M

ellit

us?

(HBA

1C: 2

0.5%

)

PO 3

18D

iar M

eith

a W

ardh

ana

Indo

nesi

aEn

docr

inol

ogy

Cor

rela

tion

of B

lood

Glu

cose

with

Non

Per

iodo

ntal

Ora

l M

anife

stat

ions

on

Type

II D

iabe

tes

Mel

litus

PO 3

19Ez

ekie

l Won

g To

h Yo

onJa

pan

Endo

crin

olog

yM

anag

ing

Post

pran

dial

Hyp

ogly

cem

ia D

ue to

Lat

e D

umpi

ng

Synd

rom

e in

A D

irect

Per

cuta

neou

s En

dosc

opic

Jej

unos

tom

y Pa

tient

Usi

ng M

iglit

ol a

nd Is

omal

tulo

se

PO 3

20Fa

isal

Par

lindu

ngan

Indo

nesi

aEn

docr

inol

ogy

Acut

e Th

yroi

d St

orm

Com

plic

ated

with

Sep

sis

and

Live

r Fa

ilure

– A

Cas

e in

A R

esou

rce-

Lim

ited

Hos

pita

l

PO 3

21Vi

na Y

anti

Susa

nti

Indo

nesi

aEn

docr

inol

ogy

Fruc

tosa

min

Lev

el in

Typ

e 2

Dia

bete

s M

ellit

us P

atie

nts

with

Dep

ress

ion

Sym

ptom

s be

fore

and

afte

r The

rapy

w

ith F

luox

etin

e, L

atih

an P

asra

h D

iri, a

nd C

ombi

natio

n of

Fl

uoxe

tine

and

Latih

an P

asra

h D

iri

PO 3

22Tj

okor

da G

de D

alem

Pe

may

unIn

done

sia

Endo

crin

olog

yW

hen

The

Alar

m to

Act

ion

is M

issi

ng: T

ype

of D

iabe

tic F

oot i

s M

atte

rs in

Det

erm

inin

g Its

Out

com

es a

fter H

ospi

taliz

atio

nPO

323

Khw

aja

Naz

im U

ddin

Bang

lade

shEn

docr

inol

ogy

Dia

bete

s Sp

ecifi

c In

fect

ions

PO 3

24Er

lina

Mar

fiant

iIn

done

sia

Endo

crin

olog

yD

iffer

ence

of B

lood

Glu

cose

Lev

els

betw

een

Smok

ing

and

Non

smok

ing

Men

in B

ayan

Dis

trict

Pur

wor

ejo

2014

PO 3

25H

endr

a G

unaw

anIn

done

sia

Endo

crin

olog

yC

orre

latio

n of

HbA

1C C

once

ntra

tion

and

Ora

l Man

ifest

atio

ns

in T

ype

2 D

iabe

tes

Mel

litus

PO 3

26Ira

wan

Faj

ar K

usum

aIn

done

sia

Endo

crin

olog

yH

ypok

alem

ic P

erio

dic

Para

lysi

s: a

Cas

e R

epor

t of a

31

year

ol

d As

ian

man

PO 3

27D

ian

Anin

dita

Lub

isIn

done

sia

Endo

crin

olog

y C

orre

latio

n be

twee

n Pa

ncre

atic

β C

ell a

nd L

ipid

Pro

file

in

Subj

ects

with

Nor

mal

Glu

cose

Tol

eran

ce

PO 3

28H

asyi

m K

asim

Indo

nesi

aEn

docr

inol

ogy

Com

paris

on o

f Gly

cem

ic S

tatu

s be

twee

n G

lyca

ted

Albu

min

an

d G

lyca

ted

Hae

mog

lobi

n in

Dia

betic

Kid

ney

Dis

ease

Su

bjec

ts

402

PO 3

29Ib

rahi

m S

ahin

Turk

eyEn

docr

inol

ogy

Effe

ct F

F R

oux-

EN Y

Gas

tric

Bypa

ss O

pera

tion

On

Bloo

d Pr

essu

re R

egul

atio

n In

Typ

e 2

Dia

betic

Obe

se P

atie

nts

PO 3

30An

thon

y Pa

ulo

Sunj

aya

Indo

nesi

aEn

docr

inol

ogy

Clin

ical

Cha

ract

eris

tics,

Gly

cem

ic P

rofil

e an

d O

bste

trica

l O

utco

mes

am

ong

Preg

nant

Mot

hers

with

Dia

bete

s M

ellit

us in

H

erm

ina

Podo

mor

o H

ospi

tal

PO 3

31M

onic

a Sa

riIn

done

sia

Endo

crin

olog

yM

arin

e-Le

nhar

t Syn

drom

e

PO 3

32Au

drey

Sur

yani

Soe

tjipt

oIn

done

sia

Endo

crin

olog

yD

iabe

tes

Know

ledg

e An

d Be

havi

or L

evel

In R

elat

ion

With

D

iabe

tic F

oot U

lcer

Com

plic

atio

ns

PO 3

33M

unir

Rul

anam

Indo

nesi

aEn

docr

inol

ogy

Hyp

ophy

sect

omy

on P

ituita

ry A

deno

ma

and

its

cons

eque

ncie

s

PO 3

34In

ês F

erra

z de

Oliv

eira

Portu

gal

Endo

crin

olog

yPO

EMS

synd

rom

e: A

rare

pro

gres

sion

of m

onoc

lona

l ga

mm

opat

hy o

f und

eter

min

ed s

igni

fican

ce

PO 3

35M

aya

Hes

tinin

gtya

sIn

done

sia

Endo

crin

olog

yLa

nger

hans

Cel

l His

tiocy

tosi

s in

Adu

lt, c

omor

bid

with

D

iabe

tes

Mel

litus

: R

are

case

PO 3

36Fe

bri A

ndin

iIn

done

sia

Endo

crin

olog

yG

lyco

syla

ted

Hae

mog

lobi

n Le

vels

and

the

Seve

rity

of S

exua

l D

ysfu

nctio

n in

Dia

betic

Wom

en

PO 3

37Sy

lva

Naz

lyIn

done

sia

Endo

crin

olog

yN

eutro

phil

to L

ymph

ocyt

e R

atio

as

Am

puta

tion

Pred

icto

r in

Patie

nt w

ith D

iabe

tic F

oot I

nfec

tion

in B

anda

Ace

h

PO 3

38Fa

rid K

urni

awan

Indo

nesi

aEn

docr

inol

ogy

The

Rur

al-U

rban

Diff

eren

ces

In A

dipo

sity

And

Adi

poki

nes

Profi

les

Amon

g In

done

sian

s

PO 3

39Sa

barin

aIn

done

sia

Endo

crin

olog

y

Cor

rela

tion

betw

een

Body

Mas

s In

dex

and

Gly

cem

ic

Con

trol i

n O

bese

Typ

e 2

Dia

bete

s M

ellit

us P

atie

nts

who

w

as R

ecei

ved

Met

form

in M

onot

hera

py a

t dr.

Zain

oel A

bidi

n G

ener

al H

ospi

tal B

anda

Ace

h

PO 3

40Ta

nia

Tedj

o M

Indo

nesi

aEn

docr

inol

ogy

Adip

onec

tine

Leve

l in

Obe

se-D

iabe

tic P

atie

nts:

trea

ted

vs.

untre

ated

A c

ase

serie

s st

udy

403

PO 3

41Er

ni E

rdor

is G

intin

gIn

done

sia

Infe

ctio

us

Dis

ease

Aspe

rgillo

ma

with

Hem

opty

sis

in Y

oung

Fem

ale

PO 3

42Ta

ufiq

Muh

ibbu

ddin

Wal

yIn

done

sia

Infe

ctio

us

Dis

ease

Thin

k Ab

out P

ossi

bilit

ies

of D

engu

e In

fect

ion

befo

re Y

ou

Play

You

r Sur

gery

Kni

fe (T

hink

Abo

ut P

ossi

bilit

ies

of D

engu

e In

fect

ion

befo

re W

e Ag

ree

To D

o Th

e O

pera

tion)

PO 3

43Ak

hmad

Nur

dani

Indo

nesi

aIn

fect

ious

D

isea

seC

orre

latio

n O

f Neu

troph

il-Ly

mph

ocyt

e R

atio

And

Pro

calc

itoni

n Le

vel I

n Se

ptic

Pat

ient

s

PO 3

44Pu

rwat

iIn

done

sia

Infe

ctio

us

Dis

ease

Patte

rn L

epto

spira

Stra

in C

ause

Of L

epto

spiro

sis

Epid

emi I

n Sa

mpa

ng M

adur

a Ea

st J

ava

Indo

nesi

a

PO 3

45Yo

vita

Har

tant

riIn

done

sia

Infe

ctio

us

Dis

ease

HIV

Infe

ctio

n M

imic

king

Aut

oim

mun

e an

d R

heum

atic

D

isea

se: T

he D

iagn

ostic

Cha

lleng

e

PO 3

46M

a. Im

ee L

ynne

C.

Esqu

ibel

Philip

pine

sIn

fect

ious

D

isea

seC

linic

al P

rese

ntat

ion

and

Cou

rse

of D

engu

e In

fect

ion

amon

g Pa

tient

s w

ith S

yste

mic

Lup

us E

ryth

emat

osus

: A C

ase

Serie

s

PO 3

47Er

ni J

uwita

Nel

wan

Indo

nesi

aIn

fect

ious

D

isea

se

Low

Yie

ld o

f Met

hici

llin-R

esis

tant

Sta

phyl

ococ

cus

Aure

us

Nas

al C

arria

ge in

Ele

ctiv

e Su

rger

y Ad

ult P

atie

nts

in C

ipto

M

angu

nkus

umo

Hos

pita

l, Ja

karta

, Ind

ones

ia

PO 3

48A.

A.Ay

u Yu

li G

ayat

riIn

done

sia

Infe

ctio

us

Dis

ease

Adva

nced

Dis

ease

at E

nrol

lmen

t in

HIV

Car

e O

ver T

wel

ve

Year

s of

HAA

RT in

San

glah

Hos

pita

l

PO 3

49Br

aman

tono

Indo

nesi

aIn

fect

ious

D

isea

se

Prev

alen

ce o

f Mul

ti-D

rug

Res

ista

nt G

ram

Pos

itive

Bac

teria

C

ause

d Ba

cter

emia

Fro

m In

tern

al W

ard,

Dr S

oeto

mo

Hos

pita

l Sur

abay

a, In

done

sia

(Six

Yea

rs S

urve

illanc

e St

udie

s)

PO 3

50D

ewi D

ian

Sukm

awat

iIn

done

sia

Infe

ctio

us

Dis

ease

Mor

talit

y R

isk

of H

uman

Imm

unod

efici

ency

Viru

s As

soci

ated

Pn

eum

ocys

tis P

neum

onia

: The

Sho

rt Te

rm S

urvi

val

Estim

atio

n

PO 3

51Ar

dhi R

ahm

an A

hani

Indo

nesi

aIn

fect

ious

D

isea

seM

yias

is in

a M

an w

ith S

epsi

s D

ue to

Ski

n an

d So

ft Ti

ssue

in

fect

ion

404

PO 3

52O

mur

Tab

akTu

rkey

Infe

ctio

us

Dis

ease

S. A

ureu

s Ba

cter

emia

with

Cav

itary

Lun

g Le

ssio

ns a

nd

Intra

abdo

min

al A

bsce

ss

PO 3

53M

uham

mad

Fai

sal P

utro

U

tom

oIn

done

sia

Infe

ctio

us

Dis

ease

Chr

onic

Con

ditio

ns a

mon

g C

are

Supp

ort a

nd T

reat

men

t (C

ST) C

lient

s at

San

glah

Gen

eral

Hos

pita

l due

to

Antir

etro

vira

l Tre

atm

ent:

a cr

oss-

sect

iona

l stu

dy

PO 3

54D

ewa

Ayu

Putri

Sri

Mas

yeni

Indo

nesi

aIn

fect

ious

D

isea

se

Asso

ciat

ion

betw

een

Den

gue

Viru

s Se

roty

pe a

nd C

linic

al

Man

ifest

atio

ns in

Den

gue

Infe

ctio

n Ad

mitt

ed a

t Wan

gaya

and

Sa

njiw

ani H

ospi

tal B

ali

PO 3

55H

adia

nti

Indo

nesi

aIn

fect

ious

D

isea

seR

ecur

rent

Pul

mon

ary

Aspe

rgillo

sis

in A

Pat

ient

with

C

arci

nom

a of

The

Ton

gue

PO 3

56I M

ade

Susi

la U

tam

aIn

done

sia

Infe

ctio

us

Dis

ease

Cha

ract

eris

tic o

f Co-

Infe

ctio

n H

IV-T

B at

San

glah

Hos

pita

l D

enpa

sar B

ali

PO 3

57C

hris

tian

Jona

tan

Indo

nesi

aIn

fect

ious

D

isea

se

The

Impo

rtanc

e of

HIV

Tes

ting

in T

B Pa

tient

s Es

peci

ally

in

HIV

Epi

dem

ic A

rea:

A C

ase

Rep

ort F

rom

Situ

bond

o, E

ast

Java

PO 3

58M

uh. N

ur Ik

hsan

Liw

ang

Indo

nesi

aIn

fect

ious

D

isea

se

Cor

rela

tion

of T

otal

Lym

phoc

yte

Cou

nt a

nd T

he N

umbe

r of

Lym

phoc

yte

T C

D4+

in M

en W

ho H

ave

Sex

with

Men

Gro

up

of H

uman

Imm

unod

efici

ency

Viru

s In

fect

ed P

atie

nts

with

C

ondy

lom

a Ac

umin

ata

PO 3

59M

uham

mad

Abd

ur R

ahim

Bang

lade

shIn

fect

ious

D

isea

seH

isto

plas

mos

is In

Ban

glad

esh

PO 3

60Li

m J

u Ye

eSi

ngap

ore

Infe

ctio

us

Dis

ease

A ca

se o

f Par

vovi

rus

asso

ciat

ed H

aem

opha

gocy

tic

lym

phis

tiocy

tosi

s

PO 3

61Jo

ana

Urz

alPo

rtuga

lIn

fect

ious

D

isea

seQ

feve

r: a

diag

nosi

s to

con

side

r whe

n in

the

pres

ence

of

pers

iste

nt fe

ver

PO 3

62Ve

roni

ka D

yah

Setiy

arum

Indo

nesi

aIn

fect

ious

D

isea

seTh

e As

soci

atio

n O

f Acu

te K

idne

y In

jury

Bas

ed O

n R

ifle

And

Akin

Cla

ssifi

catio

ns W

ith M

orta

lity

In L

epto

spiro

sis

405

PO 3

63M

elis

aIn

done

sia

Infe

ctio

us

Dis

ease

Bact

eria

l Sep

sis

of U

nkno

wn

Sour

ce in

Imm

unoc

ompe

tent

Pa

tient

with

Den

gue

Hem

orrh

agic

Fev

er

PO 3

64Su

dirm

an K

atu

Indo

nesi

aIn

fect

ious

D

isea

se

Cor

rela

tion

of T

he C

linic

al p

rofil

e an

d C

D4

leve

l of H

IV

Infe

ctio

n af

ter s

ix m

onth

Ant

iretro

vira

l tre

atm

ent a

t the

HIV

In

fect

ion

Cen

ter W

ard

Mak

assa

r Jan

uary

– J

une

2016

PO 3

65Ve

ra F

razã

o Vi

eira

Portu

gal

Infe

ctio

us

Dis

ease

Ner

vous

Sys

tem

Lym

e D

isea

se -

Cau

se O

r Exa

cerb

atio

n Fa

ctor

?

PO 3

66Ta

mba

r Kem

bare

nIn

done

sia

Infe

ctio

us

Dis

ease

Toxo

plas

ma

Ence

phal

itis

in H

IV/A

ids

Patie

nt in

H A

dam

Mal

ik

Ref

erra

l Hos

pita

l Med

an :

14 C

ase

Rep

orts

PO 3

67Pe

dro

Mig

uel D

ias

Lope

sPo

rtuga

lIn

fect

ious

D

isea

seC

lost

ridiu

m d

iffici

le -

retro

spec

tive

stud

y of

4 y

ears

in In

tern

al

Med

icin

e Se

rvic

e

PO 3

68M

aria

Gor

etti

Amet

embu

nIn

done

sia

Infe

ctio

us

Dis

ease

Tube

rcul

osis

Am

ong

Dis

able

d

PO 3

69M

aria

Gor

etti

Amet

embu

nIn

done

sia

Infe

ctio

us

Dis

ease

Extra

pulm

onar

y Tu

berc

ulos

is P

atte

rn A

nd It

s U

ltras

ound

Fi

ndin

gs

PO 3

70R

Des

y N

urha

yati

Indo

nesi

aIn

fect

ious

D

isea

seLe

vels

of I

nter

leuk

in 1

7 Ex

amin

atio

n fo

r Ear

ly D

etec

tion

of

Mul

tiple

Dru

g R

esis

tant

Tub

ercu

losi

s

PO 3

71LP

Par

amita

Indo

nesi

aIn

fect

ious

D

isea

seFa

tal c

ases

of W

eil’s

dis

ease

: A

case

repo

rt

PO 3

72Eu

n Ju

Kim

Sout

h Ko

rea

Hem

atol

ogy

/ O

ncol

ogy

Sile

ncin

g of

Sia

lyltr

ansf

eras

e In

crea

ses

Col

orec

tal C

ance

r M

etas

tasi

s by

Rel

easi

ng C

ellu

lar M

etas

tase

s Su

ppre

ssio

n C

D82

Via

Exo

som

e-M

edia

ted

Expo

rtatio

n, a

nd T

here

by

Res

cues

Inte

grin

Sig

nalin

g

PO 3

73S.

Selm

in T

opla

nTu

rkey

Hem

atol

ogy

/ O

ncol

ogy

Influ

ence

of E

xper

imen

tal H

yper

thyr

oidi

sm o

n R

heol

ogic

Pr

oper

ties

of B

lood

406

PO 3

74M

uham

mad

Noo

r Dia

nsya

h In

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Engr

aftm

ent P

erio

d An

d In

fect

ion

Inci

denc

e In

Mul

tiple

M

yelo

ma

Patie

nts

Und

erw

ent A

utol

ogus

Per

iphe

ral B

lood

St

em C

ell T

rans

plan

tatio

n

PO 3

75Ef

ata

Polii

Indo

nesi

aH

emat

olog

y /

Onc

olog

y

Cor

rela

tion

betw

een

Vita

min

D L

evel

, Int

erle

ukin

-6 a

nd Ir

on

Stat

us w

ith H

emog

lobi

n Le

vel i

n Su

bjec

ts A

nem

ia C

hron

ic

Dis

ease

You

ng A

dult

PO 3

76R

ahul

Cho

wda

ry K

onga

raIn

dia

Hem

atol

ogy

/ O

ncol

ogy

A C

ase

Rep

ort o

f Prim

ary

Leio

myo

sarc

oma

of L

iver

– A

Rar

e Pr

esen

tatio

n

PO 3

77Ba

har P

ehliv

anTu

rkey

Hem

atol

ogy

/ O

ncol

ogy

Kapo

si S

arko

ma

Exis

ting

Dur

ing

Chr

onic

Lym

phoc

ytic

Le

ukem

ia F

ollo

w-U

p

PO 3

78O

ctav

ianu

s R

.H U

mbo

hIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Cor

rela

tion

Betw

een

IL-1

β, T

esto

ster

one,

Ser

um

Eryt

hrop

oiet

in a

nd H

emog

lobi

n in

You

ng A

dults

Mal

e Su

bjec

ts w

ith A

nem

ia o

f Chr

onic

Dis

ease

PO 3

79An

gelik

i Tsi

fiG

reec

eH

emat

olog

y /

Onc

olog

yAn

Inte

rest

ing

Cas

e of

Ext

ram

edul

lary

Hem

atop

oies

is in

A

Patie

nt w

ith N

ewly

Dia

gnos

ed H

emog

lobi

n H

Dis

ease

PO 3

80Ib

rahi

m C

ETIN

DAG

LITu

rkey

Hem

atol

ogy

/ O

ncol

ogy

A C

ase

of R

enal

Cel

l Car

cino

ma,

Pre

sent

ed w

ith

Para

neop

last

ic S

yndr

ome

PO 3

81Ib

rahi

m C

ETIN

DAG

LITu

rkey

Hem

atol

ogy

/ O

ncol

ogy

The

Rar

e H

emog

lobi

n H

Dis

ease

PO 3

82M

ichi

to S

adoh

ara

Japa

nH

emat

olog

y /

Onc

olog

yA

Cas

e of

DR

ESS

synd

rom

e w

ith p

atho

logi

cally

con

firm

ed

Der

mat

opat

hic

Lym

phad

enop

athy

PO 3

83I M

ade

Bakt

aIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Apla

stic

Ane

mia

with

Par

tial R

espo

nse

to R

ituxi

mab

Tr

eatm

ent:

A C

ase

Rep

ort

PO 3

84I M

ade

Bakt

aIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Panc

ytop

enia

Due

to M

ycob

acte

rium

Tub

ercu

losi

s In

fect

ion

in

Bone

Mar

row

PO 3

85C

okor

da A

Wah

yuIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Plat

elet

Tra

nsfu

sion

for H

emat

olog

y O

ncol

ogy

Patie

nts

in

Sang

lah

Hos

pita

l

407

PO 3

86R

oza

Kurn

iati

Indo

nesi

aH

emat

olog

y /

Onc

olog

yTh

orac

ocen

tesi

s Pr

oced

ure

in A

Pat

ient

with

Sev

ere

Thro

mbo

cyto

peni

a

PO 3

87D

iego

Her

nan

Giu

nta

Arge

ntin

aH

emat

olog

y /

Onc

olog

y

Inci

denc

e R

ate

of A

myl

oido

sis

in P

atie

nts

from

A M

edic

al

Car

e Pr

ogra

m in

Bue

nos

Aire

s, A

rgen

tina:

A P

rosp

ectiv

e C

ohor

t

PO 3

88Ei

fel F

aher

iIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Com

paris

on o

f Epi

derm

al G

row

th F

acto

r Rec

epto

r (E

GFR

) Exp

ress

ion

Leve

l with

Res

pons

e of

Neo

ajuv

an

Che

mot

hera

py a

nd E

xten

sive

Lev

el o

f Tum

or P

rimer

on

Adva

nced

Nas

opha

ryng

eal C

ance

r Pat

ient

s

PO 3

89Bo

bi Y

ohan

es S

ewow

Indo

nesi

aH

emat

olog

y /

Onc

olog

yTh

e Si

eve’

s Sy

ndro

me

in A

utoi

mun

Imm

une

Hem

oliti

c An

emia

(AIH

A) p

atie

nt w

ith A

lcoh

olis

m

PO 3

90M

ujga

n G

urle

rTu

rkey

Hem

atol

ogy

/ O

ncol

ogy

Prilo

cain

e In

duce

d M

ethe

mog

lobi

nem

ia in

a P

atie

nt w

ith

Panc

reas

Car

cino

ma

PO 3

91Im

elda

Nita

Sap

utri

Indo

nesi

aH

emat

olog

y /

Onc

olog

yC

ompa

rison

of N

eutro

phil-

Lym

phoc

yte

Rat

io a

mon

g H

ealth

y Ad

ults

with

Diff

eren

t BM

I Sta

tus

in A

tma

Jaya

Hos

pita

l

PO 3

92An

di R

aga

Gin

ting

Indo

nesi

aH

emat

olog

y /

Onc

olog

yTh

e R

elat

ions

hip

of M

ean

Plat

elet

Vol

ume

(MPV

) Val

ues

With

Th

e D

egre

e O

f Sep

sis

PO 3

93Al

amsy

ahIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Asso

ciat

ion

betw

een

Abso

lute

Neu

troph

il C

ount

(AN

C) a

nd

Mor

talit

y in

Pos

t Che

mot

hera

py N

eutro

peni

c Fe

brile

Pat

ient

s In

RSU

P D

r. Sa

rdjit

o Yo

gyak

arta

Fro

m 2

014

- 201

5

PO 3

94Is

wan

di D

arw

isIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Ove

rvie

w o

f Dem

ogra

phic

and

Clin

ical

Cha

ract

eris

tics

of

Patie

nt F

ebril

e N

eutro

peni

a Af

ter C

hem

othe

rapy

in D

r. Sa

rdjit

o H

ospi

tal

PO 3

95In

ês F

erra

z de

Oliv

eira

Portu

gal

Hem

atol

ogy

/ O

ncol

ogy

Osl

er-R

endu

-Web

er D

isea

se: A

cau

se o

f rep

eate

d ha

emor

rhag

e

408

PO 3

96R

ehul

ina

BR T

arig

anIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Rel

atio

nshi

p Be

twee

n Th

e D

egre

e O

f Sev

erity

With

The

Fo

rmat

ion

Of I

nhib

itors

In P

atie

nts

With

Hem

ophi

lia A

In H

aji

Adam

Mal

ik G

ener

al H

ospi

tal M

edan

PO 3

97Ke

tut S

uega

Indo

nesi

aH

emat

olog

y /

Onc

olog

yR

et- H

e As

An

Early

Mar

ker F

or T

reat

men

t Res

pon

In P

atie

nt

With

Iron

Defi

cien

cy A

nem

ia

PO 3

98Bu

di S

etia

wan

Indo

nesi

aH

emat

olog

y /

Onc

olog

yA

63 Y

ear O

ld W

oman

With

Por

tal V

ein

Thro

mbo

sis

Et C

ausa

M

yelo

prol

ifera

tive

Neo

plas

m

PO 3

99Is

abel

Pin

heiro

Portu

gal

Hem

atol

ogy

/ O

ncol

ogy

Follic

ular

thyr

oid

canc

er p

rese

ntat

ion

as a

lum

bar m

etas

tasi

s

PO 4

00R

eza

Yoga

swar

aIn

done

sia

Hem

atol

ogy

/ O

ncol

ogy

Acut

e M

yoca

rdia

l Inf

arct

in A

cute

Mye

loid

Leu

kem

ia: a

Cas

e R

epor

t

PO 4

01H

ildeb

rand

Han

och

Vict

or

Wat

upon

goh

Indo

nesi

aG

eria

tric

Lym

phoc

yte

and

Inci

dent

of I

nfec

tions

in G

eria

tric

Patie

nts

in

Inte

rnal

Med

icin

e W

ard

at U

KI G

ener

al H

ospi

tal J

akar

ta

PO 4

02R

oza

Mul

yana

Indo

nesi

aG

eria

tric

Inte

rdis

cipl

inar

y Ap

proa

ch T

hrou

gh C

ompr

ehen

sive

Ger

iatri

c As

sess

men

t in

Man

agem

ent E

lder

ly P

atie

nt w

ith S

yste

mic

Sc

lero

sis

PO 4

03R

ensa

Indo

nesi

aG

eria

tric

Prev

alen

ce a

nd C

ilical

Pro

file

of U

rinar

y Tr

act I

nfec

tion

in

Hos

pita

lized

Eld

erly

Pat

ient

s at

Acu

te G

eria

tric

War

d

PO 4

04R

A Tu

ty K

usw

ardh

ani

Indo

nesi

aG

eria

tric

The

Effo

rts o

f Im

prov

emen

t Hol

istic

Ser

vice

s U

tiliz

atio

n G

eria

tric

Uni

t of I

nteg

rate

d Se

rvic

e Sa

ngla

h H

ospi

tal

Den

pasa

r Ind

ones

ia

PO 4

05N

Ast

ika

Indo

nesi

aG

eria

tric

Cor

rela

tion

betw

een

Inso

mni

a an

d D

epre

ssio

n in

Eld

erly

Pa

tient

s in

San

glah

Hos

pita

l, Ba

li: A

Cro

ss-S

ectio

nal S

tudy

PO 4

06N

oto

Dw

imar

tutie

Indo

nesi

aG

eria

tric

Com

paris

on O

f 30-

Day

Sur

viva

ls In

Del

irium

Ver

sus

Non

D

eliri

um E

lder

ly P

atie

nts

Adm

itted

To

Acut

e G

eria

tric

War

d

PO 4

07N

i Way

an M

eind

ra

Wirt

ayan

iIn

done

sia

Ger

iatri

cAl

bum

in L

evel

As

Inde

pend

ent P

redi

ctor

Fac

tor I

n D

eter

min

e Le

ngth

Of H

ospi

taliz

atio

n In

Ger

iatri

c Pa

tient

s

409

PO 4

08D

esak

Nyo

man

Des

y Le

star

iIn

done

sia

Ger

iatri

cC

orre

latio

n of

Alb

umin

Ser

um a

nd F

unct

iona

l Sta

tus

Amon

g El

derly

Pat

ient

s in

San

glah

Hos

pita

l Den

pasa

r Bal

i Ind

ones

ia

PO 4

09I M

ade

Wis

nu W

ardh

ana

Indo

nesi

aG

eria

tric

Cor

rela

tions

of B

ody

Mas

s In

dex

and

Plas

ma

Albu

min

with

In

fect

ion

In G

eria

tric

Popu

latio

n

PO 4

10N

i Mad

e D

arm

a Pa

tni S

ri R

ejek

iIn

done

sia

Ger

iatri

cC

orre

latio

n of

Alb

umin

Ser

um a

nd In

terle

ukin

-6 (I

L-6)

Ser

um

Amon

g El

derly

Pat

ient

s in

RSU

P Sa

ngla

h D

enpa

sar B

ali

Indo

nesi

a

PO 4

11Pu

tu D

henn

y W

ahyu

WIn

done

sia

Ger

iatri

cC

orre

latio

n be

twee

n D

eler

ium

with

Alb

umin

Ser

um A

mon

g El

derle

y in

San

glah

Hos

pita

l Den

pasa

r 201

5

PO 4

12Sh

elvy

Flo

renc

e G

ousa

rioIn

done

sia

Ger

iatri

cAs

soci

atio

n be

twee

n D

eliri

um S

tatu

s an

d An

emia

in E

lder

ly

Patie

nts

Hos

pita

lized

at G

eria

tric

War

d Sa

ngla

h G

ener

al

Hos

pita

l

PO 4

13Yo

sef S

Sug

iIn

done

sia

Ger

iatri

cIn

crea

sing

Lev

els

of S

100β

and

Inte

rleuk

in-6

Ser

um

Cor

rela

te w

ith D

eliri

um S

ever

ity in

Ger

iatri

c Pa

tient

s Th

at

Adm

itted

in S

angl

ah H

ospi

tal,

Bali

PO 4

14D

iego

God

oySp

ain

Ger

iatri

cM

icro

RN

A Pr

ofile

Ana

lysi

s in

Pat

ient

s W

ho L

ater

Suf

fere

d A

Stro

ke V

ersu

s C

ontro

ls in

An

Elde

rly M

edite

rrane

an

Popu

latio

n

PO 4

15Sh

anti

Pric

illia

Mak

agia

nsar

Indo

nesi

aG

eria

tric

Profi

le o

f Ger

iatri

c Pa

tient

s H

ospi

taliz

ed in

Acu

te G

eria

tric

War

d Ba

sed

On

Cip

to M

angu

nkus

umo

Hos

pita

l Pal

liativ

e C

are

Scre

enin

g To

ol

PO 4

16M

ade

Nop

riant

haIn

done

sia

Ger

iatri

cTh

e Im

pact

of A

nem

ia O

n C

ogni

tive

Func

tion

In H

ospi

taliz

ed

Elde

rly P

atie

nts

PO 4

17G

odfri

ed E

Y Sa

ragi

hIn

done

sia

Ger

iatri

cTh

e Im

pact

of D

epre

ssio

n on

Cog

nitiv

e Fu

nctio

n an

d Fu

nctio

nal S

tatu

s In

Hos

pita

lized

Eld

erly

Pat

ient

s: A

Cro

ss-

Sect

iona

l Stu

dy

410

PO 4

18I M

ade

Bayu

Indr

atam

aIn

done

sia

Ger

iatri

cTh

e R

isk

Profi

le A

nd P

roph

ylax

is U

se F

or D

eep

Vein

Th

rom

bosi

s In

Eld

erly

Pat

ient

s Ad

mitt

ed T

o In

tern

al M

edic

ine

Dep

artm

ent O

f San

glah

Gen

eral

Hos

pita

l

PO 4

19Fa

ndy

Sant

oso

Budi

ardj

oIn

done

sia

Ger

iatri

cR

elat

ions

hip

betw

een

Cal

cito

nin

Seru

m L

evel

and

Inci

denc

e of

Fra

gilit

y Fr

actu

res

in E

lder

ly

PO 4

20Au

lia R

izka

Indo

nesi

aG

eria

tric

Elde

rly in

Em

erge

ncy

Dep

artm

ent o

f Ind

ones

ian

Hos

pita

l: C

hara

cter

istic

s an

d O

utco

me

PO 4

21Pu

rwita

Wija

ya L

aksm

iIn

done

sia

Ger

iatri

cAn

thro

pom

etry

, Bod

y C

ompo

sitio

n an

d M

uscl

e Fu

nctio

n am

ong

Non

-Dia

betic

Pre

-Fra

il G

eria

tric

Out

patie

nts

PO 4

22Fi

ence

Reg

ina

Dor

kas

Indo

nesi

aG

eria

tric

Diff

eren

tiatio

n O

f Vita

min

D {2

5 (O

H)D

3} L

evel

s O

n Fr

agilit

y Fr

actu

res

And

Non

Fra

gilit

y Fr

actu

res

Elde

rly

PO 4

23An

ita S

anja

yaIn

done

sia

Ger

iatri

cAt

tribu

tes

Of G

eria

tric

Patie

nt A

dmitt

ed T

o Th

e Em

erge

ncy

Dep

artm

ent I

n 7

Day

s Be

fore

Eid

Al-F

itr

PO 4

24D

joha

r Nus

wan

toro

Indo

nesi

aN

ephr

olog

yD

eter

min

ant F

acto

r of C

hron

ic K

idne

y D

isea

se (C

KD) o

n Ad

ults

in T

engg

er B

rom

o M

ount

ain

and

Sura

baya

Com

mun

ity

PO 4

25R

aden

Son

y Yu

suf

Wib

ison

oIn

done

sia

Nep

hrol

ogy

Cor

rela

tion

Betw

een

Del

iver

ed K

t/V W

ith A

lbum

in L

evel

s An

d N

eutro

phils

/Lym

phoc

ytes

Rat

io In

Hem

odia

lysi

s Pa

tient

s In

D

R A

goes

djam

Hos

pita

l Ket

apan

g W

est K

alim

anta

n

PO 4

26Ib

rahi

m C

ETIN

DAG

LITu

rkey

Nep

hrol

ogy

A R

are

Cas

e - A

cute

Kid

ney

Inju

ry A

ssoc

iate

d w

ith S

ynth

etic

C

anna

bino

id U

se

PO 4

27Ad

am Is

kand

arIn

done

sia

Nep

hrol

ogy

Asso

ciat

ion

of L

ow B

irth

Wei

ght w

ith M

icro

albu

min

uria

and

H

yper

tens

ion

in A

dults

PO 4

28M

eivi

na R

amad

hani

Pan

eIn

done

sia

Nep

hrol

ogy

The

Use

of N

icot

inam

ide

in T

he M

anag

emen

t of

Hyp

erph

osph

atem

ia in

Pat

ient

s on

Hem

odia

lysi

s

PO 4

29H

arna

vi H

arun

Indo

nesi

aN

ephr

olog

yTh

e As

soci

atio

n be

twee

n El

evat

ed L

evel

s of

Ery

thro

poie

tin

and

Impr

ovem

ent

of C

ardi

ac F

unct

ion

on

Ren

al F

ailu

re

Who

Und

erw

ent K

idne

y Tr

ansp

lant

atio

n

411

PO 4

30Su

prap

tiIn

done

sia

Nep

hrol

ogy

Effe

ct o

f Los

arta

n in

Inte

rleuk

in-6

(IL-

6) S

erum

Lev

el in

H

yper

tens

ive

Patie

nts

with

Asy

mpt

omat

ic H

yper

uric

emia

at

Dr.

Moh

amm

ad H

oesi

n H

ospi

tal P

alem

bang

PO 4

31M

asay

uki K

itaga

wa

Japa

nN

ephr

olog

yA

Cas

e of

Spi

noce

rebe

llar D

egen

erat

ion

Com

plic

ated

with

Se

vere

Ren

al F

ailu

re

PO 4

32O

mur

Tab

akTu

rkey

Nep

hrol

ogy

Cas

e R

epor

t: R

habd

omyo

lysi

s an

d Ac

ute

rena

l fai

lure

due

to

Hyp

othy

roid

ism

PO 4

33O

mur

Tab

akTu

rkey

Nep

hrol

ogy

Cas

e R

epor

t : H

ypop

hosp

hate

mia

and

Rha

bdom

yoly

sis

afte

r Fe

rric

Car

boxy

mal

tose

Tre

atm

ent

PO 4

34Tr

ihar

noto

Indo

nesi

aN

ephr

olog

yTh

e D

iffer

ence

bet

wee

n Vi

sit t

o Vi

sit B

lood

Pre

ssur

e be

fore

H

emod

ialy

sis

and

Inte

rdia

lytri

c H

ome

Bloo

d Pr

essu

re

Mon

itorin

g

PO 4

35St

efan

y Ad

i Wah

yuni

ngru

mIn

done

sia

Nep

hrol

ogy

The

Cor

rela

tions

bet

wee

n Ad

equa

cy H

emod

ialy

sis

with

Q

ualit

y of

Life

of C

hron

ic K

idne

y D

isea

se P

atie

nts

in

Hem

odia

lysi

s U

nit o

f Pro

f. W

. Z. J

ohan

nes

Hos

pita

l Kup

ang

2016

PO 4

36H

eru

Den

toIn

done

sia

Nep

hrol

ogy

Perc

utan

eus

Tran

slum

inal

Ang

iopl

asty

for T

hrom

bosi

s at

Va

scul

ar A

cces

Hae

mod

ialy

sis

Arte

riove

nous

Fis

tula

s : A

C

ase

Rep

ort

PO 4

37Er

win

Azm

arIn

done

sia

Nep

hrol

ogy

Pres

crip

tion

Patte

rns

of A

ntih

yper

tens

ive

Dru

gs a

t Pol

yclin

ic

of In

tern

al M

edic

ine

in M

oham

mad

Hoe

sin

Gen

eral

Hos

pita

l So

uth

Sum

ater

a

PO 4

38I N

yom

an A

di S

upar

taIn

done

sia

Nep

hrol

ogy

Cal

cium

-Pho

spha

te P

rodu

ct L

evel

Doe

s N

ot A

ffect

The

N

umbe

r Of H

ospi

taliz

atio

n Am

ong

Reg

ular

Hem

odia

lysi

s Pa

tient

s In

1 Y

ear A

t Hos

pita

l San

glah

Den

pasa

r

PO 4

39Sa

yid

Rid

hoIn

done

sia

Nep

hrol

ogy

The

Ris

k As

sess

men

t of H

yper

tens

ion

in C

omm

unity

Set

ting:

Pr

elim

inar

y St

udy

412

PO 4

40Em

el G

okm

enTu

rkey

Nep

hrol

ogy

Insu

lin R

esis

tanc

e An

d In

flam

mat

ion

As C

ardi

ovas

cula

r Ris

k Fa

ctor

Am

ong

Non

diab

etic

Chr

onic

Kid

ney

Dis

ease

Pat

ient

s

PO 4

41O

mur

Tab

akTu

rkey

Nep

hrol

ogy

Rha

bdom

yoly

sis,

Acu

te R

enal

Fai

lure

and

Myo

card

itis

afte

r Bo

nzai

( sy

nthe

tic c

anna

bino

id)

PO 4

42R

udi S

upriy

adi

Indo

nesi

aN

ephr

olog

yC

ompa

rison

Bet

wee

n Se

rum

Lip

id P

rofil

e An

d Le

ptin

On

Fat M

ass

Leve

l Of M

aint

enan

ce H

emod

ialy

sis

Patie

nts

In

Indo

nesi

a

PO 4

43Yu

suf H

unin

gkor

Indo

nesi

aN

ephr

olog

yA

Wom

an w

ith D

iabe

tes

Mel

litus

and

Chr

onic

Kid

ney

Dis

ease

on

Hae

mod

ialy

sis,

and

with

A W

ire J

amm

ing

and

Left

Insi

de

The

Rig

ht C

omm

on Il

iac

Vein

PO 4

44Ju

spen

i Kar

tika

Indo

nesi

aR

heum

atol

ogy

A Te

enag

e G

irl w

ith A

rterio

veno

us M

alfo

rmat

ion

and

Antip

hosp

holip

id S

yndr

ome

PO 4

45Ib

rahi

m C

ETIN

DAG

LITu

rkey

Rhe

umat

olog

yA

Rar

e C

ause

of O

steo

poro

sis:

Lys

inur

ic P

rote

in In

tole

ranc

e

PO 4

46M

aria

Eiz

elle

M. F

erna

ndez

Philip

pine

sR

heum

atol

ogy

Idio

path

ic In

flam

mat

ory

Myo

path

y as

soci

ated

Mal

igna

ncy:

A

Cas

e Se

ries

PO 4

47Ku

rnia

ri P

KIn

done

sia

Rhe

umat

olog

yA

Cas

e of

Sev

ere

Syst

emic

Lup

us E

ryth

emat

osus

(SLE

) with

Pr

egna

ncy

in C

yclo

phos

pam

ide

Ther

apy

PO 4

48Ku

rnia

ri P

KIn

done

sia

Rhe

umat

olog

yD

yslip

idem

ia a

nd It

s As

soci

ated

with

Sub

clin

ical

At

hero

scle

rosi

s in

Sys

tem

ic L

upus

Ery

them

atos

us

PO 4

49Al

i Mud

iarn

isIn

done

sia

Rhe

umat

olog

ySy

stem

ic L

upus

Ery

them

atos

us in

The

Eld

erly

: A

Cas

e R

epor

t

PO 4

50H

eri K

urni

awan

Indo

nesi

aR

heum

atol

ogy

Cor

rela

tion

of B

ody

Fat D

istri

butio

n w

ith M

edia

l Tib

iofe

mor

al

Join

t Spa

ce W

idth

in K

nee

Ost

eoar

thrit

is w

ith O

besi

ty

PO 4

51Ar

iska

Sin

aga

Indo

nesi

aR

heum

atol

ogy

Cor

rela

tion

betw

een

Seru

m C

once

ntra

tion

of N

erve

Gro

wth

Fa

ctor

with

Dis

ease

Act

ivity

in P

atie

nt w

ith R

heum

atoi

d Ar

thrit

is

413

PO 4

52D

iyah

Sar

asw

ati

Indo

nesi

aR

heum

atol

ogy

The

Prev

alen

ce a

nd R

isk

Fact

ors

of G

outy

Arth

ritis

in M

alan

g,

Indo

nesi

a

PO 4

53St

efan

y Ad

i Wah

yuni

ngru

mIn

done

sia

Rhe

umat

olog

y

The

Cor

rela

tion

betw

een

Body

Mas

s In

dex,

His

tory

of

Phys

ical

Act

ivity

, Sm

okin

g H

abits

with

Sev

erity

Deg

ree

of

Knee

Ost

eoar

thrit

is P

atie

nts

at P

rof.

Dr.

W. Z

. Joh

anne

s G

ener

al H

ospi

tal i

n 20

16

PO 4

54M

uham

mad

Ans

hory

Indo

nesi

aR

heum

atol

ogy

Valid

ity o

f Mod

ified

CO

PCO

RD

Que

stio

nnai

re T

rans

late

d to

Bah

asa

Indo

nesi

a as

a S

cree

ning

Too

l for

Rhe

umat

ic

Dis

ease

PO 4

55Al

ima

Susi

law

ati S

adrin

aIn

done

sia

Rhe

umat

olog

yTh

e co

rrela

tion

betw

een

the

join

t spa

ce w

idth

(JSW

) with

th

e le

vels

of s

ynov

ial fl

uid

carti

lage

olig

omer

ic m

atrix

pro

tein

(C

OM

P) in

the

knee

ost

eoar

thrti

s su

bjec

tsPO

457

Joan

a U

rzal

Portu

gal

Rhe

umat

olog

yAt

ypic

al p

rese

ntat

ion

Hen

och

Scho

nlei

n in

adu

ltPO

458

Mig

uel C

outin

ho A

cheg

aPo

rtuga

lR

heum

atol

ogy

Adul

t-Ons

et S

till’s

Dis

ease

PO 4

59M

uham

mad

Ikhs

an

Mok

oago

wIn

done

sia

Rhe

umat

olog

yA

Cas

e of

Mul

tiple

Aut

oim

mun

e Sy

ndro

me

of S

yste

mic

Lup

us

Eryt

hem

atou

s, G

rave

s D

isea

se a

nd A

utoi

mm

une

Panc

reat

itis

PO 4

60Ig

natiu

s Ira

wan

Hid

ayat

Indo

nesi

aR

heum

atol

ogy

Asso

ciat

ion

Lym

phop

enia

with

Dis

ease

Act

ivity

, Dam

age

Inde

x, a

nd Q

ualit

y of

Life

in S

LE

PO 4

61Li

sa K

urni

a Sa

riIn

done

sia

Rhe

umat

olog

yAm

ong

Elde

rly W

ith K

nee

Ost

eoar

thrit

is, P

ain

And

Seve

rity

Wer

e O

nly

Cor

rela

ted

With

Qua

lity

Of L

ife In

Phy

sica

l Hea

lth

Dom

ain

PO 4

62Eu

gene

J. K

UC

HAR

ZPo

land

Rhe

umat

olog

ySa

tisfa

ctio

n an

d D

issa

tisfa

ctio

n of

Pat

ient

s w

ith R

heum

atic

D

isea

ses

Rec

eivi

ng B

iolo

gics

PO 4

63C

ok Is

tri Y

ulia

ndar

i Kr

snaw

arda

ni K

Indo

nesi

aH

epat

olog

yC

ritic

al F

licke

r Fre

quen

cy fo

r Dia

gnos

is o

f Min

imal

Hep

atic

En

ceph

alop

athy

in C

irrho

sis

Patie

nt a

t San

glah

Hos

pita

l D

enpa

sar B

ali

414

PO 4

64Ba

har O

zdem

irTu

rkey

Hep

atol

ogy

Rha

bdom

yoly

sis

Dur

ing

Telb

ivud

ine

Trea

tmen

t in

A C

hron

ic

Hep

atiti

s B

Patie

ntPO

465

Om

ur T

abak

Turk

eyH

epat

olog

yAu

toim

mun

Hep

atiti

s D

ue to

Par

acet

amol

: Cas

e R

epor

t

PO 4

66Fa

hmi I

ndra

rtiIn

done

sia

Hep

atol

ogy

Ther

apeu

tic e

ffect

of T

elm

isar

tan

com

pare

d w

ith V

alsa

rtan

on S

erum

Adi

pone

ctin

Lev

els

in N

on-a

lcoh

olic

Fat

ty L

iver

D

isea

se (N

AFLD

) pat

ient

s w

ith D

iabe

tes

Mel

itus

and

Hyp

erte

nsio

n

PO 4

67Pl

iego

-Rey

es C

arlo

s Le

nin

Mex

ico

Hep

atol

ogy

Prim

ary

Scle

rosi

ng C

hola

ngiti

s In

The

Eld

erly,

A D

iagn

ostic

C

halle

nge,

Pre

sent

atio

n C

ase

PO 4

68M

icha

el J

onat

anIn

done

sia

Hep

atol

ogy

Hep

atop

rote

ctiv

e Ef

fect

of E

clip

ta P

rost

ata,

an

Indo

nesi

an

Her

b Pl

ant,

on Is

onia

zid-

And

Rifa

mpi

cin-

Indu

ced

Hep

atot

oxic

ity

PO 4

69Ju

wita

Sem

birin

gIn

done

sia

Hep

atol

ogy

Leuk

ocyt

e Es

tera

se T

est f

or E

arly

Det

ectio

n of

Spo

ntan

eous

Ba

cter

ial P

erito

nitis

in P

atie

nts

with

Liv

er C

irrho

sis

PO 4

70M

yung

Jin

Oh

Sout

h Ko

rea

Hep

atol

ogy

Diff

eren

tiatio

n in

Pat

ient

s w

ith A

cute

Hep

atiti

s B

and

Chr

onic

H

epat

itis

B w

ith A

cute

Exa

cerb

atio

n

PO 4

71D

anny

Pra

tam

a Ku

swad

iIn

done

sia

Hep

atol

ogy

Trea

tmen

t of H

epat

oren

al S

yndr

ome

with

Alb

umin

for

Cirr

hotic

Pat

ient

s : A

Cas

e Se

ries

PO 4

72Yu

suf H

ANC

ERLI

Turk

eyH

epat

olog

yC

hron

ic Q

Fev

er H

epat

itis

PO 4

73O

mur

Tab

akTu

rkey

Hep

atol

ogy

Hep

atot

oxic

ity d

ue to

ana

bolic

ste

roid

use

:cas

e re

port

PO 4

74Az

zaki

Abu

baka

rin

done

sia

Hep

atol

ogy

The

Effe

ctiv

enes

s Be

twee

n La

ctul

ose,

Pro

biot

ics

And

Com

bina

tion

As T

he T

reat

men

t Of V

ario

us D

egre

es H

epat

ic

Ence

phal

opat

hy D

ue T

o C

irrho

sis

PO 4

75O

ska

Mes

anti

Indo

nesi

aH

epat

olog

yTh

e D

iffer

ence

in L

evel

s of

Pro

calc

itoni

n be

twee

n D

ecom

pens

ated

Liv

er C

irrho

tic P

atie

nts

With

and

With

out

Bact

eria

l Inf

ectio

n

415

PO 4

76Pe

dro

Mig

uel D

ias

Lope

sPo

rtuga

lPu

lmon

olog

yIt

Will

be B

enefi

cial

Per

form

Che

st C

T An

giog

raph

y in

All

Susp

ecte

d Pu

lmon

ary

Embo

lism

?

PO 4

77Ik

a Tr

isna

wat

iIn

done

sia

Pulm

onol

ogy

Fact

ors

Affe

ctin

g Th

e M

orta

lity

of P

atie

nts

with

Acu

te

Res

pira

tory

Dis

tress

Syn

drom

e in

Inte

nsiv

e C

are

Uni

t, D

r Sa

rdjit

o H

ospi

tal Y

ogya

karta

PO 4

78H

adia

nti

Indo

nesi

aPu

lmon

olog

yC

utan

eous

and

Pul

mon

ary

Aspe

rgillo

sis

in E

lder

ly

Imm

unoc

ompr

omis

ed P

atie

nt: A

Cas

e R

epor

tPO

479

Mas

ayuk

i Kita

gaw

aJa

pan

Pulm

onol

ogy

A C

ase

of P

neum

onia

Acc

ompa

nied

by

Hig

h N

T-Pr

o BN

P

PO 4

80Fa

rhan

a Af

roz

Bang

lade

shPu

lmon

olog

yR

ifam

pici

n In

duce

d Ac

ute

Inte

rstit

ial N

ephr

itis

and

Exfo

liativ

e D

erm

atiti

s C

ompl

icat

ing

Pulm

onar

y Tu

berc

ulos

is -

A C

ase

Rep

ort

PO 4

81M

anik

Ret

no W

ahyu

nitis

ari

Indo

nesi

aPu

lmon

olog

yC

ompl

emen

tary

Med

icin

e In

Pat

ient

With

Tub

ercu

losi

s

PO 4

82M

oham

ad G

untu

r M

erto

sono

Indo

nesi

aPu

lmon

olog

yTh

e C

ompa

rison

Of A

sthm

a C

ontro

l Lev

el U

sing

The

Crit

eria

O

f Glo

bal I

nitia

tive

For A

sthm

a 20

06 A

nd T

he A

sthm

a C

ontro

l Te

st

PO 4

83An

toni

a M

orita

Sak

tiaw

ati

Indo

nesi

aPu

lmon

olog

yFo

od Im

pact

s Th

e Ph

arm

acok

inet

ics

Of F

irst-L

ine

Anti

Tube

rcul

osis

Dru

gs In

Tre

atm

ent N

aive

Tub

ercu

losi

s Pa

tient

s

PO 4

84H

erlin

a Ya

niIn

done

sia

Pulm

onol

ogy

The

Cor

rela

tion

Betw

een

D d

imer

Lev

els

in C

omm

unity

Ac

quire

d Pn

eum

onia

Pat

ient

s on

the

degr

ee o

f CU

RB-

65

scor

e at

Ear

ly A

dmis

sion

in H

ospi

tal

PO 4

85M

uham

mad

Ikhs

an

Mok

oago

wIn

done

sia

Pulm

onol

ogy

Asym

ptom

atic

Lun

g Tu

berc

ulos

is P

rese

ntin

g w

ith P

anuv

eitis

PO 4

86Ke

ith S

iau

UK

Pulm

onol

ogy

Is th

ere

a ro

le fo

r ris

k st

ratifi

catio

n fo

r am

bula

tory

m

anag

emen

t of P

ulm

onar

y Em

bolis

m?

PO 4

87Si

na K

haje

h Ja

hrom

iIra

nPu

lmon

olog

yEp

idem

iolo

gic

stud

y of

lung

can

cer i

n no

rth o

f Ira

n

416

PO 4

88Ic

eu D

imas

Kul

sum

Indo

nesi

aPu

lmon

olog

y

Fact

ors

that

affe

ct s

putu

m s

mea

r con

vers

ion

at th

e en

d of

th

e se

cond

mon

th o

f tub

ercu

losi

s tre

atm

ent i

n ne

w c

ases

tu

berc

ulos

is w

ith d

iabe

tes

mel

litus

pat

ient

s in

Per

saha

bata

n H

ospi

tal

PO 4

89Ka

ka R

enal

diIn

done

sia

Gas

troen

ter-

olog

yC

ase

repo

rt: J

ejun

al A

rterio

veno

us M

alfo

rmat

ion

(AVM

) Fo

und

by E

nter

osco

py

PO 4

90O

K. Y

uliz

alIn

done

sia

Gas

troen

ter-

olog

y

Upp

er G

astro

inte

stin

al E

ndos

copi

c Fi

ndin

gs a

nd H

elic

obac

ter

Pylo

ri In

fect

ion

in P

atie

nts

with

Dys

peps

ia in

Nia

s Is

land

and

H

umba

ng H

asun

duta

n D

istri

ct, S

umat

era

Uta

ra P

rovi

nce

Indo

nesi

a

PO 4

91Ib

rahi

m C

ETIN

DAG

LITu

rkey

Gas

troen

ter-

olog

yD

eep

Iron-

Defi

cien

cy A

nem

ia C

ause

d by

Chr

onic

Gas

tritis

, an

d Bo

ugie

Dila

tatio

n of

Gas

tric

Inco

mpl

ete

Apic

al S

teno

sis

PO 4

92O

mur

Tab

akTu

rkey

Gas

troen

ter-

olog

yEv

alua

tion

of C

olon

osco

pic

Poly

pect

omie

s

PO 4

93Za

nuru

l Rifh

anIn

done

sia

Gas

troen

ter-

olog

yA

Cas

e R

epor

t of A

chal

asia

PO 4

94Am

elia

Rifa

iIn

done

sia

Gas

troen

ter-

olog

yC

ompl

ete

Hea

ling

of E

soph

agob

ronc

hial

Fis

tula

Due

to

Cor

rosi

ve S

ubst

ance

s by

Con

serv

ativ

e Tr

eatm

ent

PO 4

95Si

na K

haje

h Ja

hrom

iIra

nG

astro

ente

r-ol

ogy

Roc

kall

Scor

e in

Non

varic

eal U

pper

Gas

troin

test

inal

Bl

eedi

ng: A

Pre

dict

or o

f In-

Hos

pita

l Reb

leed

ing

PO 4

96G

i Jun

Kim

Sout

h Ko

rea

Gas

troen

ter-

olog

y

Fact

ors

Asso

ciat

ed w

ith R

e-bl

eedi

ng in

904

Pat

ient

s w

ith

Pept

ic U

lcer

Ble

edin

g: A

naly

sis

of K

orea

n Pe

ptic

Ulc

er

Blee

ding

(K-P

UB)

Stu

dy

PO 4

97Eu

n Yo

ung

JiSo

uth

Kore

aG

astro

ente

r-ol

ogy

Rec

ent E

pide

mio

logy

of P

eptic

Ulc

er D

isea

se a

nd It

s C

ompl

icat

ions

in K

orea

: Res

ults

from

The

Nat

ionw

ide

Popu

latio

n-Ba

sed

Stud

y

417

PO 4

98I K

etut

Mar

iadi

Indo

nesi

aG

astro

ente

r-ol

ogy

Prev

alen

ce o

f Hel

icob

acte

r Pyl

ori I

nfec

tion

In K

inta

man

i Bal

i an

d Th

e As

soci

atio

n w

ith S

ever

ity E

ndos

copi

c Fe

atur

es

PO 4

99Az

zaki

Abu

baka

rin

done

sia

Gas

troen

ter-

olog

y

Accu

racy

Of D

iagn

osin

g G

erd

By G

astro

esop

hage

al R

eflux

D

isea

se Q

uest

ionn

aire

And

Fre

quen

cy S

cale

For

The

Sy

mpt

oms

Of G

astro

esop

hage

al R

eflux

Dis

ease

PO 5

01M

edia

rtyIn

done

sia

Psyc

hoso

-m

atic

Cor

rela

tion

betw

een

Seru

m 2

5(O

H) V

itam

in D

Lev

el a

nd

Dep

ress

ive

Sym

ptom

s in

Acq

uire

d Im

mun

odefi

cien

cy

Synd

rom

e Pa

tient

s in

Am

bula

tory

Clin

ic o

f Dr.

Moh

amm

ad

Hoe

sin

Hos

pita

l Pal

emba

ng

PO 5

02H

alin

a Ku

szU

SAPs

ycho

so-

mat

icAn

Ass

essm

ent o

f Em

path

y in

Inte

rnal

Med

icin

e R

esid

ents

Tr

aini

ng in

Com

mun

ity-B

ased

Hos

pita

ls

PO 5

03An

di K

hom

eini

Tak

dir

Indo

nesi

aPs

ycho

so-

mat

icSc

reen

ing

of D

epre

ssio

n an

d An

xiet

y in

Hep

atiti

s C

Pat

ient

s in

Cip

to M

angu

nkus

umo

Hos

pita

l Yea

r 201

3-20

15

PO 5

04ID

G T

eguh

Kris

na M

urti

Indo

nesi

aPs

ycho

so-

mat

ic

Dep

ress

ion

Stat

e R

elat

ed w

ith U

rinar

y In

cont

inen

ce A

mon

g El

derly

Pat

ient

Hos

pita

lized

at G

eria

tric

War

d in

San

glah

H

ospi

tal

PO 5

05Ka

dek

Dw

i Wul

anda

riIn

done

sia

Psyc

hoso

-m

atic

Cor

rela

tion

Nut

ritio

nal w

ith M

ini N

utrit

iona

l Ass

esm

ent (

MN

A)

and

Dep

ress

ion

at E

lder

ly P

eopl

e in

San

glah

Hos

pita

l

PO 5

06Er

ick

Lios

Indo

nesi

aPs

ycho

so-

mat

ic

Cor

rela

tion

betw

een

Inso

mni

a an

d D

epre

ssio

n in

Eld

erly

Pa

tient

s H

ospi

taliz

ed A

t Ger

iatri

c W

ard

Sang

lah

Gen

eral

H

ospi

tal

PO 5

07S

Arya

naIn

done

sia

Psyc

hoso

-m

atic

Cor

rela

tion

betw

een

Dep

ress

ion

And

Func

tiona

l Dec

line

in

Elde

rly P

atie

nts

in S

angl

ah H

ospi

tal,

Bali:

A C

ross

-Sec

tiona

l St

udy

PO 5

08D

easy

Fet

aray

ani

Indo

nesi

aIm

mun

olog

ySi

x-Ye

ar R

evie

w o

f Dru

g R

eact

ion

with

Eos

inop

hilia

and

Sy

stem

ic S

ympt

oms

Synd

rom

e Pa

tient

s in

Dr S

oeto

mo

Gen

eral

Hos

pita

l Sur

abay

a In

done

sia

418

PO 5

09An

gelik

i Tsi

fiG

reec

eIm

mun

olog

yAt

titud

es a

nd O

pini

ons

of H

ealth

Car

e W

orke

rs T

owar

ds

Influ

enza

Vac

cina

tion

in A

Ter

tiary

Hos

pita

l in

Attic

a, G

reec

ePO

510

AP P

utra

Indo

nesi

aIm

mun

olog

ySa

rcoi

dosi

s: A

Cas

e R

epor

t

PO 5

11Ay

se C

anTu

rkey

Oth

ers

Prot

ectiv

e Ef

fect

s of

Mel

aton

in o

n M

uscl

e Ti

ssue

in

Stre

ptoz

otoc

in (S

TZ)-I

nduc

ed D

iabe

tic R

ats

PO 5

12W

infre

y Pa

nges

tuIn

done

sia

Oth

ers

Gia

nt S

crot

al H

ydro

cele

and

Bila

tera

l Leg

Lym

phoe

dem

a as

a

Man

ifest

atio

n of

Chr

onic

Lym

phat

ic fi

laria

sis

PO 5

13H

ajim

e M

aruy

ama

Japa

nO

ther

sC

YP2C

19 G

ene

Poly

mor

phis

ms

and

The

Effe

ct o

f Adj

unct

ive

Cilo

staz

ol in

Jap

anes

e Is

chem

ic S

troke

Pat

ient

s H

avin

g C

lopi

dogr

el

PO 5

14Al

va P

into

Jua

n C

arlo

sPe

ruO

ther

sC

ost C

ompa

rison

Stu

dy in

Inte

nsiv

e C

are

Uni

ts o

f Low

C

ompl

exity

Hos

pita

l VS.

Hig

h C

ompl

exity

Hos

pita

l in

Lim

a,

Perú

PO 5

15R

usta

maj

iIn

done

sia

Oth

ers

The

S-D

DD

Map

ping

of O

pioi

d An

alge

sic

in J

ava,

Bal

i, So

uth

Sula

wes

i And

Nor

th S

umat

era

PO 5

16Lo

w J

ia W

en G

lenn

Sing

apor

eO

ther

sC

omor

bidi

ty a

nd D

isab

ility

in In

tern

al M

edic

ine

Patie

nts

- A

Cor

rela

tiona

l Stu

dy

PO 5

17D

iego

God

oySp

ain

Oth

ers

Cha

nges

in G

ene

Expr

essi

on a

fter D

ieta

ry In

terv

entio

n ba

sed

on M

edite

rrane

an D

iet a

nd P

hysi

cal A

ctiv

ity in

Com

paris

on

with

A C

ontro

l Gro

up

PO 5

18Ja

e-H

oon

Lee

Sout

h Ko

rea

Oth

ers

Rel

atio

nshi

p Be

twee

n U

ric A

cid

and

Lipi

d Pr

ofile

s in

Pat

ient

s w

ith T

ype

2 D

iabe

tes

PO 5

19D

iego

Her

nan

Giu

nta

Arge

ntin

aO

ther

sPa

tient

s R

ecei

ving

Und

ertri

age

In T

he E

mer

genc

y D

epar

tmen

t: C

hara

cter

istic

s An

d M

orta

lity

PO 5

20D

iego

Her

nan

Giu

nta

Arge

ntin

aO

ther

sD

escr

iptio

n of

The

Cha

ract

eris

tics

of C

row

ding

In T

he

Emer

genc

y D

epar

tmen

t: R

etro

spec

tive

Coh

ort S

tudy

419

PO 5

21Em

my

Her

miy

anti

Pran

ggon

oIn

done

sia

Oth

ers

An E

duca

tiona

l of C

ritic

al C

are

in In

tern

al M

edic

ine;

It Is

Not

O

nly

Nee

ded,

But

It Is

A M

ust

PO 5

22R

efiye

Yan

arda

gTu

rkey

Oth

ers

In v

itro

Scre

enin

g of

Hya

luro

nida

se A

ctiv

ities

of S

ome

Med

icin

al P

lant

s

PO 5

23Ab

u Sh

ahin

Moh

amm

ed

Mah

bubu

r Rah

man

Bang

lade

shO

ther

sPa

raqu

at P

oiso

ning

- Cha

lleng

e To

The

Dev

elop

ing

Cou

ntry

PO 5

24D

wi A

stut

i Han

daya

niIn

done

sia

Oth

ers

Gen

etic

Var

iant

GC

Gen

e an

d Vi

tam

in D

Sta

tus

Amon

g Ja

vane

se E

thni

city

In In

done

sia

PO 5

25Fi

lem

on M

anas

ye W

iliam

So

ndak

hIn

done

sia

Oth

ers

Dia

bete

s Kn

owle

dge

and

Qua

lity

of L

ife in

Typ

e 2

Dia

bete

s M

ellit

us

PO 5

26En

dro

Tano

yo

Indo

nesi

aO

ther

sIn

tern

al M

edic

ine

Cas

eses

Pro

file

Visi

t In

Emer

genc

y U

nit

Dr.

Sard

jito

Gen

eral

Hos

pita

l Yog

yaka

rta, W

ithin

Sev

en D

ays

Afte

r Firs

t Day

Eid

Mub

arak

PO 5

27D

eske

Muh

adi

Indo

nesi

aO

ther

sD

ehyd

ratio

n am

ong

Haj

j Ind

ones

ia A

t Mec

ca in

201

5PO

528

Yusu

f HAN

CER

LITu

rkey

Oth

ers

Fahr

Dis

ease

Pre

sent

ed W

ith S

ynco

pe

PO 5

29Lu

cía

Cris

tina

Car

rera

Bo

laño

sPo

rtuga

lO

ther

sFr

om L

ess

Com

mon

To

Very

Lik

ely,

A C

ase

Of C

ereb

ellu

m

Stro

ke

PO 5

31Fe

mm

y N

urul

Akb

ar

Indo

nesi

aO

ther

sC

orre

latio

n Be

twee

n Li

pid

Plas

ma,

Tran

sam

inas

e Le

vel A

nd

Body

Mas

s In

dex

With

Liv

er F

ibro

sis

In N

onal

coho

lic F

atty

Li

ver D

isea

se P

atie

nts

PO 5

32Yu

di A

ndre

Mar

paun

gIn

done

sia

Oth

ers

Accu

racy

of K

ing’

s Sc

ore

Pred

icts

Liv

er F

ibro

sis

Base

d O

n Fi

bros

cani

n Pa

tient

s w

ith C

hron

ic H

epat

itis

B

420

PO 001Clinical and biochemical characteristics of type 2 diabetic elderly patients with neuropathy

Fulden Sarac1, Pelin Tutuncuoğlu2, Sefa Sarac3, Sumru Savas1, Fehmi Akcicek1

1. Department of Internal Medicine, Section of Geriatrics, Ege University Medical Faculty / Izmir / TURKEY

2. Department of Endocrinology and Metabolism, Katip Celebi University, Ataturk Training and Research Hospital / Izmir / TURKEY

3. Department of Cardiology, Katip Celebi University, Ataturk Training and Research Hospital / Izmir / TURKEY

Background: The population of elderly with diabetes mellitus is increasing worldwide. The aim of the study were to compare the clinical and biochemical characteristics of type 2 diabetic elderly with or without neuropathy. Subjects and Methods: 100 diabetic patients with diabetic neuropathy and with age≥65 years (mean age; 66.1±7.1 years) and 30 were enrolled in this study. Demographic and biochemical parameters were collected in all patients, retrospectively.

Results: Mean levels of diabetes duration were 15.1±4.7 years in patients with neuropathy and 7.9±2.1 years. Fifty-eight (58.0%) of patients with neuropathy had concurrent dyslipidemia and hypertension. However, 25 (25.0%) of patients without neuropathy had concurrent dyslipidemia and hypertension. The mean levels of systolic and diastolic blood pressures were found to be 138.7 ± 11.7 mmHg and 79.8 mmHg in patients with neuropathy. Mean levels of HbA1c, fasting glucose, postprandial glucose, B12 and 25(OH)-vitamin D were found to be 8.1±1.5, 158.8±34.5 mg/dl, 179.5±42.1 mg/dl, 259.6±32.3 mg/dl and 29.6±10.6 ng/dl, respectively, in patients with neuropathy. However, in diabetic patients without neuropathy, mean levels of HbA1c, fasting glucose, postprandial glucose, B12 and 25(OH)-vitamin D were found to be 7.5±2.4, 145.1±55.5 mg/dl, 160.0±31.1 mg/dl, 395.7±41.0 mg/dl and 43.5±12.9 ng/dl, respectively.

Conclusion: Hypertension, dyslipidemia, low B12 and 25(OH)-vitamin D levels were more common in diabetic elderly with neuropathy than diabetic elderly without neuropathy.

421

PO 002Final Results of Multi-Center, Prospective, Controlled Trial of the Duodeno-Jejunal Bypass Liner for the Treatment of Type 2 Diabetes Mellitus in Obese Patients: Efficacy and Factors Predicting a Suboptimal Effect

Spicak, Julius1; Drastich, Pavel1; Hucl, Tomas1

1. Gastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic.

Introduction: The global increase in obesity incidence results in an increase of type 2 diabetes mellitus (T2DM). Surgical treatment has proven to be effective, however it carries a high risk of complications. The duodenal-jejunal bypass liner (EndoBarrier®, GI Dynamics, EB) is an endoscopic implant that mimics the intestinal bypass portion of the Roux-en-Y Gastric Bypass. It results in weight loss and improvements in glucose control in obese patients with T2 diabetes mellitus (T2DM).

Aims & Methods: This is a final report of a prospective, controlled, multicentre study aimed to determine the effectiveness of EB and to identify factors associated with a sub-optimal outcome of EB.

Results: Seventy subjects (45 with an implant, 25 controls) were included in the study. The groups were comparable with respect to age, gender, BMI (mean 41.7 vs. 39.5 kg/m2), T2DM duration (7.8 vs. 8.3 years), HbA1c level (88 vs 86 mmol/mol) and T2DM treatment. In the EB group, all devices were successfully implanted. Only 6 devices had to be explanted prior to the end of the 10 months study period (bleeding, dislocation and need for ERCP because of choledocholithiasis). The mean procedure time was 17 minutes for an implantation and 16 minutes for an explantation. At 10 months there was significantly greater weight loss and %EWL (19% vs. 7% and 43 vs. 12) and significantly improved long term compensation of T2DM marker HbA1c (decreased by 25 vs. 10 mmol/mol) in the EB group. T2DM medicinal treatment could be reduced in more device subjects than controls. There was no serious adverse event. Mild abdominal pain and nausea after implantation were experienced by 60% of patients during first 14 days after implantation, 30% of patients during the first month and 10% of patiens after one month. Lower initial BMI and lower body height were identified as negative prognostic factors for pain, but positive for efficacy of EB.

Conclusion: The EB is safe when implanted for 10 months, and results in significant weight loss and HbA1c reduction. This suggests that this novel device is a candidate for the primary therapy of morbid obesity and T2DM. Lower initial BMI and lower body height could be negative prognostic factor for pain, but positive for efficacy.

422

PO 003PROGRAM PENDIDIKAN DOKTER SPESIALIS IIILMU PENYAKIT DALAM FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA PALEMBANGMuhammad Faisal Soleh., Sukandi, E., Indrajaya, T., Ghanie, A.

Perbandingan Efek Terapi Beraprost Sodium dan Cilostazol Untuk Mengurangi Nyeri Penyakit Arteri Perifer Pada Pasien Diabetes Mellitus dengan Claudicatio IntermittenDi RSMH Palembang

Latar belakang : Insiden penyakit arteri perifer pada pasien diabetes mellitus tertinggi timbul pada dekade ke enam dan ke tujuh, merupakan penyakit vaskuler ke tiga terbanyak setelah kardiovaskuler dan cerebrovaskuler. Penyebab terbanyak penyakit oklusi arteri perifer pada usia diatas 40 tahun adalah aterosklerosis. Beraprost sodium sebagai antiprostacycline, yang lazim dipakai pada pasien hipertensi pulmonal, dapat juga digunakan untuk mengurangi nyeri pada pasien diabetes mellitus juga menderita peripheral artery disease, yang bekerja sebagai anti trombolitik dan vasodilator. Cilostazol sebagai analog prostagladin, bekerja sebagai anti trombolitik dan vasodilator dapat mengurangi nyeri pada pasien diabetes mellitus yang menderita penyakit arteri perifer.

Tujuan : Mengetahui efektifitas beraprost sodium dan cilostazol dalam mengurangi rasa nyeri pada pasien penyakit arteri perifer.

Metode : Penelitian ini merupakan uji klinis pembanding buta ganda, dilakukan di poliklinik umum dan poliklinik penyakit dalam Rumah Sakit Mohammad Hoesin palembang, bulan mei sampai desember 2014 sebanyak 40 pasien penyakit arteri perifer stadium II, dibagi dalam 2 kelompok beraprost sodium dan cilostazol. Dilakukan perbandingan rasa nyeri dengan treadmill untuk kedua kelompok sebelum diberikan obat. Kelompok beraprost sodium diberikan 2x60 mg selama 2 bulan. Kelompok cilostazol diberikan 2x100 mg selama 2 bulan. Setelah 2 bulan dilakukan perbandingan ulang.

Hasil : Rerata nilai ankle brachial index untuk kelompok beraprost sodium sebelum dan setelah diberikan obat adalah 0,81 ± 0,089 dan 0,84 ± 0,249 (p: 0,0005) Rerata jarak tempuh untuk kelompok beraprost sodium sebelum dan setelah diberikan obat adalah 5,07 ± 0,654 dan 6,45 ± 0,666 (p: 0,0005). Rerata hasil ankle brachial index untuk kelompok cilostazol sebelum dan setelah analisa data diberikan obat adalah 0,80 ± 0,068 dan 0,94 ± 0,44 (p: 0,0005). Rerata jarak tempuh kelompok cilostazol sebelum dan setelah diberikan obat adalah 5,05 ± 0,559 dan 6,47 ± 0,697 (p: 0,0005). Terdapat perbaikan nilai ankle brachial index dan jarak tempuh untuk kelompok cilostazol.

Simpulan : Ada perbaikan nilai ankle brachial index untuk obat beraprost sodium dan cilostazol. Ada perbaikan jarak tempuh ( mengurangi rasa nyeri ) untuk obat beraprost sodium dan cilostazol. Beraprost sodium dan cilostazol sama efektif mengurangi

423

rasa nyeri penyakit arteri perifer pada pasien diabetes mellitus di RSMH Palembang. Beraprost sodium lebih efektif dibandingkan Cilostazol dalam mengurangi rasa nyeri penyakit arteri perifer pada pasien diabetes mellitus dengan Claudicatio Intermitten di RSMH Palembang.

Kata Kunci : ABI, BERAPROST SODIUM, CILOSTOL

MEDICAL EDUCATION PROGRAM SPECIALIST IIINTERNAL MEDICINE OF MEDICAL FACULTYSRIWIJAYA UNIVERSITY OF PALEMBANGMuhammad Faisal Soleh., Sukandi, E., Indrajaya, T., Ghanie, A.

The Comparison of efficacy between Beraprost Sodium and Cilostazol For reducing pain in Peripheral Artery Disease to Diabetes Mellitus Patient With Intermitten Claudicatio In Mohammadd Hoesin Hospital Palembang

Background: Incidence of peripheral artery disease in patients with the highest arise diabetes mellitus in the sixth and seventh decade, the vascular disease is the third largest after cardiovascular and cerebrovascular. Most causes arterial occlusive disease above 40 years is atherosclerosis. Beraprost sodium as anti prostacycline, which is commonly used in patients with pulmonary hypertension, can also be used to reduce pain in patients with diabetic and also peripheral artery disease, which works as an anti-thrombolytic and vasodilator. Cilostazol as prostagladin analog, works as an anti-thrombolytic and vasodilators may reduce pain in diabetic patients with peripheral artery disease.

Purpose : To know the efficacy of beraprost sodium and cilostazol reducing pain in peripheral artery disease patients.

Methods: Randomized controlled trial double blind, between performed in general polyclinic and internal medicine clinic in the Mohammad Hoesin Hospital in Palembang, on the May to December 2014 as many as 40 patients with the second stage II of peripheral artery disease, divided into two groups of beraprost sodium and cilostazol. Do comparisons between pain and treadmill for both groups before being given the drug. Beraprost sodium group was given 2x60 mg for 2 months. Cilostazol group was given 2x100 mg for 2 months. After 2 months of repeated comparisons.

Results: The mean value of Anckle Brachial Index for the group given the drug before beraprost sodium was 0.81 ± 0.089. after the drug was given was 0.84 ± 0.249 (p: 0.0005). The average distance for beraprost sodium drug group before giving the drug was 5.07 ± 0.654 and after given the drug is 6.45 ± 0.666 (p: 0.0005). The mean of Anckle Brachial Index results for cilostazol group before being given the drug is 0.80 ± 0.068. The mean results for Anckle Brachial Index after given cilostazol drug group is 0.94 ± 0.44 (p: 0.0005). The mean distance before being given cilostazol drug group was 5.05 ± 0.559.

424

After giving the drug is 6.47 ± 0.697 (p: 0.0005). There were improvements in the value of Anckle Brachial Index and mileage for cilostazol group.

Conclusion: There was improvement Anckle Brachial Index values of for beraprost sodium and cilostazol drug. There is a distance improvement (in reducing pain) for beraprost sodium and cilostazol drug. Beraprost sodium and cilostazol was the same to declined pain peripheral artery disease in diabetes mellitus patient at RSMH palembang. Beraprost sodium more effective than cilostazol to reduce pain peripheral artery desease in diabetes mellitus patients with Claudicatio Intermitten at RSMH Palembang.

Keywords : ABI, Beraprost Sodium, Cilostazol

425

PO 004Author : Haoues Rania

Grade : Resident

Specialty : Internal Medicine

Associate authors : BellaouiIbtissem, BenlahcenBoutahina, Rouabhia Samir

Author’s contact:

Adress : Service de médecine interne.CHU Batna-Algeria

Phone number: 00213 557199206

Fax:

E-mail : [email protected]

Title: Amnesia and diabetes in a pregnant woman,what diagnosis??

Introduction: Gayet Wernicke metabolic encephalopathy is an extreme manifestation of severe vitamin B1 deficiency. GWE must be viewed as a medical emergency because, indeed, late diagnosis is a threatening to irreversible neurological dysfunction.

Observation: A 32-year old woman who is 18-weeks pregnant is hospitalized for malnutrition and severe dehydration on sympathetic exaggeration signs of herpregnancy. Her medical history is otherwise unremarkable. Hyperemesis gravidarum diagnosis was retained after noticing association of vomiting, moderate increase in liver transaminases and low serum TSH level.Hyperglycemia was noticed and on the consideration of the possibility of gestational diabetes, insulin therapy was justified but despite treating the symptoms, her condition worsen with onset of neurological dysfunction (memory disturbance, multidirectional nystagmus and ataxia) Gayet Wernicke encephalopathy was suspected in front of deficiency context and particularly in front of cerebral MRI showing paramedial and periaqueductal infiltration of the thalamic.A rapid spectacular and rapid regression of all the signs after supplementation with thiamine 1g/j affirm our diagnostic hypotheses. To our surprise, though the patient started feeding naturally was hypoglycemia at a minimum dose of insulin therapy, making us declare an authentic regression of her diabetes

Discussion : EGW during hyperemesis gravidarum –though rare- was described in some

426

observation often precipitated by glucose perfusion administered classically. In our case the diabetes is due to thiamine deficiency which inturn is responsible for hyperglycemia by decrease in the production and the liberation of the insulin itself is responsible for the decrease in the intestinal absorption of vitamin B1 and therefore causing a loop of deficiency auto-aggravation.

Conclusion : The etiology spectrum of GWE should exceed alcoholism to include a state of severe deficiency; Gestational diabetes can be an exceptional situation of a vitamine deficiency in this same context.

Type de communication : Poster

427

PO 005ASSOCIATION BETWEEN AGE-RELATED DEVELOPMENT WITH T-REGULATORY FOXP3 IN GRAVES’ DISEASE PATIENTS.Dwitya Elvira

Department of Internal Medicine, Medical Faculty of Andalas University, Padang-West Sumatra, Indonesia.

BACKGROUND: Graves’ disease (GD) is an autoimmune thyroid disease with symptoms of hyperthyroidism, diffuse goiter, exophthalmos and dermopathy. Incident of GD were estimated about 0.4% of the population at age > 15 years in Indonesia based on RISKESDAS 2013. GD is caused by genetic and environmental factors; which genetic factors were predicted to play a role at a young age. Excessive thyroid autoantibodies thought to be caused by impaired of T-regulatory cells (Tregs). Age-onset of autoimmune disease were thought to be related to the quantity of Tregs or defect in function. On this study, we’re trying to investigate level of Tregs cell and association between Tregs levels with age-onset GD patients.

METHODS: Thirty GD patients recruited from Endocrinology Outpatient of M.Djamil Hospital in Padang, Indonesia based on clinical and laboratory diagnostic. Age, gender was noted as characteristic subject. Tregs were measured using Foxp3, a transcription factor specific for Tregs. Correlation of age-onset and Tregs cell were analyzed using Spearman test-ranking. Statistical analysis was using SPSS software program version 21 (SPSS Inc.)

RESULT: On this study, from 30 patients there were 66,7 % female and 33,3 % male. Age-onset >40 found the most, followed by <30 and 30-39 years old. We were also found increasing of Tregs cell with mean 23,51 15,7 pg/ml. There is no association between age-onset with Tregs cell in Graves’ disease patient.

CONCLUSION: There is no association between age-onset of Graves’ disease with T-regulatory cell using Foxp3 marker. Therefore, this study shown that T-regulatory level was tend to increased with age.

Keyword: Age-onset, T-regulatory, Foxp3, Graves’ disease.

428

PO 006Diabetes and thyroid cancer risk HoChun Choi, South Korea

Background/Objectives: The incidence of thyroid cancer is increasing worldwide. Hence, the Thyroid Cancer Longitudinal Study (T-CALOS) was initiated to analyze characteristics of thyroid cancer and we analyzed effects of diabetes mellitus (DM) on thyroid cancer to find out characteristics of thyroid cancer associated with chronic diseases in rapidly increasing environment.

Subjects/Methods: From among examinees who had been examined thyroid sonography and had been consulted for checkup between March 2013 and April 2015 in Seoul National University Hospital Center for Health Promotion and Optimal Aging, 308 were selected for the potential control subjects. Meanwhile, 616 potential case subjects were matched to control group by age and sex from among thyroid cancer patients who agreed to enroll in the T-CALOS between April 2010 and August 2014. Obesity was defined as a body mass index ≥25 kg/m2.

Results: The thyroid cancer risk was lower in individuals with DM than those without DM only among women, after adjusting for age, hypertension, ischemic heart disease, obesity, dyslipidemia, benign thyroid disease, and other cancers (odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.21-0.99, P = 0.048). Individuals with DM duration <5 years had a lower thyroid cancer risk, compared to those without DM (OR: 0.49, 95% CI: 0.27-0.92, P = 0.026). Negative relationships between DM duration and thyroid cancer risk are preserved from 1 year to 9 years of DM duration (P <0.1).

Conclusions: Women with DM had a decreased thyroid cancer risk, and individuals with early DM also had a decreased thyroid cancer risk and this effect preserved from 1 year to 9 years of DM duration.

429

PO 007Correlation of Glycohemogobin and the Value of Brachial Artey Flow-Mediated Dilatation (FMD) in PrediabeticFatimah Eliana*, Pradana Suwondo**, Lukman H. Makmun**

Faculty of Medicine, Yarsi UniversityFaculty of Medicine, University of Indonesia

Aim: The aim of our study was to to determine the correlation between glycohemoglobin (HbA1c) with value of brachial artey flow-mediated dilatation (FMD) by ultrasound study, in prediabetes. Data obtained from this study may be useful to explain whether there has been already an endothelial dysfunction in pre diabetic and assuming on how far the dysfunction had occurred in keeping with the increase of HbA1c level.

Methods: The case control study was carried out in 140 prediabetes and 140 control subjects aged between 30-55 years of age. To asses brachial FMD, the left brachial artery diameter was measured both at rest and during reactive hyperemia. The vessel diameter in scans after reactive hyperemia was expressed as the percentage relative to resting scan (100%). All ultrasound scans were analyzed by a single reader.

Results: The result of our study in pre-diabetic subjects suggested association and negative correlation between FMD and HbA1c level. There was a significant correlation between FMD value with 2-hours post prandial blood glucose (p 0,01 and r -0.487) and HbA1c (p <0,001 and r -0.763). The probability of pre-diabetic subjects with HbA1c > 6% to have an abnormal FMD, i.e. less than 11%, was 97.47%.

Conclusion: Based on the study results, we could conclude that there is a correlation between glycohemoglobin (HbA1c) and endothelial function in pre-diabetic as proven by a reverse significant association with strong correlation between HbA1c level with FMD level. It is expected that if intervention had been taken to decrease HbA1c level, then endothelial function would return to normal.

Key words: prediabetes, HbA1c, FMD.

430

PO 008CARDIOGENIC SHOCK AND ISCHEMIC HEPATITIS IN MALE WITH ATRIAL FIBRILLATION DUE TO GRAVES DISEASE : A CASE REPORTMarina Epriliawati, Ida Ayu Kshanti

Department of Internal Medicine, Fatmawati General Hospital, Jakarta

Graves disease is an autoimmune disease characterized by hyperthyroidism due to overproduction of thyroid hormones, which less likely to affect men. This disease should be treated properly since uncontrolled hyperthyroidism can lead to serious complications, mainly related to the heart. We report a case, 34 years-old male with Graves disease without any previous treatment who came to the hospital with unconsciousness and cardiogenic shock due to atrial fibrillation with rapid ventricular response. In the emergency unit he received 4 times electrical cardioversion up to 200 Joules and the electrocardiogram showed conversion of atrial fibrillation to sinus rhythm. This patient developed cardiogenic ischemic hepatitis within 48 hours of hospitalization, presented with jaundice following a marked and rapid increase of transaminases level. Considering the abnormal liver function test, we chose radioactive iodine (I-131) ablation for the treatment of Graves disease and he underwent RAI ablation on the 8th day hospitalization. The patient was discharged after the serum transaminases almost reached normal level in 10 days.

Keywords: Graves disease, atrial fibrillation, ischemic hepatitis, radioactive iodine ablation

431

PO 009HbA1c correlates weakly with Fructosamine in late pregnancy

Ali Abdulnabi Mohamed; Mohammad Sadiq Hurmatali; Jessica Spiteri Paris; Gerald Buhagiar; Charles Savona Ventura

Background: A good correlation has been demonstrated between glycated haemoglobin (HbA1c) and glycated protein (fructosamine) and the overall glycaemic control of diabetic patients. While HbA1c has been shown to be a useful correlate to glycaemic control in pregnant women, the role of fructosamine in managing pregnant diabetics is still not established. The influence of altered proportions of haemoglobin types as occurs in thalassaemia states on the glycaemic assessment role of HbA1c is also not established.

Aim: To investigate the correlation between fructosamine and HbA1c in diabetic and non-diabetic pregnant women in the third trimester of pregnancy thus assessing whether glycated protein assessments can be used during pregnancy to assess glycaemic status; and to investigate the influence of altered proportions of haemoglobin types on the use of HbA1c as a glycaemic index.

Methods: A prospective cohort of 71 pregnant women at 26-36 weeks’ gestation were enrolled into the study between October 2013 and June 2014. Patient age, gestational age, parity, diabetes status and type of diabetes, family history of diabetes, weight and height were documented. HbA1c, fructosamine and haemoglobin electrophoresis were measured. The majority of women had normal haemoglobin electrophoresis. Only four patients were found to have thalassemia while a further two has thalassemia trait. Correlation and multiple regression statistics were used for analysis.

Results: The 65 women with normal haemoglobin electrophoresis showed a weak but statistically significant correlation between fructosamine and HbA1c (r=0.283, P=0.014). However, no statistical correlation was demonstrable in those six women with abnormal haemoglobin electrophoresis (r=0.265, P=0.49). A multiple regression was run to predict fructosamine levels from age, BMI and HbA1c. All these variables statistically and significantly predicted fructosamine level - F(3,61)=5.256, P=0.003, R2=0.205.

Conclusion: It would appear that, in the third trimester of pregnancy, fructosamine correlates significantly with HbA1c and thus can be used judiciously to assess long-term glycaemic control. Fructosamine on the other hand correlated poorly with HbA1c in women with thalassaemia or thalassaemia trait suggesting that the altered proportions of haemoglobin types may influence the glycaemic relationship of the HbA1c assay. In these circumstances fructosamine assay may be the better alternative.

432

PO 010Association of Depression with Type 2 Diabetes Mellitus among the patients attending at the tertiary level hospital in Bangladesh- case control study

Shahabul Huda Chowdhury. Nazmul Karim. Shahjada Selim. Abul Kalam Azad.Ferdous Ur Rahman. M A Jalil Chowdhury

OBJECTIVE— The purpose of this study was to describe the association of depression among diabetic patients in tertiary care hospitals of Bangladesh compared with people without diabetes.

RESEARCH DESIGN AND METHODS— We conducted a case-control study in Bangabandhu Shiekh Mujib Medical University to assess the study objective. We identified 121 cases of type 2 diabetes based on diagnostic criteria and prescription records for individuals had the evidence of least one year treatment irrespective of their sex. For each case subject, one control subjects were randomly selected from the non diabetic population during the same index period. Since the cases and controls are at first screened and confirmed by trained medical officer and specialist psychiatrics of BSMMU using HADS and DSM-IV questionnaire respectively. Simple and multivariate logistic regression analysis was used to estimate the odds ratio (OR) and 95% CIs, after adjusting for age, sex.

RESULTS— According to DSM-IV, 68(56.2%) of Diabetics had depression while 30(24.8%) of control having depression, so that association of depression was almost double in diabetics than control population. The risk of developing depression among diabetic was around seven fold higher than people without diabetes [OR 7.005 95% CI 3.44-14.284,p= .000]. we found higher WHR and higher income were found to be associated with depression but this association was no longer significant at the multivariate level when controlling for other demographic and clinical variables{BMI[OR 0.43 95% CI 0.17-1.01,p=0.08],Income p=0.388}. high prevalence of depression among female [OR 4.27 95% CI 2.06-8.87 p=.000] even after controlling for potential confounding factors, gender remained as the strongest risk factor for depressive symptoms, with nearly a fivefold increase risk in females compared with males.

CONCLUSIONS— significantly higher association of depression in patient with diabetic had been found in our study. So diabetes may be a risk factor for developing depression and vice versa. But the causal relationship between diabetes and depression is still unexplored.

433

PO 011INCIDENCE OF CIN IN PATIENTS WITH TYPE 2 DIABETES MELLITUS AND ITS ASSOCIATION WITH HBA1C LEVEL AND DURATION OF DIABETES

Eddy Chandra1, Margrette Ruth L Bernardo1

1Department of Internal MedicineDe La Salle University Medical Center, Philippines

Background: Contrast Induced Nephropathy (CIN) is the third leading cause of hospital-acquired acute kidney injury and one complication after intravascular contrast media exposure. The presence of diabetes mellitus is associated with higher risk for CIN. It is still unclear if CIN is associated with the duration of diabetes and Glycosylated Hemoglobin (HbA1c) level. The aim of this study is to determine the incidence of CIN post contrast enhanced Computed Tomography (CT) scan and whether duration of diabetes and HbA1c level were associated with the occurrence of CIN among diabetic patients.

Methods: This is a retrospective cross-sectional analytic study. 186 diabetic adult patients who underwent CT scan of the chest, abdomen, and cranial CT-angiogram with intravenous contrast from January 2010 to June 2015 were included. Stepwise regression analysis was done to confirm their association with the development of CIN.

Results: The incidence of CIN was 30.1% (56/186). There were no significant differences in age, gender, BMI, and baseline creatinine between the CIN positive (n=56) and CIN negative (n=130) groups. However, the eGFR was significantly lower (69.1±30.8 vs 79.1±23.2 ml/min/1.73m2, p=0.017) in the CIN positive group. The presence of pre-existing kidney disease was associated with the development of CIN (p=0.002). The duration of diabetes was not significantly associated with the occurrence of CIN (p=0.157). However, HbA1c level ≥ 7% was significantly associated with the development of CIN (OR [95%CI] = 20.15 [8.558 to 47.449], p=0.0001). The multivariate analysis confirmed the association of the HbA1c level ≥ 7% with the development of CIN after adjustment for baseline confounding factors (adjusted OR [95%CI] = 20.12 [8.17 to 49.53], p=0.0001).

Conclusions: The incidence of CIN post contrast enhanced CT scan in diabetic patient was 30.1%. HbA1c level ≥ 7% was significantly associated with the risk of CIN among patients with type 2 diabetes mellitus.

434

PO 012Laboratory Parameters in Patients with Acute Coronary Syndrome and Type 2 Diabetes MellitusBerns S.A.1,2, Zacharova V.A.1,2, Lynev V.S.2

1. GOU VPO «Moscow State University of Medicine and Dentistry named after A.I.Evdokimova», Moscow, Russia

2. State Budget Healthcare Institution «City Clinical Hospital named after M.E. Zhadkevich by the Department of Healthcare in Moscow», Moscow, Russia

The target of the study was to assess clinical signs and laboratory parameters in patients with acute coronary syndrome without ST elevation depending of presence of II type diabetes mellitus.

Material and Methods: 72 patients with acute coronary syndrome without ST elevation were examined. The first group consisted of 20 (27.8%) patients for whom diabetes mellitus has been confirmed (glycosylated hemoglobin – 7.15%), and the second group included 52 (72.2%) patients with no diabetes (glycosylated hemoglobin –5.44%). Standard laboratory and instrumental examination including: coagulogram, troponin-T, brain natriuretic peptide (BNP), creatine phosphokinase, procalcitonin, myoglobin, fatty acid binding protein, total cholesterol, serum glucose, blood creatinine, hemoglobin, C-reactive protein high sensitivity (hsCRP), glycated hemoglobin (glycosylated hemoglobin - HbA1c), electrocardiography, echocardiography, coronary angiography have been evaluated during two hours after admission to hospital.

Results: There were no significant difference between both groups’ medical histories. Arterial hypertension took place in 18 patients (90%) of the diabetes group and in 45 patients (87%) in the non-diabetic group. Old myocardial infarction has been confirmed in 8 patients (40%) and 30 patients (58%), correspondingly. Two patients (10%) of diabetic group demonstrated heart failure (Killip III, IV) signs, which was more often than in non-diabetes group – 4 patients (7.61%), correspondingly. Diagnostic angiography and Coronary arteries stenting has been fulfilled significantly (p=0.002) more often in diabetic group - [100% coronary angiography and stenting in 11 patients (55%) and 96% Coronary angiography and coronary stenting in 14 patients (28%)]. We presume that diabetic patients would demonstrate more severe conditions and that has been confirmed partly by some laboratory results. So in diabetic group hsCRP has been significantly higher (p=0.003) 25.8 against 9.79 mg/l, creatinine – 121.92 against 105.54 mkmol/l (p>0.05), total cholesterol – 5.17 against 4.85 mmol/l (p=0.04) and creatine phosphokinase – 405.8 against 92.9 Unit/l (p=0.008). It was found that Toponin T and BNP levels has been significantly higher and myoglobin and procalcitonin levels non-significantly higher in patients without diabetes mellitus: 2.4 against 0.38 (р=0.04); 188.13 against 77.27 (p=0.05); 165.17 against 94.34; 0.106 against 0.46, correspondingly.

435

Positive fatty acid binding protein level increased more often but non-significantly in patients with diabetes mellitus – in 11 patients (55%) against 25 patients (46%) without diabetes.

Conclusion: Severity of disease in patients with Acute Coronary Syndrome without ST elevation and diabetes is associated with levels of hpCRP, creatinine, creatine phosphokinase, total cholesterol and Positive fatty acid binding protein.

436

PO 013New Advances in Insulin Induced Lipohypertrophy Diagnostics in Diabetic Patients: Estimation Risk Model

N.I. Volkova, I.Y. Davidenko, J.A. RudakovaRostov State Medical University, Rostov-on-Don, Russian Federation

Objectives. To develop the estimation risk model of insulin induced lipohypertrophy (LH) in diabetic patients.

Methods. This study was done on 140 diabetic patients who had been under the treatment with insulin a mean 8 years. Ultrasonography of subcutaneous fat was used in assessing LH in these diabetics. All patients were divided into two groups. First group included 117 patients with LH, second – 23 diabetics without pathologic areas of subcutaneous fat. Further, all known, as well as additional LH risk factors were statistically processed using Spearman`s, Kendall tau, Gamma rank correlation coefficients and binary logistic regression. Results were statistically significant when p<0,05. Also measure area under curve (AUC) was determined.

Results. All risk factors were analyzed using rank correlation coefficients on first stage. Statistically insignificant parameters were eliminated (p>0,05). 10 factors from 23 were remained after first stage. Further, 10 parameters were subjected to ROC-analysis. All risk factors had high predictive value (AUC > 0,5). They were used to development the estimation risk model. On the basis of binary logistic regression the estimation risk model was created. Predictive value of model was 86% taking into account threshold cut-off 0,3 and confidence interval 95%. Efficacy of estimation risk model were tested on 34 diabetic patients.

Conclusion. Nowadays, LH remains severe insulinotherapy complication. Primary prevention is necessary for diabetic patients with pathologic areas of subcutaneous fat. Therefore, we developed the estimation risk model with good quality and high predictive value (86%) for diabetic patients who are under the treatment with insulin.

437

PO 014GLYCEMIC STATUS OF TYPE 2 DIABETIC SUBJECTS ON DIFFERENT ANTI-DIABETIC MANAGEMENT

Tasrina Shamnaz Samdani1, Muhammad Abdur Rahim2, Palash Mitra2, A.K.M. Shaheen Ahmed3, Khwaza Nazim Uddin3

1Department of Medicine, Delta Medical College and Hospital, Dhaka, Bangladesh2Department of Nephrology and Dialysis, BIRDEM General Hospital, Dhaka, Bangladesh3Department of Medicine, BIRDEM General Hospital, Dhaka, Bangladesh

Background: Diabetes mellitus (DM) is a complex multisystem disorder that may lead to diabetes specific complications and target organ damage which can be prevented or delayed by good glycemic control. Our aims were to evaluate the glycemic status of adult type 2 DM (T2DM) patients on different anti-diabetic management, to evaluate role of education and earning status on glycemic control and to correlate glycemic status with complications.

Methods: This cross-sectional study was conducted in BIRDEM General Hospital from November 2013 to April 2015. Data were collected purposively and consecutively, in a pre-formed data collection form, from 300 T2DM patients who were diagnosed as diabetic for 3 months or more and were compliant, after face to face interview and undergoing the required physical examinations. Then data were compiled and analyzed accordingly.

Result: Only 17% of the patients had good glycemic control (HbA1c <7) irrespective of different anti-DM managements. The overall mean HbA1C was 8.9±1.9%, among which the group of patients with medical nutrition therapy had the lowest mean HbA1c level (8.5±1.3%). Neither the different educational level (p=0.88) nor the difference in monthly earning (p=0.08) had any influence on glycemic control. Diabetic nephropathy (45%) and polyneuropathy (40%) were the two common complications among the participants with a positive and significant (r=1, p=0.000) correlation between both macro and microvascular complications of DM with uncontrolled glycemic status.

Conclusion: Glycemic control was rarely achieved irrespective of different treatment regimen and no regimen was proved to be superior to other in achieving glycemic control. Patients’ educational or earning level did not have any influence over glycemic control. There was a strong positive correlation between uncontrolled T2DM and its’ complications.

438

PO 15Correlation Between Soluble Cd163 and Low Density Lipoprotein Cholesterol, Not With Glycemic Control

in Type 2 Diabetes Patients

Hermina Novida, Soebagijo Adi, Ari Sutjahjo

Background: Cardiovascular disease is the major cause of mortality in type 2 diabetes mellitus (T2DM). In recent years several inflammation-related plasma protein have been recognised as predictors of CVD such as TNFα, IL-6 and CRP. Plasma soluble CD163 (sCD163) is regarded as a marker of macrophage activity, a long circulating marker of TNFα and has an association with atherosclerosis. The objective is to determine the correlation between sCD163 with lipid profiles and glycemic control in patients with T2DM.

Methods: This is observational analytic study with cross sectional design conducted in the Diabetes Clinic Dr. Soetomo Hospital. Patients who met the inclusion and exclusion criteria were interviewed and checked for anthropometric measurement, fasting plasma glucose, post prandial glucose, HbA1c and lipid profile. Soluble CD163 level were measured by quantitative sandwich enzyme immunoassay technique using monoclonal antibodies specific for human CD163. The results were analyzed using Kolmogorov-Smirnov for normality of distribution and Pearson correlation test.

Results: In this study, there were 40 subjects with the average age of 59.55 ± 8.14 years. Most patients with poor glycemic control with average HbA1c 8.01 ± 1.39%. The overall mean of BMI was 25.66 + 2.91 kg/m2, LDL-cholesterol level was 145,02 ± 33,92 mg/dL, HDL-cholesterol was 45,25 ± 11,98 mg/dL, total cholesterol was 213,20 ± 33,64 mg/dL and triglyceride was 172,07 ± 51,38 mg/dL. The average level of sCD163 was 741.22 ± 262.20 mg/dL. There was correlation between sCD163 level and LDL-cholesterol level (r 0.378; p <0.05), and also between sCD163 level. Interestingly, there was no correlation between sCD163 level and HbA1c level as a marker glycemic control (r 0.133; p 0.415) in T2DM patients.

Conclusion: There was correlation between sCD163 level and LDL-cholesterol, but there was no correlation between sCD163 and glycemic control in T2DM patients.

439

PO 016Mortality Rate of Thyroid Storm Patients at dr. Soetomo General Hospital During Period of 2010-2014

Edward Putera, Jongky Hendro Prajitno, Ari Sutjahjo

Internal Medicine Department - Endocrinology DivisionMedical Faculty of Airlangga University- Dr.Soetomo General HospitalSurabaya, Indonesia

Background : Thyroid storm is complication of thyrotoxicosis which usually has an poor prognosis, especially on undertreated or underdiagnosed case. Literatures reported that mortality rate of thyroid storm despite adequate treatment is between 20%-30%. Mortality rate of thyroid storm in Indonesia is rarely recorded despite this atrocious phenomenon. In this study we try to identify the mortality rate of thyroid storm between the year of 2010-2014 in dr. Soetomo general hospital.

Objective : The purpose of this study is to observe mortality rate of patients with thyroid storm at dr. Soetomo general hospital during period of 2010-2014.

Material &Methods :The study was a descriptive study in 56 thyroid storm patients who were admitted to dr. Soetomo general hospital during period of 2010-2014. All patients were underwent routine physical, laboratory, radiography examinations, and therapies according to guideline of thyroid storm. Patients with other diagnosis than thyroid storm were excluded from this study.

Result :Among 56 patients with thyroid storm who are hospitalized in dr. Soetemo general hospital during period of 2010 – 2015, 18 patients did not survived due to multiple cause of complications. According to these findings, mortality rate for hospitalization of thyroid storm at dr. Soetomo general hospital during these 5 years period is 32.14%.

Conclusion :Our findings stated that mortality rate of thyroid storm patients who were hospitalizedduring period of 2010-2014 at dr. Soetomo general hospital is 32.14%.

Keyword : Thyroid Storm, Mortality Rate.

440

PO 017CLINICAL EVALUATION OF PATIENTS WITH APPARENTLY IDIOPATHIC SIADH

A. Soupart, MD, PhD(1,2), G. Decaux, MD, PhD(2), M. Coffernils, MD(4), F. Gankam, MD, PhD(3), B. Couturier, MD(2), F. Vandergheynst, MD(2), D. François, MD(5)

Department of Internal Medicine(1), HIS-Molière Hospital; Departments of Internal Medicine(2) and Nephrology(3), Erasme University Hospital; Departments of Internal Medicine(4) and Radiology(5), Jolimont-Tubize Hospital

Idiopathic SIADH is a poorly studied disorder. It refers to patients with hyponatremia and no obvious cause (± 30% of SIADH). The syndrome can be associated with numerous diseases and can predate their diagnosis for months (e.g. malignancy). The incidence of SIADH increases also with aging. Which diagnostic tests should be performed in these patients in search of occult diseases is unknown.

Patients and Methods:Between 2008 and 2014, 84 successive patients with SIADH lasting for at least 1 month and no obvious cause were enrolled in a prospective study. Inclusion criteria were: patients with no specific symptoms or signs and no biological abnormalities pointing toward a diagnosis and a normal X-ray of the chest. Further investigations consist for all the patients in a brain CT scan and a FDG-PET.

ResultsMeans ± SD Total cases Negative cases Positive casesN n = 84 n = 58 (69%) n = 26 (31%)Age70 ± 11

70 ± 1466 ± 12

(range)(28-99)

(51-99)(28-84)

Male sex n = 53 (63%) n = 32 (55%) n = 21 (80%)Male sex n = 53 (63%) n = 32 (55%) n = 21 (80%)Previous duration of Hypon-atremia (months) 37 ± 38 41 ± 35 30 ± 44

Hyponatremia < 12 months n = 30 (35%) n = 16 (28%) n = 14 (53%)Mortality n = 20 (23%) n = 9 (15%) n = 11 (42%)

An underlying diseases reported to be associated with SIADH was found in 31% of the cases and were intrathoracic in 73% (10 malignancy, 7 infections, 3 bronchiectasis), cerebral in 19% (chronic subdural hematoma, normotensive hydrocephaly, intracranial cavernoma, empty sella syndrome, olfactive neuroblastoma), abdominal in 3%, ENT cancer in 3% and 1 NSIAD. Neoplasms were found in 50% of the patients with a high mortality rate (70%). Final diagnosis was made by chest CT scan in the majority (73%) of the cases. Old ischemic brain lesions were also found in 37% of the patients.

441

Conclusions

In this first prospective study we show that in asymptomatic patient with apparently idiopathic SIADH, additional investigations can lead to diagnosis of treatable diseases in a significant number of cases. This study shows also that extensive diagnostic procedures are unnecessary and the diagnostic work-up should include only a chest CT scan. In young patients with negative chest CT, brain CT scan can be done. The prognosis of positive cases is poor despite early care.

442

PO 018Interconnection of The Form and Level of Glycemic Rehabilitation of Patients with Ischemic Stroke

Dzherieva I.S., Goncharova Z.A., Maslova N.P., Krivorotov N.A.

Objectives: Have analyzed the regression of neurological dysfunctions during rehabilitation of patients with ischemic stroke (IS) depending on the type of hyperglycaemia (HG) in time of stroke.

Materials and Methods: 1st stage: A retrospective analysis of disease histories of neurological clinic RostGMU of Rostov-on-Don. Selection criteria - verified diagnosis: IS confirmed by CT, MRI.

2nd stage: distribution groups. Distribution criterion - glucose levels in the first 24 hours after stroke. Attended by 122 patients (54 women and 68 men) with IS: Group 1 (60 patients) - with normoglycemia, group 2 (27 patients) - a stress HG and Group 3 (35 patients) with chronic HG.

3rd step: Determination of the average relative level of rehabilitation (ARLR) in NIHSS table.

4th stage: Statistical data processing. Basic statistical characteristics were calculated: the mean (M), the average error (m). Comparison of averages was carried out using the Kruskal-Wallis test (a posteriori pairwise comparisons were made using the method of Niemen). Results recognized statistically significant at p <0.05.

Results: ARLR by NIHSS table score in subjects with normoglycemia and stressl HG was 50% (CI: 45-75%) and 50% (CI 32-73%), respectively. Statistically significant differences were found between the groups 1 and 3. ARLR patients with chronic GH was 33% (from 22% to 50%, p = 0.023).

Conclusions: In patients with normoglycemia and stress HG revealed identical results ARLR. Also it revealed a slowdown in the dynamics of the regression of neurological deficit in patients with chronic HG compared to with normoglycaemia and stress HG.

443

PO 019Prevalence of Thyrotoxicosis Periodic Paralysis Among Paralysis Cases and Thyrotoxicosis Cases in dr.Soetomo General Hospital

Hadiati Setyorini, Deasy Ardiany, Agung Pranoto


Background : Muscle weakness is a common manifestation of hypokalemia, and Thyrotoxicosis Periodic Paralysis (TPP) is one of the frequent cause of it. TPP is a weakened muscle condition caused by potassium shift to intracellular in hyperthyroid patient. This is a rare condition, but suprisingly a common cause of paralysis in asian population. This condition usually occur in male populations, even though thyrotoxicosis is a disease with female predominance. The initial episode was said to start in age 20-40 years old.

Objective : The purpose of this study is to observe the prevalence of TPP among paralysis and thyrotoxicosis patients in Dr. Soetomo general hospital between 2012-2015.

Material & Methods : This is a cross sectional study in patients who were hospitalized and diagnosed with thyrotoxicosis periodic paralysis in RSUD Dr. Soetomo Surabaya.

Result : There was 134 patients with paralysis admitted between 2012 until 2015 and 13 of them (9,7%) was due to thyrotoxicosis periodic paralysis. While, among thyrotoxicosis patients in the same periode (350 patients) the prevalence was 3,7%. Most of the patients (77%) is male with age 18-40 years old (mean 33,3 years).

Conclusion : Our findings confirm the data from literature, it revealed that TPP is quite rare among thyrotoxicosis patients and paralysis patients, with middle aged male predominance.

Keyword : Periodic paralysis, Thyrotoxicosis

444

PO 020The Prevalance of Diabetes Mellitus, Impaired Fasting Glucose, Impared Glucose Tolerance and Obesity in MalatyaLezan Keskin1,Ozlem Nalbantoglu Elmas2, Irem Pembegul Yıgıt3

1. Endocrinology and Metabolism Clinic of Malatya State Hospital, Malatya2. Pediatric Endocrinology Clinic of Malatya State Hospital, Malatya3. Nephrology and Hypertension Clinic of Malatya State Hospital, Malatya

AIM: Type 2 diabetes (DM) is an significant disease which has a increasing effect on morbidity and mortality risk all around the world. Moreover,it’s known that there is a relationship between impaired fasting glucose(IFG), impaired glucose tolerance(IGT) and obesity. In our study, we aimed to determine the prevelance of risk factors related to diabetes in our city, Malatya.

MATERİAL AND METHOD: Capillary glucose was obtained in the patients who applied to Endocrinology clinic of Malatya State Hospital and the antropometric measurements was assesed in patients who have diabetes and related risk factors (IFG,IGT).Data were collected abut positive familiar anamnesis for diabetes,HTAtreatment and smoking.

RESULTS: One thousand ninety five who have no any diagnostic before(DM, IFG,IGT) were incorporated into the study. Four hundred and ten (37.8%) patients were male and 685(62.3%) of them were female. The average age was 46.7±22.14. Also, the average body mass index was found to be 29.9±3.1. %12.43 percent of the patients are considered to be diabetic patients whereas 19.3 percent is considered as IFG and 16.3% is considered as IGT.The mean age of the patients with diabetes was found to be 44.5 ± 11.3 In diabetic group, the percentage of the overweighted people is obtained as 35% whereas it is found to be 28 % for the presence of the obesity and 18 % for morbid obesity.

CONCLUSION: Prediabetes is a collective term for different subphenotypes (impaired glucose tolerance [IGT] and/or impaired fasting glucose [IFG]) with different pathophysiologies. A positive family history for type 2 diabetes (FHD) is associated with increased risk for type 2 diabetes

Type 2 diabetes is an increasingly prevalent disease in the WORLD, and is associated with microvascular and macrovascular complications. Lifestyle improvements, including weight loss and increased physical activity are effective in reducing the conversion of IGT to type 2 diabetes by 58%.

445

PO 021PREVALENCE OF TYPE-2 DIABETES MELLITUS IN ELDERLYMINAHASA NORTH SULAWESI INDONESIA

Mandang V*, Pandelaki K*, Langi Y*, Jim E**, Runtuwene T***, Tinangon R****Division of Endocrine-Metabolic, **Division of Geriatrics***Department of Internal Medicine Sam Ratulangi University / Prof. R.D. Kandou General Hospital Manado Indonesia

Background: Diabetes mellitus (DM) is one of the disease which prevalence is increasing dramatically. Age is one of the risk factor for developing Type-2 DM. The proportion of elderly in line with life expectancy increment.

Aim: This study aims to determine the prevalence of T2DM in the elderly Minahasa, North Sulawesi, Indonesia.

Methods: Samples were taken by stratified random sampling method. Sample size is purposes sampling. The districts and villages will be taken randomly from each regency in Minahasa. Every independent elderly in the village were taken overall. Peripheral blood glucose tests performed during fasting and 2 hour postprandial (2h-PP) with glucose rapid test tool. The variables studied were age, gender, fasting blood glucose (FBG), 2h-PP blood glucose. Criteria for the elderly is based on Law of Health in 1960. Criteria for the diagnosis of T2DM is based on PERKENI, ADA and ASCE citeria 2016. Statistical analysis using SPSS.

Result: Total samples are 168 elderly, 57 men (33.9%) and 111 women (66.1%). The average age of the sample was 69 years old. The amounts of diabetic patients were 36 (21.4%), consisted of 10 men (5.95%) and 26 women (15.47%). Prevalence of Prediabetic is 122 patients (72.6%).

Discussion: The prevalence of T2DM in line with increasing age. WHO (2016) report the global average prevalence of diabetes in adulthood was 8.5%, Indonesia was 7 %. The prevalence of diabetes in elderly of this study was 21.7%, Canada was 22%. The prevalence in women is greater than men namely 15.47% and 5.95%. Prediabetic in this study is very high 72.6%.

Conclusion: The prevalence of T2DM in elderly in Minahasa was 21.3% and higher in women. Prediabetic is 72.6%.

Keywords: diabetes, elderly

446

PO 022Correlation between Triiodothyronine, Thyroxine, Free Thyroxine and Thyrotropin with Thyrotoxicosis Periodic ParalysisHadiati Setyorini, Deasy Ardiany, Sri Murtiwi


Background : Most patients with thyrotoxicosis periodic paralysis (TPP) have only mild elevated serum thyroid hormone levels and only a small portion of them showed clinical symptom of thyrotoxicosis. The main laboratory abnormality found in these patients was hypokalemia, with symmetrical paraplegia as main symptom. Henceforth, correlation between severity of thyroid function, potassium level, and clinical symptom severity was rarely addressed.

Objective : The purpose of this study is to observe whether there is correlation between triiodothyronine (T3), thyroxine (T4), free thyroxine (FT4) level and thyrotropin (TSH) level with manifestation in TPP patients.

Material & Methods : This is a cross sectional study in patients who were hospitalized and diagnosed with thyrotoxicosis periodic paralysis in Dr. Soetomo general hospital. All patient underwent biochemical evaluations in particular : FT4 or T3 and T4, and TSH. Patient with other causes of periodic paralysis were excluded from this study.

Result : Our study shows that while T3 had negative correlation with potassium serum, it has positive correlation with motoric strenght and reflex. T4 had negative correlation with potassium serum, motoric strenght, and reflex. FT4 only had positive correlation with motoric and reflex, TSH only had negative correlation with potassium and reflex, while potassium had positive correlation with motoric strength and reflex.

Conclusion : Our findings shows that T3, T4, and TSH may had role in hypokalemia in TPP, but only T4 and TSH had negative correlation with muscle weakness as a main symptom in TPP.

Keyword : Periodic paralysis, Thyrotoxicosis, Hypokalemia

447

PO 023Correlation Betweeen Waist Circumference And Ankle Brachial Index In MenopauseIyan Tarigan, Hikmat Permana, Nanny NM Soetedjo Department of Internal Medicine Padjadjaran University Medical SchoolHasan Sadikin General Hospital Bandung

Abstract

Peripheral arterial disease (PAD) is estimated to affect 15-20 % of the population and strongly associated with poor quality of life. Ankle-brachial index (ABI) is a simple non-invasive method which can be as a diagnostic tool for PAD and can predict general atherosclerotic process. Menopausal transition is associated with unfavorable changes in body composition and abdominal fat deposition. Obesity, especialy central obesity influences atherosclerotic process, so it could be expected that central obesity is also associated with PAD. The aim of this study was to determine the relationship between waist circumference and ABI in menopause women.

This Cross-sectional study was conducted on Women above 50 years old who routinely visit to Geriatric and Internal Outpatient Clinic Hasan Sadikin Bandung in October 2015. Subjects who met the inclusion criteria examined body mass index (BMI), waist circumference (WC), systolic and diastolic blood pressure, lipid profile and ABI measurement.

Subjects consisted of 51 women and all subjects has waist circumference above normal value (> 80 cm). Mean of age was 68.41 ± 9.23 years. Most of the subjects had hypertension (86.27%) and dyslipidemia (72,54%). Mean of BMI was 24.29 ± 3.54 kg/m2. Spearman correlation test between waist circumference and ABI showed no significant correlation. Strongest correlation was shown between systolic pressure and ABI with a correlation coefficient of -0.336 and p value of 0.016

This study shows no correlation between waist circumference and ABI. There was a weak, negative and significant correlation between systolic pressure and ABI. Further research is needed to determine the relationship between waist circumference and ABI in menopause women.

Keywords: ABI, menopause, waist circumference

448

PO 024The Correlation between Simvastatin Use with Fasting Blood Glucose and Two Hour Post Prandial Glucose Level in Dislipidemia PatientsPetrina Kemala Dewi1, Nanny N.M Soetedjo2, Erwan Martanto31Internal Medicine Department, Medicine Faculty of Padjadjaran University/Dr. Hasan Sadikin Hospital Bandung, 2Endocrinology and Metabolism Division, 3Cardiovascular Division, Internal Medicine Department, Medicine Faculty of Padjadjaran University/Dr. Hasan Sadikin Hospital Bandung

Abstract

Statins are the drug of choice for lipid lowering agent based on NCEP-ATP III guidelines, simvastatin is a statin that is used more widely because of the potential and an affordable price. FDA in 2012 declared that statins may affect the levels of HbA1c and fasting blood sugar, even though the research on statins is still controversial. Statins can affect fasting blood sugar through insulin resistance mechanism. Fasting blood sugar and 2 hour post prandial blood sugar are practical examination to determine insulin resistance. The aim of this study was to determine the correlation between simvastatin use with fasting blood sugar and 2 hour post prandial blood sugar.

The study design was cross sectional study on 54 patients with dyslipidemia who received simvastatin therapy ≥4 years. Subjects who met the inclusion and exclusion criteria examined fasting blood sugar and 2 hour post prandial blood sugar. Data were analyzed by Spearman correlation test.

Subjects consisted of 54 people with mean of age was 70 ± 8 years, with a majority subject given 10 mg simvastatin was 33 study subjects (60%). Subjects with increased diabetes risk score was 43.6%, and middle diabetes risk score 45.5%. Spearman correlation test between simvastatin use with fasting blood sugar and 2 hour post prandial blood sugar levels showed no significant correlation. A significant correlation was shown between the levels of risk factors for diabetes mellitus with 2 hour post prandial blood sugar with a correlation coefficient 0.356 and p-value of 0.004.

This study showed no correlation between simvastatin use with fasting blood sugar and 2 hour post prandial blood sugar levels. There was a positive correlation between the risk factors for diabetes mellitus with 2 hour post prandial blood sugar. Further research to determine the correlation between the of use of simvastatin with fasting blood sugar and 2 hour post prandial blood sugar with the cohort study design is still needed.

Keywords: Simvastatin, fasting blood sugar, 2 hour post prandial blood sugar

449

PO 025A Profile of Diabetic Patients in Diabetic Outpatient Clinicat Haj Hospital Surabaya Indonesia Year 2015

Batari Retno Minanti

Departement of internal medicine, Haj Hospital, Surabaya Indonesia

Abstract

Introduction: Diabetes mellitus in Indonesia is a global health problem. Since diabetes become more and more all over the world, so it does in Surabaya, Indonesia. We’d like to present about profile of our diabetic patients, who came to our diabetic outpatient clinic all over the year at 2015.

Methods and procedures: This study aims to determine the profile of diabetes mellitus patients in diabetic outpatient clinic at Hajj Hospital Surabaya, Indonesia using descriptive observational method. We collect data from medical records, include all patients who came to our diabetic outpatient clinic at the year 2015.

Results: There were 441 participants were enrolled in this research, include 256 (58,05%) women and 185 (41,95%) men. Most are between the age range 51 – 60 years (38,32%), with the oldest age was 83th years old and the youngest one was 15th years old. Most of them were paid by national health insurance (96,14%). Most clinical symptoms at these patients was hypertension on 106 (24,04%) patients. Diabetic ulcer was found in 23 (5,22%) patients, dyslipidemia was found in 17 (3,85%) patients, chronic kidney disease at 10 (2,27%) patients and coronary heart disease and cerebrovascular disease were obtained in each 11 (2,49%) and 19 (4,31%) patients. Based on HbA1C status, most patients had HbA1C between the range 6% – 8% (17,69% patients), with the lowest value was 5,1% and the highest one was 15,3%.

Conclusions: There were 441 patients who visiting diabetic outpatient clinic at Haj Hospital Surabaya. We still need better recording and reporting system to improve our medical records, so in the future we can collect much more important data from those.

450

PO 026Ketoacidosis in Pheochromocytoma Patient

Margareth Gracia1, Fiona Tjiputra1, Riki Tenggara2, Tjie Hendra3, Aida Lydia3, Adenan Irianto3, Wiguno Prodjosudjadi3Medical Staff of Pantai Indah Kapuk Hospital, Jakarta1Gastroenterologist of Pantai Indah Kapuk Hospital, Jakarta2Division of Nephrologist of Pantai Indah Kapuk Hospital, Jakarta3

Introduction: Intra-abdominal mass should be investigated further more to find the origin of the mass, especially when the mass is accompanied by hypertension crisis, hyperglycemia and ketosis. Pheochromocytoma is a rare cause of hypertension (less than 0.2% of patients with hypertension). Further investigation showed that big polycystic mass behind the liver and 24-hour urine collection contained with high-level of metanephrine.

Case Report: A 55-year-old male was admitted to the Emergency Room with chest pain, epigastric pain, vomiting, numbness in his fingers and toes. His prior medical history was hypertension and diabetes mellitus type 2. Blood pressure was extremely high (190/110 mmHg), an irregular heart rate and pain on epigastric area. Laboratory studies revealed normal leukocyte counts, ketosis, acidosis and high-level of blood glucose. Ultrasonography study was performed and it showed a big cystic mass behind the liver which suspected to be liver abscess. His working diagnosis was ketoacidosis, hypertension urgency, suspected liver abscess and diabetes mellitus type 2. Ketoacidosis was treated with diabetic ketoacidosis algorithm and the urgency hypertension was treated with antihypertensive agents. The blood pressure was dropped shortly in 2 hours. Catecholamine urine laboratory study was performed and revealed 4-fold increase in metanephrine, which strongly suggestive to pheochromocytoma.

Discussion: The mass behind the liver needs further investigation. This special case showed that diabetic ketoacidosis with no precipitating factor such as infection. In further investigation, 24-hour urine metanephrines increased on its level, which strongly suggestive of pheochromocytoma, a catecholamine-producing tumor, that located precisely under the liver. Diabetic ketoacidosis might be caused by hormonal changes in pheochromocytoma. The size was larger than 6 cm in diameter that we suggested the patient to undergo surgical treatment.

Reference:

1. Sydney Westpal. Diagnosis of Pheochromocytoma. Am J Med Sci 2005;329(1):18–21.

451

2. Karel Pacak, Jacques Lenders, Graeme Eisenhofer. Pheochromocytoma: Diagnosis, Localization, dan Treatment. Blackwell Publishing. 2007.

3. Mary Ann Nguyen-Martin, Gary D. Hammer. Pheochromocytoma: An Update on Risk Groups, Diagnosis and Management. Hospital Physician: February 2006.

4. Jacques W. M. Lenders, dkk. Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 99: 1915–1942, 2014

5. Koichiro Homma, Koichi Hayashi, Shu Wakino, Rie Irie, Makio Mukai, Hiroo Kumagai, dkk. Primary Malignant Hepatic Pheochromocytoma with Negative Adrenal Scintigraphy. Hypertens Res Vol. 29, No. 7 (2006).

6. Samuel M. Zuber, Vitaly Kantorovich, Karel Pacak. Hypertension in Pheochromocytoma: Characteristics and Treatment. Endocrinol Metab Clin North Am . 2011 June ; 40(2): 295–311.

7. Gabriele Parenti, Benedetta Zampetti, Elena Rapizzi, Tonino Ercolino, Valentino Giachè, dan Massimo Mannelli. Updated and New Perspectives on Diagnosis, Prognosis, and Therapy of Malignant Pheochromocytoma/Paraganglioma. doi:10.1155/2012/872713.

8. Wei S, Wu D, Yue J. Surgical resection of multiple liver metastasis of functional malignant pheochromocytoma: A case report and literature review. J Can Res Ther 2013;9:S181-3.

9. E. M. Minnaar, K. E. Human, D. Henneman, C. Y. Nio, P. H. Bisschop, dan E. J. M. Nieveen van Dijkum. An Adrenal Incidentaloma: How Often Is It Detected and What Are the Consequences?

10. William F. Young. The Incidentally discovered Adrenal Mass. N Engl J Med 2007;356:601-10.

11. Jeffrey Stephen Hedley, Sidney Law, Sujoy Phookan, Maria Nien-Feng Lee, Adriana Ioachimescu, Rebecca D. Levit. Pheochromocytoma Masquerading as “Diabetic Ketoacidosis”. Journal of Investigative Medicine High Impact Case Reports April-June 2016 vol. 4 no. 2 2324709616646128.

452

PO 027Asian specic denition for the metabolic syndrome and the relationship with alanine aminotransferase in an Indonesian population: the Jakheart studyMetabolic syndrome and the relationship with ALT in Indonesians

CJM van Boheemen , RP Sibarani , IA Ksanthi , JM Dekker , ME Tushuizen , M Diamant ,HW de Valk , RJ Heine

AIMS: The Jakheart study is a cross-sectional observational study of 167 healthy inhabitants of Jakarta, aged between 35 and 65 years. Body mass index(BMI), waist (WC) and hip (HC) circumference, blood pressure, as well as fasting blood glucose, triglycerides, HDL-cholesterol and ALT weremeasured. The WHO WC cut-o points for Asians were applied in the ATPIII criteria.

RESULTS: Sixteen percent of the subjects fullled the ATPIII criteria of MetS. Adaptation of WC cut-o points to Asian specic values resulted in an increase ofMetS to 25%. The prevalence and severity of individual components of MetS in the people, who were identied with the adapted denition (N=16),were similar to people with the MetS according to the original ATPIII criteria. ALT was signicantly associated with measures of obesity.

CONCLUSIONS: The use of WHO Asian specic WC cut o points in an Indonesian populations adequately captures a population with dierent features of the MetS.Also in this population, ALT, as a marker of NAFLD, is associated with the components of the MetS.

Abbreviations:ALT, alanine aminotransferase; APP, Asian Pacic Perspective; ATPIII, National Cholesterol Education Program on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults(Adult Treatment panel III); BF, body fat; BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease;DEPKES, mininstry of health Indonesia; DM, diabetese mellitus; HC, hipcircumference; HDL, high dense lipoprotein; IPAQ, International Physical Activity Questionnaire; MetS, metabolic syndrome; MWU, Mann Whitney test; NAFLD, non-alcohol fatty liver disease;WC, waist circumference; WHO, World Health Organisation

453

PO 028Indonesian Physician-Pharmacist Collaborative Practice in Diabetes Care:A Qualitative Study

Yosi Irawati Wibowo, Bruce Sunderland, Jeffery HughesIndonesia

Background: Indonesia is among the top ten countries with the highest number of people with diabetes. The increasing prevalence and burden of diabetes requires all Indonesian health professionals to work collaboratively to improve access to diabetes care so as to optimise patient outcomes. This study aims to explore Indonesian physicians’ and pharmacists’ current collaborative practises in diabetes care as well as the expected collaborative roles of pharmacists.

Methods: A qualitative study using in-depth face-to-face interviews of 10 physicians and 10 pharmacists in Surabaya, Indonesia, was conducted. A semi-structured interview guide was used to explore current practice and the roles of pharmacists. Interviews were audio-recorded and transcribed. QSR NVivo version 9.0 was used to assist thematic content analysis of the data.

Results: The data were saturated after the eighth interview in both pharmacist and physician groups. Pharmacists and physicians in Surabaya, Indonesia, reported a low level of professional collaboration in diabetes care. Physicians were generally involved in diagnosing and prescribing; whilst community pharmacists mainly dispensed medications (with limited labelling) and provided basic information on how to use medications. There was strong agreement between physician and pharmacist groups that pharmacists should provide education on medications (i.e. directions for use). A lower level of agreement was reported regarding pharmacists conducting prescription review (clinical aspects), education related to medications (i.e. common/important adverse effects) and healthy living (i.e. exercise and diet); and the monitoring of medication compliance and treatment outcomes (i.e. checking on patients’ glycaemic control and problems)

Conclusions: Indonesian pharmacists should extend their clinical roles in order to build a stronger collaborative practice with physicians. The Government and the professional bodies should develop strategies to support pharmacists’ extended roles and thus their collaboration with physicians in the interest of improving the health of type 2 diabetes patients in Indonesia.

454

PO 029ABSTRAK

Nama : Komariatun

Program Studi : Kedokteran

Judul : Pengaruh Polimorfisme Gen Apolipoprotein E terhadap kejadian Nefropati Diabetik Penyandang DM Tipe 2 di Palembang

Latar Belakang: Nefropati diabetik (ND) merupakan komplikasi mikrovaskular yang berkontribusi terhadap end stage renal disease (ESRD) pada penyandang DMT2. Polimorfisme gen apolipoprotein E (APOE) dihubungkan dengan dislipidemia merupakan faktor risiko untuk timbulnya ND.

Tujuan: Mengetahui pengaruh polimorfisme gen APOE terhadap kejadian ND penyandang DMT2 di Palembang dan menganalisis pengaruh polimorfisme gen APOE terhadap perubahan profil lipid penyandang DMT2 dengan ND.

Metode: Penelitian kasus kontrol pada penyandang DMT2, membandingkan pengaruh polimorfisme gen APOE pada penyandang DMT2 dengan ND dan tanpa ND.

Hasil: Terdapat 37 penyandang DMT2 dengan ND dan 42 tanpa ND. Tidak terdapat perbedaan bermakna pada usia, jenis kelamin, lama DM, tinggi badan, tekanan darah sistolik, glukosa darah puasa, HbA1c dan profil lipid. Terdapat perbedaan bermakna pada berat badan, IMT, TD diastolik, hemoglobin, ureum, kreatinin dan eGFR antara kasus dan kontrol. Distribusi genotip tidak berbeda bermakna. Pada kelompok kasus didapatkan peningkatan frekuensi alel gen APOE ε2 dibanding kontrol (62,2% vs. 37,8%). Dengan analisis bivariat didapatkan penyandang DMT2 yang mengandung alel gen APOE ε2 2,5 kali lipat dan bermakna (p=0,023) dibandingkan gen APOE ε3 dalam menyebabkan ND dengan OR 2,50 (IK 95%; 1,64-6,04) dan alel ε4 0,65 kali lipat dan tidak bermakna (p=0,37). Profil lipid tidak berbeda bermakna baik pada ND maupun penyandang DMT2 tanpa nefropati.

Simpulan: Frekuensi alel gen APOE ε2 tinggi pada penyandang DMT2 dengan ND dan alel gen APOE ε2 merupakan faktor risiko timbulnya ND. Tidak ada pengaruh polimorfisme gen APOE ε2, ε3 dan ε4 terhadap perubahan profil lipid penyandang DMT2 dengan ND.

Kata Kunci: Gen APOE, Nefropati diabetik, Profil lipid

ABSTRACT

455

Name : Komariatun

Study Program : Medicine

Title : The Effect of Apolipoprotein E Gene Polymorphism to Diabetic Nephropathy Incidence in T2DM at Palembang

Backgrounds. Diabetic nephropathy is microvascular complication, largely contributed to end stage renal disease in T2DM patients. Apolipoprotein E (APOE) genetic polymorphism in association with dyslipidemia have been proposed as one of the risk factors for the development of diabetic nephropathy (DN).

Aim: To examine the effect of apolipoprotein E (APOE) gene polymorphism to diabetic nephropathy incidence with T2DM and to analyze the effect of APOE gene polymorphism to lipid profile to DN.

Method. A case control study comparing the effect of APOE gene polymorphism to patients T2DM with nephropathy and without nephropathy.

Results. There were 37 patients with DN and 42 patients without nephropathy. No significant differences in age, sex, length of DM, height, SBP, fasting glucose, HbA1c and lipid profiles between the two groups. There were significant differences in weight, BMI, DBP, haemoglobine, ureum, creatinine and eGFR with p value 0.028, 0.013, 0.017, <0.001, <0.001, <0.003 and 0.002 respectively. The distribution of APOE genotypes between groups are the same. The ε2 allele frequency was significantly higher in case group compared to control group (62.2% vs 37.8%), with bivariate analysis ε2 allele 2.50 times to DN risk with OR 2.50 (95% CI; 1.64-6.04) p 0.023 and ε4 allele 0.65 times to DN risk. No significant difference in lipid profile between the two groups.

Conclusions. APOE ε2 allele was significantly higher in macroalbuminuria group. These result suggest that ε2 allele may be associated with the development of diabetic nephropathy and ε4 allele was protective factor in T2DM patients. There were no correlation between APOE gene polymorphism and lipid profile.

Key words: Apolipoprotein E; Diabetic nephropathy; Dyslipidemia.

456

PO 030A Case of Hypogonadotropic Hypogonadism Due to Microadenoma in Gynecomastia Male Patient

Nugraheny Prasasti Purlikasari, Rio Wironegoro, Hermina Novida, Ari Sutjahjo


Background: A 44 years old man came to Endocrinology division with complained of both breasts enlargement

Case Report: The patient felt both of his breasts enlarged since for the last 3 years. Moreover, there was nipple discharge, body hair loss and decreasing of libido. Patient had history of heart rhythm disturbances and took bisoprololfumarate, aspilet, and simvastatin. Patient denied use of hormonal drugs or injections. Patient had been married for 18 years and had 3 children. From physical examination, there were gynecomastia grade II, galactorrhea, and decrease in testical volume. Laboratory results show decrease in the level of LH (< 0.07 mIU/mL), FSH (< 0.3 mIU/mL), testosterone (22.65 ng/dL), but normal level of prolactine (8,65 ng/mL). From the ultrasound of mammary gland, there were bilateral gynecomastias with bilateral ductal ectasis. From MRI with contrast revealed microadenoma of hypophysis. We concluded this patient suffered from secondary hypogonadism due to hypohysis microadenoma. This patient took testosterone injection (sustanon) 250 miligram intramuscularly, but reluctant to continue the treatment regularly. This patient also refused to be consulted to other departement, except for Andrology department.

Conclusion: It was reported a male patient with manifestation of gynecomastia, which caused by secondary hypogonadism due to hypophysismicroadenoma.

Keywords: gynecomastia, secondary hypogonadism, microadenoma

457

PO 031Subjective Global Assessment as A Screening for Malnutrition in Elderly Patient with Type 2 Diabetes Mellitus : A Case Report

Nur Aini Hanifiah1 Trisya Syachruddin1

Department of Internal MedicineKanujoso General Hospital, Balikpapan, East Kalimantan

Background: Malnutrition is often underdiagnosed among elderly patients with type 2 diabetes mellitus (T2DM). Elderly patients with T2DM are more likely to have comorbid condition that may impact their nutritional requirement. Problems of appetite changes, dietary restriction, depression, demensia may affect the nutritional status. The nutritional assessment is comprehensive evaluation and important factor in management of elderly patients with T2DM at risk from malnutrition.

Case illustration: A 69-year-old woman was diagnosed as type 2 diabetes mellitus for 25 years. She has had poor control for 3 years. She was admitted to Kanujoso General Hospital, Balikpapan, because she experienced fatigue, diarrhea, nausea, and vomiting. She has had trouble feeding herself for 2 months and has lost 5 kg. She has received insulin to control her blood glucose for 15 years. She has maintained her diet with carbohydrate dietary restriction for 10 years. Patient height is 155 cm and weight is 43 kg (BMI=17.9 kg/m2). Her blood glucose is 321 mg/dl. Her nutritional status was evaluated in subjective global assessment (SGA). SGA has 5 components of medical history (weight change, food intake, gastrointestinal symptoms, functional capacities, and diseases) and 3 components of physical examination (loss of subcutaneous fat, muscle wasting, and oedema/ascites). The SGA overall score of this patient is B, moderately malnourished. The score B for weight change, food intake, functional capacity, diseases, loss of subcutaneous fat. The score C for gastrointestinal symptoms (she experienced diarrhea, nausea, vomiting). The score A for oedema, she had no oedema in her extremity or ascites. The patient is currently receiving insulin and MUFA enteral nutrition.

Conclusion: Malnutrition will increase the morbidity and mortality in elderly patient with T2DM. Therefore, management should begin with a comprehensive assessment. Nutritional assessment with SGA is important to identify and treat elderly patients with T2DM at risk from malnutrition.

458

PO 032The Effect of Nrf2 Activation on Endothelial Function in Diabetes

Luddwi A. Rizky1, Arpeeta Sharma2, Judy B. de Haan2

1. Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia2. Baker IDI Heart and Diabetes Institute, Monash University, Melbourne, Australia

[Correspondence email: [email protected]]

Background. Diabetes is associated with impairment of the vascular endothelium characterized by increased inflammation and increased oxidative stress. Therefore, improving endothelial dysfunction by reducing oxidative stress and inflammation is therapeutically relevant. Nrf2, a redox sensitive transcription factor activated in response to oxidative stress, causes an upregulation of a host of anti-oxidative defences and lowers inflammatory genes. The aim of this project was to investigate the effects of Nrf2 activation using a known activator, dh404, on endothelial function in a Type 1 model of diabetes (T1D), namely the Akita mouse and human aortic endothelial cells (HAECs) isolated from and normal and diabetic patients.

Methods. dh404 at 3mg/kg was administered to Akita mice from 6 weeks of age for 20 weeks. On termination, vascular reactivity was assessed by wire myography. Pro-inflammatory gene expression was assessed in the aortas by qRT-PCR. In vitro studies included assessment of pro-inflammatory genes by qRT-PCR in HAECs derived from normal and diabetic patients in the presence or absence of dh404. Oxidative stress was assessed by two methods, L-012 and DCFDA. A static adhesion assay determined the leukocyte-endothelial interaction in the presence or absence of dh404.

Results. dh404 significantly lessened diabetes-associated endothelial dysfunction in diabetic Akita mice characterized by reduced contraction to phenylephrine and downregulation of inflammatory genes (p65 subunit of NF-kB, VCAM-1 and ICAM-1). Complementary in vitro studies in diabetic HAECs treated with dh404 (25 nM and 50 nM) exhibited cytoprotective effects, reflected by significant upregulation of Nrf2-responsive genes, NAD(P)H quinone oxidoreductase 1 (NQO1) and heme oxygenase-1 (HO-1), reduction of oxidative stress markers (O2•− and H2O2), inhibition of inflammatory genes (VCAM-1 and p65) and attenuation of leukocyte-endothelial interactions. The reduction in p65 and the leukocyte-endothelial cell interaction appeared dose-dependent with lower dose dh404 being more protective. The higher dose of dh404 was associated with increased expression of p65 subunit of NF-kB.

Conclusion. These studies suggest that activation of Nrf2 by dh404 is a feasible therapeutic strategy to lessen diabetes-associated endothelial dysfunction. However, doses need to be carefully considered to maximize the potency of this drug.

459

PO 033Protective Effects of Zinc Sulfate Against Oxidative Stress in The Gastric Tissue of Streptozotocin-Induced Diabetic Rats

Ozlem Sacan1, Ismet Burcu Turkyilmaz1,Bertan Boran Bayrak1, Ozgur Mutlu1, Nuriye Akev2, Refiye Yanardag1

1. Department of Chemistry, Faculty of Engineering, Istanbul University, Avcilar-Istanbul, TURKEY

2. Department of Biochemistry, Faculty of Pharmacy, Istanbul University, Beyazit-Istanbul, TURKEY

Diabetes mellitus is the most common serious metabolic disorder and it is considered to be one of the five leading causes of death in the world. Hyperglycemia-mediated oxidative stress plays a crucial role in diabetic complications. Zinc exerts a wide range of important biological roles. Zinc is a mineral that plays a vital role in many biological processes and plays an important role in insulin action and carbohydrate metabolism. The aim of this study was to investigate the protective role of zinc on the biochemical changes in the gastric tissue of streptozotocin (STZ) induced diabetic rat. Female Swiss albino rats were divided into 4 groups. Group I, control; Group II, control + zinc sulfate; Group III, STZ-diabetic; Group IV, diabetic + zinc sulfate. Diabetes was induced by intraperitoneal injection of STZ (65 mg/kg body weight). Zinc sulfate was given daily by gavage at a dose of 100 mg/kg body weight every day for 60 days to groups II and IV. At the last day of the experiment, rats were sacrificed and gastric tissues were taken. Tissues were homogenized in saline to make 10% (w/v) homogenate and were centrifuged. In supernatants, glutathione peroxidase (GPx), paraoxonase (PON), lactate dehydrogenase (LDH), xanthine oxidase (XO), prolidase activities,and advanced oxidized protein product (AOPP) levels were determined. The results show that stomach GPx and PON activities were found to be decreased while LDH, XO, prolidase and AOPP levels was increased in diabetic group. Administration of Zn reversed these afore mentioned changes in the diabetic group. It can be concluded that, zinc treatment may protect from diabetes-induced gastric injury by ameliorating the changes due to oxidative stress.

460

PO 034Oxidative Stress, Cyclophilin A and Nuclear Factor Kappa B in Relation with The Development of Complications of Diabetes

1. Omur Tabak1, Mahir Cengiz2, Volkan Sozer3, Serap Yavuzer2, Isıl Bavunoglu2, Gamze Kondakcı1, Caner Kacmaz4, Iffet Dogan5, Abdulhalim Senyigit6, Remise Gelisgen7, Sinem Durmus7, Gonul Simsek8, Hafize Uzun7

2. Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Department of Internal Medicine

3. Cerrahpasa Faculty of Medicine, Istanbul University, Department of Internal Medicine4. Yildiz Technical University, Department of Biochemistry, Istanbul, Turkey5. Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Department of

Cardiology6. Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Department of

Radiology7. Medicine Hospital, Internal Medical Clinic, Istanbul, Turkey8. Cerrahpasa Faculty of Medicine, Istanbul University, Department of Biochemistry9. Cerrahpasa Faculty of Medicine, Istanbul University, Department of Physiology

Diabetes is also associated with accelerated atherosclerotic disease affecting arteries that supply the heart, brain, and lower extremities. We aimed to evaluate the oxidative stress markers as pro-oxidant antioxidant balance (PAB) and total antioxidant capacity (TAC), cyclophilin A (CyPA) and nuclear factor kappa B (NF-кB) in type 2 diabetes mellitus (T2DM) patients with and without complications. Subjects were categorized as T2DM patients (n=30), T2DM+microvascular complications (n=90), T2DM+macrovascular complications (n=30), cardiovascular disease (CVD) patients (n=30) and healthy controls (HC) (n=30). Serum PAB, CyPA, and NF-кB levels were significantly higher among T2DM with macrovascular complications and CVD patients than T2DM with microvascular complications (p<0.01), T2DM patients (p<0.001) and HC (p<0.001). TAC levels in all patient groups were significantly lower than HC group (p<0.001) while TAC were not found different between patient groups. CyPA was positively correlated with PAB and NF-кB while there was a negative correlation with TAC in patient groups. Our results indicate that NF-κB is induced by oxidative stress which can cause the vascular complications of diabetes by increased CyPA. CyPA may secrete in response to oxidative stress or NF-кB. CyPA and NF-кB are cardiovascular risk biomarkers in T2DM patients. CyPA and NF-кB may represent a novel therapeutic approach to prevent CVD in T2DM. Further large scale studies evaluating CyPA, NF-KB, PAB in T2DM patients with complications may help to understand more about the strict mechanism.

461

PO 035Serum Glucagon Like Peptide -1 Levels and Dipeptidyl Peptidase-4 Activity in Type 2 Diabetes Mellitus with Microvascular ComplicationsHafize Uzun (Turkey)

462

PO 036The Level of Insulin Resistance Substrate and Fasting Blood Sugar in Rat after Administration of High Fat Diet and Injection of StreptozotocinWahyuni Lukita Atmodjo (Indonesia)

463

PO 037The Role of a New Vanadium Complex on the Kidney of Streptozotocin-Diabetic Rats

Serap Sancar-Bas1, Sevim Tunali2, Tulay Bal-Demirci3, Bahri Ulkuseven3, Refiye Yanardag2, Şehnaz Bolkent1

1. Istanbul University, Faculty of Science, Department of Biology, Molecular Biology Division, 34134, Vezneciler, Istanbul/Turkey

2. Istanbul University, Faculty of Engineering, Department of Chemistry, Biochemistry Division, 34320, Avcilar, Istanbul/Turkey

3. Istanbul University, Faculty of Engineering, Department of Chemistry, Inorganic Chemistry Division, 34320, Avcilar, Istanbul/Turkey

Some medicinal researches have shown that vanadium compounds has glucose-lowering and antidiabetic effects, and are candidates for antidiabetic treatments. In our previous study, we found that a new oxovanadium (IV) chelate (VOL) (L: N1-2,4-dihydroxybenzylidene-N4-2-hydroxybenzylidene-S-methyl-thiosemicarbazidato) can regenerate beta cells of the pancreas in experimental diabetes and has antidiabetic and protective effects on the pancreas. Diabetic nephropathy is a serious complication in the diabetic patients. In this study, we investigated the effects of VOL on the kidney of STZ-diabetic rats, morphologically and biochemically. The animals were randomly divided into four groups. Group I: control (intact) animals. Group II: control animals administered VOL. Group III: STZ-diabetic animals. Group IV: STZ-diabetic animals administered VOL. Diabetes was induced by a single intraperitoneal injection of STZ (65 mg/kg). VOL was given to some of the experimental animals by gavage at a dose of 0.2mM/kg every day for 12 days. On day 12, the blood and kidney tissue samples were taken from the rats. Serum urea and creatinine levels, and glutathione and catalase activities were increased, while kidney superoxide dismutase activity was decreased in diabetic group. The degenerative changes in proximal tubules in kidney tissue of diabetic animals were particularly observed. Administration of VOL to the diabetic rats reversed this diabetic effects on the kidney due to its insulinomimetice ffects. According to the results obtained, it was concluded that VOL has a protective effect on the kidney in experimental diabetes.

464

PO 038Hospitalization of Adult Patients with Low-Risk Community-Acquired Pneumonia　: A Retrospective Observational Study Using a National Inpatient Database in Japan.Sayuri Shimizu (Japan)

465

PO 039Correlation Of Physical Examination And Neutrophil To Lymphocyte Ratio With Cortisol Serum In Patients With Cushing SyndromeHendra Gunawan (Indonesia)

466

PO 040Frequency of Hyperhomocysteinemia in Patients with Polycystic Ovary Syndrome

Şakir Özgür Keşkek¹, Ahmet Akın², Mehmet Bankir¹, Gülay Ortoğlu¹, Sinan Kırım¹¹ Department of Internal Medicine, Numune Training and Research Hospital, Adana, Turkey ²Department of Internal Medicine, Dr Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey

Introduction: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women between the ages of 18 and 44. Due to the tendency towards central obesity and other symptoms associated with insulin resistance, PCOS was found to be associated with cardiovascular diseases. Hyperhomocysteinemia is accepted as an independent risk factor for cardiovascular diseases. In this study, we aimed to investigate the homocysteine level and frequency of hyperhomocysteinemia in patients with PCOS.

Methods: A total of 32 female subjects were included in this cross-sectional cohort study. The study group comprised 18 patients with PCOS according to the Rotterdam criteria and the control group comprised 14 healthy subjects. Homocysteine levels and frequency of hyperhomocysteinemia of the groups were calculated. MedCalc 16.4.3 software (MedCalc, Belgium) was used for all statistical analyses. Chi square test was used for comparison of demographic data. T test or the Mann-Whitney U test was used to compare the groups.

Results: Groups were matched according to the age (27.5±4.9 vs. 28.1±4.8 p=0.741). The mean body mass index and insulin levels of patients with PCOS were higher than those in healthy group (27.7±2.2 and 15.4±8.2 vs. 24.2±2.7 and 9.5±4.8, respectively, p=0.004 and 0.02, respectively). Vitamin B12 and folate levels of the groups were comparable (365.3±154.9 and 8.9±1.8 vs. 279.5±79.6 and 7.8±1.4, p= 0.06, p=0.08, respectively). The mean homocysteine level was high in patients with PCOS (15.0±4.9 vs. 11.6±3.8 p=0.045). The frequency of hyperhomocysteinemia was significantly higher in the PCOS group (66.6% vs. 28.5%). There is an association between PCOS and hyperhomocysteinemia (OR 5.0, Cl 95% 1.09-22.8, p=0.037).

Conclusion: High frequency of cardiovascular disease in women with PCOS may also be associated with high homocysteine level.

467

PO 041Prevalence of peripheral arterial disease in patients with diabetes mellitus in a primary refferal hospital

Nikko DarnindroInternist, Cilincing General Hospital, Jakarta Indonesia

Background: Peripheral arterial disease (PAD) is one of the macrovascular complications of type 2 diabetes mellitus. The prevalence of diabetes is getting higher and management at primary health care plays an important role. Early screening, identification of risk factors and good glycemic control in primary health care can prevent PAD.

Objective: To determine the prevalence of PAD in diabetic patients in primary care

Method: A cross sectional study was conducted in diabetic patients over 18 years old at Clincing General Hospital. Structured questionnaires for demographic characteristics and risk factors were done. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.91 and/or Toe-Brachial Index <0.61 on either leg with VASERA 1500N FUKUDA DENSHI.

Result: We studied 41 patients (7 men and 34 women; mean age 58.1 +/- 9.5 years; median duration of diabetes 3, min 0 max 26years). The prevalence of PAD was 56.1% with women having a slightly lower prevalence as compared to men (55.9 % vs 57.1%, p>0.05). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, body mass index, proteinuria, stage of renal disease, symptoms of claudicatio, history angina, and PAD.

Conclusion: The prevalence of PAD in diabetic patients was high. The awareness and early screening of PAD are urgently needed. There is no significant risk factors have been found. Further and larger study is needed to determine independent risk factors.

Key words: Peripheral arterial disease, Ankle brachial pressure, Diabetes mellitus

468

PO 042Presenter Name : Mujgan Gurler, Asst. Prof.

Adress : Abant Izzet Baysal University, Faculty of Medicine,

Department of Internal Medicine, 14820, Bolu, Turkey.

Phone : +903742534656/3550

E-mail : [email protected]

Serum Visfatin Levels in Patients with Subclinical and Newly Diagnosed Type 2 Diabetes Mellitus

Abstract

Aim: The present study aimed to compare serum visfatin levels among subjects with subclinical diabetes/pre-diabetes (impaired fasting glucose [IFG] alone and IFG+impaired glucose tolerance [IGT]), subjects with newly diagnosed type 2 diabetes mellitus (DM), and healthy nondiabetic normoglycemic controls and to evaluate the relation of serum visfatin levels with some metabolic parameters and insulin resistance.

Methods: The study was conducted in 80 subjects, of whom 52 (65%) were female and 28 (35%) were male. The subjects were divided into 4 groups as control, IFG, IFG+IGT, and newly diagnosed type 2 DM groups, containing 20 subjects in each. Waist and hip circumferences, age, gender, body mass index (BMI), and demographic characteristics were recorded in each group. The levels of fasting plasma glucose, fasting serum insulin, C-peptide, cortisol, glycosylated hemoglobin (HbA1c), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), very low-density lipoprotein cholesterol (VLDL-C), triglyceride (TG) were measured and insulin/C-peptide ratio and the homeostasis model assessment-insulin resistance (HOMA-IR) were calculated and compared among the groups.

Results: In line with glucose metabolism disorder, significant increases were observed in the insulin, C-peptide, insulin/C-peptide ratio, HbA1c (%), HOMA-IR values, cardiovascular risk parameters (Total cholesterol, LDL-C, VLDL-C, triglyceride), and visfatin levels in the subclinical diabetes and diabetes groups as compared to the control group (all p<0.05).

Conclusions: Visfatin could be considered among therapeutic agents used in the prevention and amelioration of critical complications in diabetes. Moreover, the treatments targeted to reduce serum visfatin levels may contribute to the metabolic control in diabetes mellitus.

Keywords: Diabetes mellitus, insulin, visfatin.

469

PO 043Presence of Diabetes and Its Association with Depressive Symptom and Treatment: The 6th Korean National Health and Nutrition Examination SurveySung Soo Shim (South Korea)

1 Chang-pyung Public Health Office, Damyang-kun, South Korea2 Subook Public Health Office, Damyang-kun, South Korea3 Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, South Kore

The purpose of this study was to investigate the association between presence of diabe-tes and depressive symptoms and treatment in Korean national survey. We performed cross-sectional analysis 7277 participants on 6th Korean National Health and Nutrition Examination Survey. We examined the presence of diabetes, presence of depression (based on EuroQoL survey) and treatment of depression. The presence of depressive symptom was seen in 8.4% of all participants. The presence of diabetes was seen in 15.0% of all participants. In logistic regression model, diabetes was associated with the presence of depression (Odds ratio [OR]: 1.68, 95% confidence interval: [1.31-2.15]). The presence of diabetes was also associated with whether the participant was actively treated for depression (OR: 2.67, 95% confidence interval: [1.43-4.98]). In conclusion, de-pressive subjects were more likely to get treatment in diabetes. This suggests that active screening for comorbid conditions such as diabetes should be actively sought.

470

PO 044SUCCESSFUL MANAGEMENT OF INSULIN HYPERSENSITIVITY ON TYPE 2 DIABETES MELLITUS PATIENT : A CASE REPORT

Agus Joko S1, Iris Rengganis2, Dirga Sakti R3, Olivia Cicilia W3

1. Allergy Immunology Division,Internal Medicine Departement, Sebelas Maret University - dr. Moewardi Hospital, Surakarta.

2. Allergy Immunology Division, Internal Medicine Departement, University of Indonesia - RSCM, Jakarta.

3. Endocrinology and Metabolic Division, Internal Medicine Departement, University of Indonesia-RSCM, Jakarta.

Abstract

Background: Insulin therapy is usually given to type 1 and type 2 diabetics. Insulin allergy is rare, only about 2.4% in prevalence. Clinical feature of insulin hypersensitivity varies greatly. The IgE- or IgG-mediated allergic reaction may start from pruritus, wheal formation, rash, to anaphylactic shock. Skin prick test may be positive.

Case: A 37-year-old woman has been diagnosed for diabetes for 6 years. She regularly checks her blood glucose but the oral hypoglycemic drug she took fail to control her diabetes. She had insulin Aspart for four years until she developed allergy to it. She suffered from wheals on her skin that start to form 1-3 minutes after insulin injection. Her doctor switched the insulin from Aspart to Lispro, and again she developed hypersensitivity to Lispro after one year. The patient then underwent a desensitization protocol involving seven types of insulin. She appears to be tolerant to Glulisin insulin.

Discussion: Types of insulin that associated with allergic reactions are Glargin, Detemir, Crystalline, NPH, Aspart and Lispro. Some of the substance inside the insulin such as Metacresol and Protamine has also been associated with hypersensitivity reaction. In this particular case, the patient seems to be allergic to numbers of insulin types except for Glulisin. Limitation of this case report are the lack of insulin-specific IgE/IgG antibodies data.

Conclusion: Hypersensitivity to insulin could be adequately managed by joint management and collaboration between Immunology and Diabetes experts.

Key words: diabetes mellitus, insulin therapy, insulin hypersensitivity, skin prick test, desensitization.

471

PO 045CORRELATION OF HIGH MOLECULAR WEIGHT ADIPONECTIN WITH FASTING INSULIN IN THE TYPE-2 DIABETES MELLITUS Deasy Ardiany, Soebagijo Adi, Askandar Tjokroprawiro, Sri Murtiwi

Surabaya Diabetes and Nutrition Centre - Dr. Soetomo Teaching HospitalFaculty of Medicine Airlangga University, Surabaya

ABSTRACT

Background: Adiponectin is an adipocyte-derived hormone that enhances insulin sensitivity and plays an important role in glucose and lipid metabolism. Adiponectin has been associated with insulin sensitivity, as circulating levels are reduced in a number of insulin-resistant conditions, including obesity, type 2 diabetes mellitus (T2DM) and cardiovascular disease. High molecular weight adiponectin (HMW-adiponectin) is considered the active form of adiponectin and better marker of insulin resistance. The effect of insulin resistance on plasma HMW- adiponectin level in human subjects has not been well studied. Our objective was to investigate the correlation between HMW-adiponectin with fasting insulin and Homeostatic Model Assessment – Insulin Resistance (HOMA-IR) in the T2DM.

Method: This is a cross sectional study with T2DM who came to the outpatient clinic Soetomo Hospital in Surabaya during January 2010 to December 2012. Subjects met the inclusion and exclusion criteria were measured their HMW-adiponectin level in plasma by using ELISA method. Measurements of fasting insulin and HOMA-IR were used as an index of insulin resistance.

Results: Forty type-2 DM patients consisted of 16 (40%) males and 24 (60%) females who met the inclusion and exclusion criteria were enrolled in this study. Their mean of age was 51 ± 5,2 years old, and duration of illness was 16.49 ± 23.4 months, HMW- adiponectin level was 2195.6 ± 4.6 ng/ml, A1C was 8.52 ± 0.9%, BMI was 26.62 ± 4.5 kg/m2, fasting insulin was 9.16 ± 4.8 µU/ml, and HOMA-IR was 3.62 ± 2.1. Spearman’s correlation analysis showed that fasting insulin significantly correlated with the HMW-adiponectin level (p = 0,035; R = -0.449), while HOMA-IR did not.

Conclusion: Fasting insulin is negatively correlated with HMW-adiponectin level in patients with T2DM.

Keywords: Type-2 diabetes mellitus, HMW-adiponectin, fasting insulin, HOMA-IR

472

PO 046SYSTEMATIC REVIEW OF THE EFFICACY OF INTERLEUKIN-1 RECEPTOR ANTAGONIST IN TYPE 2 DIABETES S PUSPADINA, S RAHMAYANTI

ENDE DISTRICT HOSPITAL, EAST NUSA TENGGARA

BACKGROUND: Interleukin (IL)-1 impairs insulin secretion and induces β-cell apoptosis. Meanwhile its natural competitive inhibitor, the IL-1–receptor antagonist (IL-1RA) protects human β-cells from glucose-induced functional impairment and apoptosis. The expression of IL-1 is increased while the expression of IL-1RA is decreased in β-cell obtained from patients with type 2 diabetes (T2D). As conventional antidiabetic agents being less desirable regarding its potential adverse effects, we aim to review IL-1RA’s therapeutic impact in T2D.

METHODS: We conducted a systematic review of randomized controlled trials (RCTs) to assess the efficacy of IL-1RA in β-cell function control and glycemic control in patients with T2D. A search for RCTs was conducted using the PubMed and Cochrane databases (2006-2016). Two RCTs met the inclusion and exclusion criteria which later were appraised using the Oxford Center for EBM appraisal tool for therapy.

RESULTS: The studies randomly assigned 70 patients with T2D to receive a recombinant human IL-1RA (anankira) or placebo. Study shows that in the anankira group, the level of glycated hemoglobin was higher (p=0,03), ratio of proinsulin to insulin (PI/I)), IL-6 levels, C-reactive protein were significantly reduced (p<0,05), plasma glucose level at beginning and end of a 2-hour oral glucose-tolerance test were insignificantly reduced. Insulin resistance, insulin-regulated gene expression in skeletal muscle, serum adipokine levels, and the BMI were similar in the two study groups. A follow up study shows that 39 weeks after anankira withdrawal the PI/I ratio remain improved.

CONCLUSIONS: Studies suggest that antagonism of interleukin-1 has possible therapeutic potential in the treatment of T2D. But further study has to be conducted to see if recombinant human IL-1RA could be used as substitute therapy in patient with T2D.

473

PO 047Clinical Features of Hypothyroidism and Helath-Related Quality of Life After Radiotherapy: Justifying Thyroid Function Screening for Indonesian Nasopharyngeal Cancer Survivors

Yusuf Aulia Rahman1, Em Yunir2, Andhika Rachman3, Siti Setiati4

1Internal Medicine Resident, 2Metabolic-Endocrinology Division, 3Hematology-Medical Oncolgy Division, 4Clinical Epidemiology Unit

Internal Medicine Department – Cipto Mangunkusumo Hospital, Jakarta

Background. Nasopharyngeal cancer (NPC) ranks the 4th most common cancer in Indonesia and have a good survival rate with radiotherapy. This study aims to evaluate the health-related quality of life (HR-QoL) of NPC survivors after radiotherapy and to investigate their thyroid function, which to our knowledge has not been studied.

Methods. This cross-sectional study involved 97 NPC survivors who had completed scheduled radiotherapy in Cipto Mangunkusumo Hospital for a minimum of six months prior to the study. Anamnesis and physical examinations are used to find 12 clinical signs and symptoms of hypothyroid using Zulewski’s score as reference. All subjects were asked to fill the validated Indonesian version of European Organization for Research and Cancer Treatment Quality of Life Questionnaire-C30 (EORTC QLQ-C30), and tested for serum thyroid function (free thyroxine & thyroid stimulating hormone). The subjects were then classified into three groups of euthyroid, subclinical and clinical hypothyroid based on laboratory results. The clinical and HR-QoL scores was then compared between groups.

Results. Majority of subjects were men (63.9%), Hypothyroid found in 23 subjects (23.71%), which 10 manifested as clinical hypothyroid. There is a small Zulewski’s score difference between hypothyroid and euthyroid. The hypothyroid group has a lower quality of life than the euthyroid.

Conclusion. Albeit subtle of signs and symptoms, hypothyroid is prevalent among NPC survivors, which potentially lowering the HR-QoL. The findings support the case for thyroid function screening for NPC survivor patients.

474

PO 048CLINICAL PROFILE OF MOLA HYDATIDOSA PATIENTS WITH HYPERTHYROID

Nugraheny Prasasti Purlikasari, Deasy Ardiani, Sri Murtiwi, Rio Wironegoro

Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Hyperthyroidism is a form of thyrotoxicosis that is caused by the synthesis and secretion of thyroid hormone in thyroid gland. Pregnancy is hyperdynamic condition with symptoms that are similar to hyperthyroid. The aim of this study is to observe the clinical profiles that occur in mola hydatidosa patients with hyperthyroid in Dr. Soetomo general hospital from January 2012 to December 2015.

Material & Methods: A descriptive study of mola hydatidosa patients with hyperthyroid admitted in Dr. Soetomo Teaching Hospital was performed. This study used secondary data from medical record of Obstetry Gynecology Department of Dr. Soetomo general hospital from January 2012 to December 2015. Mola hydatidosa patients with subclinical hyperthyroid, euthyroid and history of hyperthyroid before pregnancy were excluded from this study.

Results: A total of 26 patients were included. Mostly patients came to hospital due to vaginal bleeding (61.5%), abdominal bloating (11.5%), abdominal pain (7.7%), nausea and vomiting (7.7%). From 26 patients, 53.8% were in first trimester of pregnancy, 26.9% were in second trimester, and the remains were unclear because they didn’t remember the first day of the last menstrual periods. None of patient had thyroid storm and only 1 patient suffered from impending thyroid storm. From hyperthyroid signs and symptoms: 38,5% had tachycardia, 46,2% had heat intolerance, none of the patient had frequent stool, fever, or even exophthalmia. All patients underwent curettage as the primary treatment of mola hydatidosa and received anti thyroid treatment before curettage. All patients had good prognosis.

Conclusion: Our findings confirmed the data from literature of hyperthyroid signs and symptoms. More than one-third patients had tachycardia and heat intolerance as signs and symptoms. None of patient had thyroid storm.

Keywords: mola hydatidosa, hyperthyroid, thyrotoxicosis

475

PO 049CORTISOL HORMONE PROFILE IN MACROADENOMA HYPOPHISIS PATIENTS WHO UNDERGO SURGERY IN Dr. SOETOMO GENERAL HOSPITAL SURABAYA INDONESIA

Renny Anggraeni Puspitasari, Hermina Novida, Soebagijo Adi


Background: Macroadenoma hypophysis is a benign tumor of the pituitary gland with size larger than 10 mm. Altough the tumor is benign, it may affect pituitary function and influences hormones such as cortisol, thyroid, prolactin, and also growth hormone. Cortisol is a life sustaining adrenal hormone essential to the maintenance of homeostasis. Operative management (transsphenoidal surgery) is the most common way to remove adenoma hypophisis. The aim of this study is to observe the cortisol hormone profiles that occur in macroadenoma hypophysis patients who undergo surgery in Dr. Soetomo general hospital, from January 2012 to Desember 2015.

Material & Methods: A descriptive study of macroadenoma hypophysis patients admitted in Dr. Soetomo general hospital was performed. This study used secondary data from medical record of Neurosurgery and Neurology Department of Dr. Soetomo general hospital from January 2012 to Desember 2015. All macroadenoma patient with the result of cortisol hormone were include from this study.

Results: A total of 47 patients were included, 23 male and 24 woman. Mostly macroadenoma hypophisis patients from age group 25-44 (46,8%), 45-64 (38,2%), >65 (0,06%), 15-24 (0,06%),5-15 (0,02%). Hypocortisol was found in 12 patients (25,6%) which 7 patients were male and 5 patients were female, hypercortisol in 8 patients (17%) where 2 patients were male and 6 patients were female, normal cortisol hormone in 14 patients (29,8%), and no data (27.6%).

Conclusion: Our findings confirmed the data from literature, that mostly macroadenoma hypohisis patients in Dr. Soetomo general hospital who undergo surgery in group age 25-44 years old had cortisol hormone disruption (mostly hypocortisol).

Keywords: pituitary adenoma, macroadenoma hypophisis, hypothiroid, hyperthyroid, hypocortisol, hypercortisol, hypoprolactin, hyperprolactin.

476

PO 050CORTISOL HORMONE PROFILE IN MACROADENOMA HYPOPHISIS PATIENTS WHO UNDERGO SURGERY IN Dr. SOETOMO GENERAL HOSPITAL SURABAYA INDONESIA

Renny Anggraeni Puspitasari, Hermina Novida, Soebagijo Adi


Background: Macroadenoma hypophysis is a benign tumor of the pituitary gland with size larger than 10 mm. Altough the tumor is benign, it may affect pituitary function and influences hormones such as cortisol, thyroid, prolactin, and also growth hormone. Cortisol is a life sustaining adrenal hormone essential to the maintenance of homeostasis. Operative management (transsphenoidal surgery) is the most common way to remove adenoma hypophisis. The aim of this study is to observe the cortisol hormone profiles that occur in macroadenoma hypophysis patients who undergo surgery in Dr. Soetomo general hospital, from January 2012 to Desember 2015.

Material & Methods: A descriptive study of macroadenoma hypophysis patients admitted in Dr. Soetomo general hospital was performed. This study used secondary data from medical record of Neurosurgery and Neurology Department of Dr. Soetomo general hospital from January 2012 to Desember 2015. All macroadenoma patient with the result of cortisol hormone were include from this study.

Results: A total of 47 patients were included, 23 male and 24 woman. Mostly macroadenoma hypophisis patients from age group 25-44 (46,8%), 45-64 (38,2%), >65 (0,06%), 15-24 (0,06%),5-15 (0,02%). Hypocortisol was found in 12 patients (25,6%) which 7 patients were male and 5 patients were female, hypercortisol in 8 patients (17%) where 2 patients were male and 6 patients were female, normal cortisol hormone in 14 patients (29,8%), and no data (27.6%).

Conclusion: Our findings confirmed the data from literature, that mostly macroadenoma hypohisis patients in Dr. Soetomo general hospital who undergo surgery in group age 25-44 years old had cortisol hormone disruption (mostly hypocortisol).

Keywords: pituitary adenoma, macroadenoma hypophisis, hypothiroid, hyperthyroid, hypocortisol, hypercortisol, hypoprolactin, hyperprolactin.

477

PO 051ASSOCIATION BETWEEN GLOMERULAR FILTRATION RATE AND INTACT PARATHYROID HORMONE LEVEL IN NON-DIALYTIC DIABETIC KIDNEY DISEASE PATIENTS

Achmad Syaiful Ludfi, Nunuk Mardiana, Widodo, Djoko Santoso, Mochammad Thaha, Chandra I Mohani, Aditiawardana, Artaria Tjempakasari

Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Hyperparathyroidism is one of mineral and bone metabolism disorder in CKD, currently known as chronic kidney disease-mineral and bone disorders (CKD-MBD). CKD-MBD is defined as a systemic disorder of mineral and bone metabolism characterized by alteration of calcium, phosphate, parathyroid hormone (PTH) and vitamin D. As renal function deterioration progressed hyperparathyroid developing, the rate and severity are different between diabetic and non diabetic patients. This study analyze the association between GFR and iPTH levels in non-dialysis diabetic kidney disease patient at Internal Medicine Outpatient Clinic Dr. Soetomo Hospital Surabaya

Method : This was an observational analitic study with cross sectional design. It involved 41 non-dialytic diabetic kidney disease patients who meet the inclusion and exclusion criterias. The variables studied were GFR calculated by the CKD-EPI formula and iPTH levels measured by Electro-chemiluminescence immunoassay (ECLIA) methode. The association between GFR and iPTH levels was calculated by Pearson or Spearman non-parametric tests according to variable distribution.

Result : Of the 41 patients, the mean age was 51.71 ± 7.48 years, most patients (78%) were male. The mean concentration of Ca was 8.49 ± 0.72 mg/dl and P 4.99 ± 1.97 mg / dl. GFR median was 15 ml / min and iPTH median was 78.26 pg / ml. There was a negative correlation between iPTH and GFR. Spearman correlation test revealed association between GFR and iPTH (r = -0.571, p = 0.000).

Conclusion : There is a significant association between GFR with iPTH levels in non-dialytic diabetic kidney disease patients

Keywords : CKD-MBD, GFR, iPTH, non dialytic

478

PO 052FREQUENCY AND RISK FACTORS OF DIABETIC COMPLICATIONS AMONG SELECTED GROUP OF DIABETIC PATIENTS: REAL-LIFE SCENARIO FROM A DEVELOPING COUNTRY, BANGLADESH.

Hasna Fahmima Haque1, Palash Mitra2, Muhammad Abdur Rahim2, Farhana Afroz1, Samira Rahat Afroze1, AKM Shaheen Ahmed1, AKM Musa1

1 Internal Medicine, 2Nephrology and Dialysis, BIRDEM, Dhaka, BangladeshBackground/Rationale: Diabetes mellitus is a major global public health problem and its complications like coronary artery disease (CAD), stroke, amputations, nephropathy and retinopathy are alarming public health issues. These complications result in significant morbidity, mortality and huge economic burden for the patient/ society. This current study aimed to evaluate the frequency of different diabetic complications and their risk factors in a real-life setting.

Methods: This cross-sectional study was done in BIRDEM General Hospital from July to December 2015. Diagnosed adult diabetic patients of either sex irrespective of duration and type were consecutively and purposively included in this study. Enrolled patients were evaluated clinically and biochemically.

Results: Total patients were 400 with female predominance (57.8%). Mean age was 54.5±10.9 years. Majority (57.5%) were from urban areas. Only 6.5% were smokers, 82% had hypertension and 37.5% had dyslipidaemia. Mean duration of diabetes was 11.6±7.6 years, body mass index was 24.6±4.5 kg/m2, HbA1c was 9.1±2.0%. Nephopathy (42.5%) was the commonest complication followed by retinopathy (37.8%), neuropathy (29.8%), CAD (25.8%), peripheral vascular disease (14%) and stroke (11%). Long duration (>5 yrs) and poor control of diabetes (HbA1c >7%), family history of diabetes, hypertension, dyslipidaemia, smoking and male sex were significant risk factors for diabetic complica-tions.

Conclusions: Complications of diabetes are common. Glycaemic control and control of hypertension, dyslipidaemia, weight management and smoking cessation may halt or delay the development of complications of diabetes. Patient education is of paramount importance in this regard.

Presenter: Dr. Hasna Fahmima Haque, Registrar, Internal Medicine, BIRDEM General Hospital, Dhaka, Bangladesh. Email: [email protected]

479

PO 053DETECTION OF MONOCYTE CHEMOATTRACTANT PROTEIN-1 IN KIDNEYS OF DIABETIC MICE WITH AND WITHOUT FUNCTIONAL ENDOTHELIAL HEPARAN SULFATE

Firas Farisi Alkaff1, Ditmer Talsma2, Jaap Van den Born2

1Faculty of Medicine, Airlangga University, Surabaya, East Java, Indonesia2Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

Introduction: Diabetic nephropathy, one of the most important diabetes complications, is a growing worldwide epidemic. An estimated 366 million people suffer from diabetes worldwide. Recently, it has been found that inflammation is a main instigator of kidney damage rather than high plasma glucose. Heparan sulfate proteoglycans (HSPGs) are known for their role in leukocyte recruitment and tissue remodelling. A critical enzyme in the biosynthesis of HSPGs is N-deacetylase N-sulfotransferase-1 (NDST-1), crucial in the sulfation of the HSPG glycosaminoglycan side chains. The aim of the study is to detect monocyte chemoattractant protein-1 (MCP-1) in the kidneys of these diabetic mice as a marker for inflammation.

Materials and Methods: Age matched male and female C57Bl/6J - WT and C57Bl/6J – Tie2 Cre+ NDST1 flox/flox mice were used for this study. Diabetes was induced by i.p. injections with streptozotocin for five days. Mice were sacrificed two months after diabetes induction and kidneys were harvested for immunohistochemistry. This research is a qualitative study. Frozen 4µm sections were blocked for endogenous peroxidase. Thereafter Rabbit anti-mouse MCP-1 was incubated in different concentrations and detected using a Goat anti-rabbit HRP labelled antibody followed by the Tetramethylrhodamine System. Sections were scored subjectively under a fluorescence microscope and MCP-1 localization, intensity and staining quality was assessed.

Results: MCP-1 staining was seen in the vascular endothelium of both large and small renal arteries in both wild type and knockout diabetic mouse, but barely in venes, venules and capillaries. In high concentration of antibody, staining was clearly seen in both large and small arteries, and in low concentration, the small arteries staining were not detected, indicating less MCP-1 synthesis in smaller arteries. Negative control showed no staining.

Conclusion: There is no difference in MCP-1 expression between functional and non-functional endothelial Heparan Sulfate.

Keywords: MCP1, NDST1, Heparan Sulfate, Diabetic Nephropathy, Kidney

480

PO 054Hürthle cell Carcinoma of thyroid gland Epidemiology study

Olivia C. Walewangko*, Benyamin Makes**, Dante Saksono Harbuwono**Divisi Endokrin, Metabolik dan Dislipidemia, Departemen Ilmu Penyakit Dalam,FK Universitas Indonesia, RSUPN Cipto Mangunkusumo Jakarta** Departemen Medik Patologi Anatomi, FK Universitas Indonesia, RSUPN Cipto Mangunkusumo Jakarta

Background: Hürthle cell carcinoma of thyroid gland is a rare and unusual type of thyroid carcinoma, accounts only 3-10% from all differentiated type and derived from follicular cells. These variants have different behaviors and more aggressive than the follicular type (Aytug et al, 2015) and FNA alone is not enough to identify and specify (Barnabei et al, 2009).

Method: Data were collected from medical record and Anatomy Pathology Department during the year of 2005 to 2015 in Cipto Mangunkusumo National General Hospital Jakarta.

Result: Data from Cipto Mangunkusumo National General Hospital shows during 2005 to 2015 there were 30 cases of Hürthle cell tumor (20 carcinoma cell Hürthle, 8 adenoma cell Hürthle, and 2 mixed type). Based on age group carcinoma cell Hürthle mostly found in age above 40 years old, adenoma cell Hürthle in age 30-50 years old, and mixed type in age 40-50 years old. All of the cases are mostly found in women more than in men. Cytological diagnosis obtained through frozen section thyroid gland tissue compared with FNAB.

Conclusion: Hürthle cell carcinoma can show a similar histology behavior with Hürthle cell adenoma, women is more common then men, and age when first diagnosed is above 40 years old. A precise method and histopathology will give a guidance for the ideal treatment, and the molecular testing as an adjunctive test in thyroid nodule FNA, is recommended for an early detection of malignancy.

Key words: Hürthle cell, thyroid, epidemiology, diagnostic

481

PO 055SERUM INTACT PARATHYROID HORMONE LEVEL IS INVERSELY CORRELATED WITH GLYCATED HAEMOGLOBIN IN DIABETIC CKD STAGES 3-5 PREDIALYSIS PATIENTS

Wasim Md. Mohosin ul Haque1, Muhammad Abdur Rahim1, Tabassum Samad1, Palash Mitra1, Samira Humaira Habib2, Sarwar Iqbal11 BIRDEM General Hospital, Nephrology, Dhaka, Bangladesh, 2 BADAS, Health Eco-nomics Unit, Dhaka, Bangladesh

Background/Rationale: Diabetes mellitus (DM) is a leading cause of chronic kidney disease (CKD). Management of chronic kidney disease-mineral and bone disorder (CKD-MBD) is an integral part of CKD management. Intact parathyroid hormone (iPTH) level is the key target of managing this disorder. High blood glucose impairs PTH secretion. Patients on haemodialysis with high glycated haemoglobin (HbA1c) levels are reported to have low iPTH. Data regarding HbA1c and its relation with iPTH in CKD stages 3-5 predialysis patients are limited. This study was designed to evaluate the glycaemic status and level of iPTH among diabetic CKD stages 3-5 predialysis patients.

Methods: This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. Diabetic patients suffering from CKD stages 3-5, who were not on dialysis, were consecutively and purposively included in this study. Along with base-line characteristics, laboratory data including HbA1c and iPTH levels were recorded for all patients. Data were analyzed by using SPSS version 20.0 and Pearson’s correlation test was applied to evaluate the relationship between HbA1c and iPTH.

Results: Total patients were 306, including 166 (54.2%) males. Mean age was 56.5±11.3 years. Mean duration of DM and CKD were 12.8±7.6 and 2.9±1.7 years respectively. Among the study population, 16.0% were in CKD stage 3, 29.4% in CKD stage 4 and rest 54.6% in CKD stage 5. Mean HbA1c (%) and iPTH (pg/ml) were 7.77±2.14 and 229.7±151.2 respectively. Mean HbA1c (%) and iPTH (pg/ml) in CKD stages 3, 4 and 5 were 8.36±1.59 and 171.7±127.9, 7.99±1.92 and 179.5±131.4, and 7.77±2.14 and 273.8±119.2 respectively. On correlation analysis, HbA1c had a significant negative cor-relation with iPTH (r=-0.002).

Conclusion: The results of current study showed that most diabetic CKD stages 3-5 predialysis patients had poor glycaemic control and HbA1c had negative correlation with iPTH.

Authors

Wasim Md. Mohosin ul Haque, Associate Professor, Department of Nephrology, BIRDEM General Hospital, Shahbag, Dhaka-1000, Bangladesh. Email: [email protected]

482

Muhammad Abdur Rahim, Assistant Professor, Department of Nephrology, BIRDEM Gen-eral Hospital, Shahbag, Dhaka-1000, Bangladesh. Email: [email protected]

Tabassum Samad, Junior Consultant, Department of Nephrology, BIRDEM General Hos-pital, Shahbag, Dhaka-1000, Bangladesh. Email: [email protected]

Palash Mitra, Assistant Registrar, Department of Nephrology, BIRDEM General Hospital, Shahbag, Dhaka-1000, Bangladesh. Email: [email protected]

Samira Humaira Habib, Senior Research Officer, Health Economic s Unit, BADAS, Dha-ka, Bangladesh. Email: [email protected]

Sarwar Iqbal, Associate Professor and Head, Department of Nephrology, BIRDEM Gen-eral Hospital, Shahbag, Dhaka-1000, Bangladesh. Email: [email protected]

483

PO 056EFFECT OF PHYSICAL ACTIVITY INTENSITY TO HBA1C LEVEL IN NON DIABETIC SMOKING MENJessica Natasya Tanjung*, Lisa Kurnia Sari**, Iswanto***, Sapto Priatmo****

*Faculty of Medicine, Duta Wacana Christian University Yogyakarta, Indonesia**Internal Medicine Department, Faculty of Medicine, Duta Wacana Christian University – Bethesda Lempuyangwangi Hospital, Yogyakarta, Indonesia***Pulmonology Department, Faculty of Medicine, Duta Wacana Christian University – Bethesda Hospital, Yogyakarta, Indonesia****Internal Medicine Department, Faculty of Medicine, Duta Wacana Christian University – Bethesda Hospital, Yogyakarta, Indonesia

Correspondence : [email protected]

Background: Smoking can increase insulin resistance. Moderate to vigorous physical activity have been knowing can increase insulin sensitivity which may decrease blood sugar levels. HbA1C level can give a picture of average blood glucose control for the past 2 to 3 months. The effect of physical activity to counter blood sugar level raising in healthy smoking men has not been known, yet.

Objective: This study aims to compare HbA1c levels in smoking men with moderate to vigorous physical activity and smoking men with light physical activity.

Methods: This was an observational analytic study using case-control design. Physical activity was determined based on International Physical Activity Questionnaire (IPAQ), and classified into moderate to vigorous physical activity and light physical activity. Cases consisted of 24 smoking men, aged 20-40 years old, from Duta Wacana Christian University, with moderate to vigorous physical activity. Controls consisted of 24 smoking men with light physical activity. HbA1c level of each subject was assesed using turbidimetric inhibition immunoassay method.

Results: HbA1c levels (%, mean±SD) were not different significantly (p=0,373) between smoking men with moderate to vigorous physical activity (5.00±0.21) compared to smoking men with light physical activity (5.05±0.23). There was a significant difference (p = 0,004) between HbA1C levels of men who had smoked for 1–5 years (4,95±0.21) and men who had smoked for 16–20 years (5,45±0.7).Conclusion: There was no significant difference between HbA1c levels of smoking men with moderate to vigorous physical activity and smoking men with light physical activity.

484

PO 057Correlation Between Glycemic Characteristic And Erythrocyte Indices In Obese Subjects With Different Glycemic Status

Brama Ihsan Sazli, Dharma Lindarto, Dairion Gatot, Santi Syafril

ABSTRACT

Background: Hemorheological inflammatory parameters in diabetes mellitus are often disturbed. Erythrocyte of patients with type 2 diabetes are known to aggregate more readily than those of normal subjects, with excessive aggregation of erythrocytes considered one of the most prominent features in diabetes patients with poor glycemic control

Aim: To evaluate the correlation between glycemic characteristic and erythrocyte indices in obese subjects with different glycemic status.

Methods: The cross-sectional study enrolled 80 obese subjects. The correlations between glycemic characteristic (FPG, PPG, HbA1c and HOMA-IR) and erythrocyte indices (Hb, RBC, MCV, MCH and MCHC) were evaluated.

Results: Of 80 obese subjects have different glycemic status, including 48 patients with only obesity (HbA1c < 5.7%), 19 patients with prediabetes (HbA1c 5.7–6.4%), and 13 patients with diabetes (HbA1c > 6.4%). Glycemic characteristic and profile lipid (HDL-C and TG) differ significantly in the different HbA1c level. Erythrocyte indices did not differ significantly in the different HbA1c level. Partial Spearman’s correlation analysis showed that only MCV was significantly correlated with glycemic characteristic of FPG, PPG, HbA1c and HOMA-IR (r=-0.36, p=0.001; r=-0.29, p=0.007; r=-0.27, p=0.014 and r=-0.236, p=0.035; respectively).

Conclusions: MCV was significantly correlated with glycemic characteristic (FPG, PPG, HbA1C and HOMA-IR). Further investigations are recommended to clear the problem.

Key words: glycemic-characteristic, HbA1c, erythrocyte-indices

485

PO 059Thyroid Diseases : Characteristic Symptoms in Adult Woman in Urban Cities in Indonesia

Djamal Rizky Syawaluddin1, Wijaya Kristian2, Effendy Cut Azlina3

Subang General Hospital, West Java, Indonesia1,2, Gatot Soebroto Central Army Hospital, Jakarta, Indonesia3

Background: Thyroid diseases are one of the most common endocrine disorders. Studies in USA and Europe have found the prevalence of hypothyroid was 3.5 per 1000 women and 0.6 per 1000 men while hyperthyroid prevelance in women was 0.4 per 1000 women and 0.1 per 1000 men. The estimation of women in Indonesia suffers from hypothyroidism and hyperthyroidism were 2.2% and 14.7% respectively. The data also shown that adult women prevalence portion of thyroid disease in Indonesia was three times higher than adult men.

Obejective: Objective of this study was to know the characteristic symptoms in adult woman with thyroid disease.

Method: A cross sectional design was used in this corelational study, and conducted from October to December 2015. The subject of this study was adult women age >20 years old diagnosed with hypothyroidism or hyperthyroidism in Jakarta, Bandung, Semarang, Surabaya, Yogyakarta, Medan. Questionnaire was used as the instrument of survey.

Result: From total 361 samples: 71% were diagnosed with hypothyroidism while the rest 29% were diagnosed with hyperthyroidism. In this study we found Fatigue and muscle weakness (66%), Difficulty sleeping (54%), Anxiety, nervousness and irritability (48%), Very fast heart rate and palpitations (46%), Trembling hands (38%), Weight change despite eating normally (34%), Joint or muscle pain (32%), Excessive sweating (28%), Increased sensitivity to warm or cold temperatures (12%), Thinning skin (4%), Thin and brittle hair or fingernails and / or dry flaky skin (4%), Puffy face, hands and feet (4%), Frequent bowel movements (2%), Decreased libido (2%) as the symptoms in adult woman with thyroid disease.

Conclusion: Hypothyroidism prevelance was more common than hyperthyroidism as seen in the result. Fatigue and muscle weakness, difficulty sleeping, anxiety, nervouseness and iritability, very fast heart rate and palpitation were the most common symptoms complained by patients while other symptoms are more likely to be ignored/ less felt.

486

PO 060NOT AN ORDINARY UTI: A CASE OF MULTIPLE MYELOMA STAGE III WITH NO BONE PAIN, HYPERCALCEMIA, OR OSTEOLYTIC LEISONS

Yue Shi, MS3; Zarah Lucas, MD; KavitaKalra, MD

Hematology/ Oncology, University of Maryland, Midtown Campus, Baltimore, MD.

Introduction: Multiple Myeloma (MM) is a cancer of abnormal plasma cells that accumulate in bone marrow, where they interfere with the production of normal blood cells. The typical clinical presentation of MM is summarized as “CRAB” features (hypercalcemia, renal insufficiency, anemia and lytic bone lesions). In MM, there is an increase in osteoclast activity caused by osteoclast activating factors (OAFs). The OAFs are known to be released by tumor plasma cells.

Case Description: A 63-year-old African American male was admitted for dysuria and brown-colored urine of 2 weeks’ duration. He had no fever but had on and off chills. He reported a 23-lb weight loss and decreased appetite. Work-up on admission revealed anemia with a hemoglobin of 7.5g/dL and renal insufficiency with creatinine as 1.67mg/dL. He was treated with intravenous ceftriaxone which relieved his dysuria and discolored urine. However, his renal insufficiency persisted despite hydration and antibiotics. Due to his anemia and renal insufficiency, multiple myeloma was suspected. Serum protein electrophoresis showed M protein of 4.4g/dL with Immunoglobulin G (IgG) kappa and free lambda on serum immunofixation. IgG was 6911 mg/dL. Kappa light chains were 622.3 mg/L with kappa/lambda ratio of 3.66. Subsequently, bone marrow biopsy showed 90% cellularity with 70-80% plasma cells that were kappa-restricted. The following cytogenetics by FISH were reported: CCND1-IGH fusion, extra signal for chromosome 9, and loss of one copy of 13q14. Interestingly, the patient denied bone pain and had no lytic lesions on skeletal survey. He also did not have hypercalcemia, instead he actually hadhypocalcemia with calcium level of 7.7mg/dL.The patient was diagnosed with IgG kappa multiple myeloma, International Staging System Stage III, as his B2-microgobulin level is 10.3 mg/L. Since the patient had high risk disease, he was started on bortezomib, lenalidomide, and dexamethasone.

Discussion: This case illustrates a patient diagnosed withIgG kappa MM ISS Stage III with no lytic bone lesions or hypercalcemia, which is rarely reported in currentmedical literature. However, MM patients can present with a variety of complaints and collateral signs. Interestingly, the International Myeloma Working Group had revised the definition of multiple myeloma to include sixty percent or more plasma cells in the bone marrow as one of the myeloma-defining events regardless of the presence of CRAB features.

487

PO 061Thyroglobulin Measurement in Needle Washouts from Fine-Needle Aspiration Biopsy: Useful Tool for the Diagnosis of Cervical Lymph Node Metastases from Papillary Thyroid Cancer before Thyroidectomy

Dae-Weung Kim1,2, Se Jeong Jeon3, Chang Guhn Kim1

1Department of Nuclear Medicine and Institute of Wonkwang Medical Science, Wonk-wang University School of Medicine, Iksan, Jeollabuk-do, Korea2Research Unit of Molecular Imaging Agent (RUMIA), Wonkwang University School of Medicine, Iksan, Jeollabuk-do, Korea3Department of Radiology, Wonkwang University School of Medicine, Iksan, Jeolla-buk-do, Korea* For correspondence and reprints contact to: Dae-Weung Kim, M.D.Department of Nuclear Medicine, Wonkwang University School of Medicine, 344-2 Shinyong-Dong, Iksan, Jeollabuk-do, 570-711, Republic of Korea* Acknowledgement: This research was supported by Basic Science Research Pro-gram through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2013R1A1A2059262).

Background/Rationale: In evaluating cervical lymph node (LN) metastasis from papillary thyroid cancer (PTC), ultrasonography (US)-guided fine-needle aspiration biopsy (FNAB) is very important tool. There were limited number of studies about the diagnostic value of thyroglubion measurement in FNAB (FNAB-Tg) in non-thyroidectomized patients. There-fore, in this study, the authors evaluated the role of FNAB-Tg in diagnosing cervical LN metastases in patients with PTC before thyroidectomy.

Methods: A total 91 suspicious LNs of 68 patients were undergone US-guided FNAB-Tg and cytology. Any FNAB-Tg concentration > 50 ng/ml considered as positive, irrespective of thyroid gland presence.

Results: Based on the final pathology, 49 LNs were positive, and the remaining 42 LNs were negative for metastasis. The sensitivity, specificity and accuracy of FNAB-Tg in thyroidectomized patients were 80.0%, 100.0% and 88.9%, respectively. The diagnostic performance of FNAB-Tg was not compromised by the presence of thyroid gland (sensi-tivity, specificity and accuracy = 95.0%, 90.9% and 93.2%, respectively).

Conclusions: FNAB-Tg is useful and simple method for the diagnosis of metastatic cervical LNs from PTC. The diagnostic performance of FNAB-Tg was not compromized by the presence of thyroid gland. Therefore, FNAB-Tg could be performed actively for the LN staging of PTC.

Keywords: Thyroglobulin; Fine-needle aspiration biopsy; Cervical lymph node; Thyroidectomy

488

PO 062KIMURA DISEASE in Young Indonesian Male a Rare Case in Fatmawati General Hospital

Iskandar M, KN Maizan4, Shabrina A5

1 Departement of Internal Medicine, Fatmawati General Hospital, Jakarta, Indonesia4,5 Medical Student of State Islamic University, Jakarta, Indonesia

Kimura disease is a chronic inflammatory disease that mainly manifests as a lump in the head and neck region. Patients usually present with non-tender mass in the cervical region with elevated eosinophils count and high levels of serum immunoglobulin type E.

Males are affected by Kimura disease more commonly than females, with a 3.5:1 to 9:1. Kimura disease is usually seen in young adults during the third decade of life. Spontaneous regression is common, but persistent lesions may require treatment.

We reported a case of Kimura Disease that present as painless orbital and retroauricular swelling in 26-year-old man. The patient was treated with systemic corticosteroid. This treatment was effective and the lesion subsided.

KEYWORDS: Kimura disease; lump in head and neck;Eosinophilia; Immunoglobulin type E

489

PO 063PROGNOSTIC UTILITY OF SERUM ST-2 LEVEL AS A PREDICTOR OF CLINICAL OUTCOMES IN INCIDENTAL DIALYSIS PATIENTS

Yunju Nam1,2, Eunjin Kang1,2, Hye Eun Yoon1,2, and Seok Joon Shin1,2

1. Division of Nephrology, Department of Internal Medicine, Incheon St. Mary’s Hospital, Incheon, Korea

2. Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea

Background: ST-2 is an emerging biomarker of heart failure and is associated with tissue fibrosis and cardiac remodeling. ST-2 concentration is known to be a predictor for mortality and hospitalization due to cardiovascular (CV) disease. End-stage renal disease (ESRD) patients show higher prevalence of heart failure and CV disease. However, the prognostic implications of serum ST-2 level are unknown in ESRD patients starting maintenance dialysis. This study was to evaluate the prognostic value of serum ST-2 level in incident dialysis patients, in terms of mortality and CV events.

Method: A total 182 ESRD patients starting maintenance dialysis at Incheon St. Mary’s Hospital from November 2011 to December 2014 were enrolled. We measured the pre-dialysis serum ST-2 level. Patients were divided into two groups according to the median ST2 level ; high ST2 group and low ST2 group. Primary end-points were all-cause deaths and non-fatal CV events. Event-free survival rates were compared between the two groups. The associations between serum ST-2 level and mortality and non-fatal CV events were investigated.

Results: There was no significant difference in baseline characteristics between the two groups in terms of demographic characteristics and comorbidities. The patient survival rate was significantly lower in the high ST-2 group compared with the low ST-2 group (69.2% vs. 86.9%, P= 0.023). The event free survival rate for death and non-fatal CV event was significantly lower in the high ST2 group (59.4% vs. 80.3%, P =0.008). In multivariate Cox regression analysis, the ST-2 level was a significant predictor for composite of end-points after adjustments for traditional CV risk factors and laboratory measurements (HR = 1.011, P = 0.003).

Conclusion: This study showed that serum ST-2 level independently predicted mortality and CV events in ESRD patients. High ST-2 concentration could be an additive predictor for adverse CV outcomes in dialysis patients.

490

PO 064EPIDEMIOLOGICAL TRENDS IN COLORECTAL CANCER IN CHINA

Jinzhou Zhu1,2, Kelseanna Hollis-Hansen2, Chaohui Yu1, Youming Li1

1. Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China

2. Department of Epidemiology and Environmental Health, University at Buffalo, The State University of New York, Buffalo, USA

Abstract

Background: China has experienced rapid economic development and a considerable change of disease burden over the past decades. Due to the changes in lifestyle and dietary behaviors, the incidence of colorectal cancer (CRC) has been rapidly increasing in China.

Aims and Methods: To present the trends of CRC in China over the past decade, using data from a series of nationally representative data including the National Central Cancer Registry of China (NCCR), the GLOBOCAN project and the Global Burden of Disease (GBD).

Results: According to NCCR data, the age-standardized rate (ASR) of incidence increased from 12.8 in 2003 to 16.8 per 100,000 in 2011, while the ASR mortality rose from 5.9 to 7.8 per 100,000. The age group most effected by incident CRC cases were those aged 60-74 years old, whereas CRC death was most associated with those >74 years old. Furthermore, the east coast of China presented a higher ASR mortality rate (> 15 per 100,000 in men and 10-14.9 per 100,000 in women), while it was lower in central/west China (5-14.9 per 100,000 in men and 5-9.9 per 100,000 in women) (GBD 2013). Compared with other countries worldwide (GLOBOCAN 2012), China indicated lower rates of incidence, mortality, and 5-year prevalence than most other developed countries. However, China had a higher case-fatality ratio and mortality/incidence ratio than other developed countries. Lastly, Disability Adjusted Life Years attributed to CRC in China was 224.2 per 100,000, which closely resembles the US.

Conclusion: This study revealed the domestic diversity of age, gender, and geography, and also presented the differences between China and developed countries. It might yield insights for national programs and policies.

Key words: colorectal cancer, China, epidemiology.

491

PO 065Association of multiple myeloma and adenocarsinoma of unknown primary

Bahar Ozdemir, Gamze Gulcicek, Betul Erismis, Hakan Kocoglu, Mehmet Husitoglu, Yıldız Okuturlar, Ozlem Harmankaya

Bakırkoy Dr.Sadi Konuk Training and Research Hospital, Istanbul

Introduction: Multiple myeloma (MM) is a malignant disease of plasma cells, which manifest as monoclonal increase of plasma cells production, one or more lytic bone lesions, and monoclonal protein in the blood and/or urine. Association of Solid tumors with MM has been demonstrated. However, it is a controversial subject whether MM is a risk factor for the development of a secondary tumor. We present here a case of MM in combine with adenocarsinoma.Case: A 72-year-old male patient referred to our clinic with complaints of severe waist and back pains and night sweats of two months duration.There was no significant findings in his physical examination. Laboratory tests revealed the presence of mild anemia (hemoglobin: 12.3 g/dl ), an erytrocyte sedimentation rate (ESR) of 80 mm/hr, total serum protein of 8.5 g/dL, albumin of 3.9 g/dL, serum creatinine of 1.10 mg/dL, serum calcium of 10.0 mg/dL, C-reaktive protein (CRP) of 3.89 mg/dL and serum beta-2 microglobulin 3.99 mg/L. Monoclonal gammapathy was observed in protein electrophoresis. Immunoglobulin levels were found as follow: Serum Ig G 8.32 g/L, Ig A 27,01 g/L, and Ig M 0,40 g/L. Bone marrow aspirate was convenient with MM. Bone marrow biopsy examination showed dysplastic plasma cells infilteration (36%) and metastasis of low differentiated adenocarsinoma. The origin of this adenocarcinoma couldn’t be identified by all conventional examinations (endoscopic and radiologic examinations) and by PET CT examination as well. So this case accepted as MM associated with adenocarcinoma of unknown primary origin. Conclusion: Coexistence of these two disease entities needed to be explained by further large-scale researches

492

PO 066TYPE 2 NORMANDY VON WILLEBRAND DISEASE A RARE CASE REPORT

Andy P, Ugoseno YB, Sedana MP,Ashariati ADepartment Of Internal MedicineFaculty of Medicine Airlangga UniversityDr. Sutomo Hospital Surabaya

ABSTRACT

BACKGROUND: Von Willebrand disease (VWD) is an inherited bleeding disorder characterized by excessive mucocutaneous bleeding symptoms. The prevalence of clinically significant cases is 1 per 10,000 and affecting up to 1% of the general population. Research has shown that as many as 9 out of 10 people with VWD have not been diagnosed. The diagnosis of VWD is difficult even for an experienced doctor.

CASE: A 19 years old male, student, blood type B, presented with three years history of everyday nose and gum bleeding with easily bruising in all of his body. Sometimes he get knees swelling and bloody stool. No family history of bleeding tendency. Complete blood count, coagulation test, bleeding time, fibrinogen, serum iron, total iron binding capacity, and peripheral blood smear was normal. Anti nuclear antibody negative, c3 complement 114. Platelet aggregation test for ADP and colagen was hypoagregation, Epinefrin was normoagregation. Von Willebrand level (VWFAg) 41%, ristocetin cofactor (VWFRco) 30%, factor VIII 24%. He got desmopressin acetate nasal spray once daily. Epistaxis and gum bleeding was stopped.

DISCUSSION: Interpretation of the laboratory results involved in making the diagnosis of VWD is often very difficult. This patient has slightly low Von Willebrand factor, low ristocetion cofactor, low factor VIII and VWFRco/VWFAg ratio > 0.6. The diagnosis is type 2 Normandy VWD. This type is much rarer only 20-30% of VWD. More often, VWD can be detected in women based on the bleeding tendency during menstruation and may be more severe or apparent in people with blood type O. Treatment of bleeding included parenteral or nasal administration of desmopressin and the intravenous infusion of plasma derived Von Wlillebrand factor or factor VIII concentrate.

CONCLUSION: VWD present with varying degree of bleeding tendency. Proper tests need to be performed. Treatment to increase VWF.

KEYWORDS: Von Willebrand Disease

493

PO 067Gastric Plasmacytoma and a Sugestive Pancreatic Plasmacytoma Vila Franca de Xira Hospital;Service of Internal Medicine in Lisbon, PortugalAutors: Jerry Simões, Tiago Camacho, José Lourenço, José Barata

Extramedullary plasmacytoma (EMP) represents approximately 3% of all plasma cell neoplasms and pancreatic plasmacytoma is a rare disorder wich may presented with obstructive jaundice. Only a few cases have been reported in the english literature. We presented a case of gastric plasmacytoma and a sugestive pancreatic plasmacytoma, diagnosed with biopsy of gastric mucosa. A 68 years old male with a known history of mul-tiple myeloma presented with obstructive jaundice and a visible mass involving pancrea-tic head suggestive of a lynfome in MRI. The diagnosis was estabilished with biopsy of gastric polips. In the myelogram is was presented 16.4% of plasmocytes. Extramedullary plasmacytoma should be suspected in the diagnosis of myeloma. After the diagnosis radiation should be the first aproach in pancreatic plasmacytomas.

494

PO 068BCR-ABL MOLECULAR DIAGNOSTIC FOR CHRONIC MYELOID LEUKEMIA IN BANYUMAS REGENCY, INDONESIA

Djatmiko W *, Suharti C **

* Laboratory of Internal Medicine, Faculty of Medicine, University of Jenderal Soedirman, Purwokerto, Indonesia

** Sub-Division of Hematology and Medical Oncology, Departement of Internal Medicine, Faculty of Medicine, University of Diponegoro, Semarang, Indonesia

Background: Chronic myeloid leukemia (CML) treatment’s era with Tyrosine Kinase Inhibitors requires certain diagnostic methods. Cytogenetic diagnostic by detection of Philadelphia chromosome require a sample from bone marrow aspiration, not easy to do in Banyumas because there is no hospital has facilities there. Molecular diagnostic by detection of BCR-ABL transcripts can be done simply by send a peripheral blood sample to the KalGen laboratory Jakarta within 48 hours after sampling.

Patients and methods: Subject was selected with the inclusion criteria : leukocytosis (>50,000/mm3), anaemia, peripheral blood smear obtained of WBC differential shows granulocytes in all stages of maturation and splenomegaly with shuffner ≥3. A total of 10 mL of peripheral blood taken at the local laboratory, and then sent to the KalGen laboratory.Samples will be examined by RNA extraction using phenol-based reagent, followed by one step probe based qRT-PCR using one step BCR-ABL qRT-PCR kit (Molecular MD). This method is able to detect b2a2 and b3a2 (P120 major breakpoint cluster) BCR-ABL transcripts.

Result: A total of 26 patients with suspect CML earned during the period 2014-2015. A total of 20 patients met the inclusion criteria. 19 of 20 samples (95%) indicated the presence of BCR-ABL transcript.

Conclusion

Detection of BCR-ABL transcripts by sending samples to the KalGen Laboratory very helpful to determine CML diagnostic in the regional hospital. Using that criteria and continued with detection of BCR ABL transcripts, accuracy of results obtained by 95%.

Keywords: CML, BCR-ABL, regional hospital

495

PO 069Rheumatoid arthritis-like syndrome presenting in acute promyelocytic leukemia

Diana Jeni H.*, Shinta O**

*Resident of Internal Medicine, Department of Internal Medicine, Medical Faculty of Brawijaya University, Saiful Anwar Hospital, Malang **Staff of Hematology-Oncology, Department of Internal Medicine, Medical Faculty of Brawijaya University, Saiful Anwar Hospital, Malang

Rheumatologic disorders (RDs) are associated with – or precede – by a short period of time the diagnosis of malignancy and represent an important clue for the early diagnosis and effective treatment of the cancers. Seronegative rheumatoid arthritis is the most frequently reported as a paraneoplastic RDs. Most paraneoplastic RDs are difficultly distinguishable from idiopathic RDs. Even so, some atypical features of the clinical presentation raise the suspicion of an underlying tumor. This is a case report of rheumatoid arthritis-like syndrome in female 49 years old which is preceding 3 months before the patient diagnosed with acute promyelocytic leukemia (AML M3). This patient already has swan-neck deformity for the last 2 months and still presenting with joint pain. We use palliative treatment for this paraneoplastic syndrome to increase her quality of life.

Key Word: Rheumatoid arthritis-like syndrome, acute promyelocyt-ic leukemia

496

PO 070THE CHARACTERIZATION OF PHOSPHORYLATION LEVEL OF AUTOPHAGY SKELETON PROTEIN BECLIN1 IN CLINICAL RECTAL CANCER SAMPLES

Zhilin ZHOU2, Yunfang LI3, Na LI4, Wenchao YANG1, Xiaohua LI1* | 1The Hong Kong Polytechnic University Shenzhen Research Institute, State Key Laboratory of Chinese Medicine and Molecular Pharmacology (Incubation), Shenzhen, 518057, PRC, 2Department of General Surgery, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PRC, 3School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan PRC, 4Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, PRC

Background Beclin1 is a scaffold protein in the Class III Phosphatidylinositol 3-Kinase VPS34 complex which is crucial for mammalian autophagy. The functional role of Beclin1 depends on its structural basis which promotes subcomplexes formation to initiate autophagy. Phosphorylation on Beclin1 may serve as one regulatory mechanism of its function. Methods We collected the clinical rectal cancer samples from surgery and characterized the expression level of Beclin1 by IHC and WB. We further extracted Beclin1 protein from the above samples by IP and probed the phosphorylation of Beclin1. Besides, rectal cancer cell lines were cultured to perform the cell biological studies for the investigation of Beclin1 phosphorylation and autophagy. We further demonstrated the autophagy regulatory ability of the drugs commonly used in clinic for rectal cancer to find the clue of the relationship between autophagy and the effect of medical treatment. Finally, in vitro studies including biophysical and biochemical characterization for the wild type and mutants (phosphorylation deficient or mimicking) of Beclin1 in combination with molecular dynamics (MD) simulation and energy calculation of Beclin1 homodimer are undergoing. Results Our data implies that Beclin1 phosphorylation is related to clinical staging of rectal cancer diagnosis, drug effects and prognosis. After data analysis, we propose that the ratio of total expression level of Beclin1 to the tyrosine-phosphorylation level of Beclin1 is a significant index for the rectal cancer. Conclusion Our findings suggest a potential biomarker for rectal cancer and also provide clue to conceive new strategies targeting autophagy for therapeutic purpose of rectal cancer.

497

PO 071End-of-Life Care Decisions Using Korean Advance Directives among Cancer Patient-Caregiver Dyads Shinmi Kim,a RN, PhD, SuJin Koh, MD,b PhD, JinShil Kim,c RN, PhD

aChangwon National University, Department of NursingbUniversity of Ulsan College of Medicine, Ulsan University Hospital, Department of Hematology and OncologyCGachon University, College of Nursing

Objective: The Korean advance directives (K-ADs) consist of a value statement, treatment directives (cardiopulmonary resuscitation [CPR], preferences for artificial ventilation, tube feeding, and hospice care. K-ADs can facilitate a patient’s decision-making for end-of-life (EOL) care. This study aims to examine the extent to which patient-caregiver dyads agreed on decisions for EOL care using the K-ADs.

Method: Using a descriptive study design, 81 cancer patients were invited to participate. The final sample consisted of 44 patient-caregiver dyads who completed K-ADs; 36 (44.4%) THIS ADDS UP TO 80 NOT 81?of the initial 81 patients declined to participate.

Results: Patient participants had different cancer diagnoses: 29.5% colorectal cancer, 29.5% breast, and 15.9% liver/biliary tract cancers; 59% of the sample had advanced stage cancer. Spouse (70.5%) and adult children of the patient (20.4%) were primary caregivers with perceived bonding rated as fair (31.8%) or good (65.9%). Rejection of K-ADs was mainly because of difficulty in deciding EOL care (50%). Comfort in dying was the most common theme of the value statement for patients (73.8%) and caregivers (66.7%). For treatment directives, dyads advocated for hospice care (66.7%) and reduced support for aggressive treatments of CPR or artificial ventilation, k = .43, p = .004 and k = .28, p = .046, respectively. These approaches showed significantly mild to moderate concordance among the dyads. Sixteen out of the 21 dyads identified their spouses as a proxy, with others designating their adult children.

Conclusion: The findings of the study are exploratory but suggest the need for ongoing EOL discussion where patient-caregiver dyads are encouraged to participate in the decision-making for EOL care.

498

PO 073Abnormal DNA Methylation-induced gene Inactivation is Related to the T-cell Leukemias Diagnosis and/or Therapy

Minyoung Lee, Yu Ri Jung and EunJu Kim

Division of Radiation Effect,Korea Institute of Radiological & Medical Sciences, Seoul 01812, Korea

Background/Rationale: Aberrant hypermethylation of tumor suppressor genes is known to play an important role in the development of many tumors, and aberrant DNA hypermethylation was recently identified in hematologic malignancies, where it is thought to hold relevance in leukemogenesis. These observations led us to focus on our comprehensive study to examine the prevalence of aberrant promoter methylation in a selected panel of genes that could be potentially involved in T-cell leukemia. In addition to identifying new biomarkers, exploration of methylation patterns could be used to guide T-cell leukemia therapies.

Methods: Here, we used pyrosequencing (a sensitive, easy and effective real-time sequencing-by-synthesis technique) to assess changes in the methylation levels of individual genes between normal peripheral blood (in which they are not normally methylated) and two T-cell keukemia cell lines (in which they are hypermethylated).

Results: We report that there are differences in the DNA methylation patterns seen in normal peripheral blood and two T-cell leukemia cell lines. We identify nine genes (CLEC4E, CR1, DBC1, EPO, HAL-DOA, IGF2, IL12B, ITGA1, and LMX1B) that are significantly hypermethylated in T-cell leukemias cell lines, and suggest that aberrant hypermethylation of these normally unmethylated genes may induce their transcriptional and expressional silencing. Furthermore, we observed that the expression levels of DNMT1 and DNMT3a were significantly decreased by 5-aza-2’-deoxycytidine (5-Aza-dC), which is a demethylation agent known to deplete DNA methyltransferases (DNMTs) in leukemia cancer cells and restore the expression levels of their target genes in Jurkat cells.

Conclusion: Together, our results show that aberrant hypermethylation is an important molecular mechanism in the progression of T-cell leukemias, and thus could prove useful as a prognostic and/or diagnostic marker. Moreover, 5-Aza-dC might be a promising candidate for the treatment of T-cell leukemia.

499

PO 074PRIMARY SEMINOMA IN THE MEDIASTINUM CASE REPORT IN A 26 -YEAR-OLD MALE

Nor Hedayanti , Djoko Heri Hermanto

Division Hematology and Oncology Medic, Department of Internal Medicine, Brawijaya University in Malang Indonesia

Introduction: The primary tumor cell extra gonadal germ is rare, only about 1% to 5% of all germ cell malignancies, the most common extragonadal on mediastinal and retroperitoneal.

Case Report: A 26 years old man with sudden shortness and become heavy, the results of the examination found a mass in the anterior mediastinum and increased levels of beta-HCG, LDH and FNAB as a picture seminoma, then the diagnosis is established as seminoma extra gonad. Patients then chemotherapy with BEP regimen (Bleomysin, Etoposide and Cisplatin) of 4 cycles, evaluated by thoracic CT scan obtained lymphadenopathy on suspicion of sub aortic and left lung metastasis process similar sicatric and concluded as a partial response. Then it was decided to do additional chemotherapy two cycles and evaluated on a complaint that does not exist, the examination within the normal range, X-rays of the thoracic and CT scan of the thorax which is not found mass in the mediastinum, is only obtained their lymphadenopathy multiple on paratrachea with sizes smaller than before so concluded as complete response.

Discussion: Symptoms appear on the shortness present in 75.8% of patients with mediastinal seminoma, FNAB become a standard diagnostic procedure in finding a mass in the mediastinum with high sensitivity and specificity, amount 87-90% and 80-100%,It would appear histomorphological synonymous with germ cell tumors arising in the testis. Seminoma is very sensitive to chemotherapy and radiotherapy. Conventional chemotherapy cisplatin-based chemotherapy is safe and was selected for the case of germ cells in this case with a good prognosis and life expectancy by 90% in the first 5 years.

Keywords: young age, mediastinum seminoma, chemotherapy

500

PO 075CORRELATION BETWEEN NEUTROPHIL COUNT AND HEMOGLOBIN ACHIEVEMENT TARGET IN HEMODIALYSIS PATIENTS AT HEMODIALYSIS UNIT RSUD DR TJITROWARDOJO PURWOREJO

Danang*, Bambang Djarwoto**, Iri Kuswadi**, Heru Prasanto**, Suhardi D.A.***Resident of Nephrology**Nephrology Division Internal Medicine Department, Faculty of Medicine Gadjah Mada University, RSUP DR Sardjito Yogyakarta

Background: Chronic kidney disease (CKD) is a serious public health problem which the incidence keeps increasing. Anemia is one of the complications that most commonly happened. Anemia in CKD is mostly caused by relative decrease in erythropoietin (EPO) production. Laboratory tests or clinical indications that suspect the presence of inflammation are hypoalbuminemia, decreased transferrin level, increased neutrophil count, and increased erythropoietin resistance. Among hemodialysis patients, there are a lot of patients who can’t achieve targeted hemoglobin (Hb) level, even though they have already received iron and erythropoietin therapy. This research objective is meant to know the correlation of high neutrophil count with the failure to achieve targeted hemoglobin level in hemodialysis patients.

Methods: This research is done using cross-sectional study towards 38 hemodialysis patients at RSUD Tjitrowardojo Purworejo from March to April 2016. Statistical test that is used is contingency coefficient correlation.

Result: From statistic test result, the correlation between Hb < 10 g/dL with neutrophil count > 70% is not significant with r = 0,12 (p = 0,42). Correlation between CRP ≥ 5 mg/dL with Hb < 10 g/dL is not significant with r = 0,16 (p = 0,32). Meanwhile, correlation between albumin < 3,8 mg/dL with Hb < 10 g/dL is significant with r = 0,37 (p = 0,01).

Conclusion: Correlation of neutrophil count > 70% with Hb < 10 g/dL in CKD patients with hemodialysis at RSUD Tjitrowardojo Purworejo is not significant. It needs further research with larger samples.

501

PO 076Phlegmasia Cerulea Dolens and recurrent thrombosis in Anti Phospholipid Syndrome and Evans syndrome

Riswan Arisandi, Kartika Widayati, Johan Kurnianda, Mardiah Suci Hardiyanti

Division of Hematology and Medical Oncology, Department of Internal Medicine, Dr Sardjito General Hospital, Yogyakarta, Indonesia

Introduction: Although thrombosis in anti phospholipid is main symptom, but severe thrombosis is quite rare. Phlegmasia cerulea dolen is severe thrombosis manifestation characterized by severe venous outflow obstruction, marked by swelling, pain, blueish discoloration and even venous gangrene. Etiological factor include malignancy, surgery, antiphospholipid syndrome, heart failure and pregnancy. Evans syndrome with positif IgG anti cardiolipin antibody will increase risk venous thromboembolism 4-5 fold. Most predilected area is in lower extremity. The exact incidence of this disorder is not well reported.

Case Presentation: A 19 year old woman was presented to our hospital on June 2014 with hematemesis and prolong menstrual period. She has been diagnosed as evans syndrome and taken steroid and imunosupressan since 1 year ago. On day 6th of hospitalization, she complained edema and pain at left lower arm, with cold sensation in all left finger, cyanosis and presenting of bulous and progressively starting necrosis in entire left manus. Venous Doppler ultrasound confirm massive thrombus on subclavia vein, brachialis till antebrachii vein with arteriografi found stenosis 30% on proximal brachialis arteri and then stop flowing at proximal phalanx on digiti I to V. Anti-cardiolipin antibody was positif in twice examination. Treatment including high dose steroid, imunosupressan and low moleculer weight heparin. Trans radial amputated was done after 30 days of hospitalization, then started rehabilitation program, imunosupressan, steroid and warfarin on ambulatory.

On ambulatory follow up on March 2016, day of patient monthly visit, she had suffer again with swelling, redness and pain of left leg. Dopller ultrasound confirm thrombus on left popliteal vein. She continue to get rivaroxaban and imunosupresssan.

Conclusion: Phlegmasia cerulea dolens result from massive thrombosis compromising venous outflow that causing ischemia. It is life threatening condition with high mortality rate. Adequate treatment for antiphospholipid syndrome will reduce venous thromboembolism morbidity and mortality.

Keywords : antiphospholipid syndrome, Phlegmasia Cerulea Dolens, recurrent thrombosis, evans syndrome

502

PO 077Differentiation Of Benign And Malignant Breast Lesions Using Complete Blood Count Parameters

Hakan Kocoglu, Bahar Ozdemir, Didem Acarer, Betul Erismis, Tarık Ercan, Sibel Ocak Serin, Basak Oguz, Selin Kaplan, Yildiz Okuturlar, Meral Gunaldi, Mehmet Hursitoglu, Ozlem Harmankaya

1. Department of Internal Medicine, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey

2. Department of Internal Medicine, Umraniye Education and Research Hospital, Istanbul, Turkey

3. Department of Internal Medicine, Istanbul Bilim University, Florence Nightingale Hospital, Istanbul, Turkey

4. Department of General Surgery, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey

5. Department of Medical Oncology, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey

Background: To determine whether complete blood count (CBC) parameters could help accurately distinguish benign solid breast lesions from malignant lesions and whether this distinction could be definite enough to obviate biopsy.

Material and Methods: A total 264 woman participants consisted of 71 with biopsy proven benign lesions, 140 with biopsy proven malignant lesions and 53 controls were retrospectively evaluated. Obtained data were analyzed by using SPSS 22 software (IBM Corp, Armonk, NY). During the evaluation of study variables, descriptive statistics, One-Way Anova and Kruskal Wallis tests, ROC analysis, regression analyses were used. Logistic regression was also used to test for associations between predictors (CBC parameters and clinical variables) and malignant lesions of breast (benign biopsies and healthy individuals were treated as controls). Non-linear models and semi-supervised models were also examined. A “model” for predicting malignant lesions was yielded and a cut-off value with a best sensitivity and specificity was determined.

Results: There was no difference for age among groups (malignant vs benign vs control). Mean age of the study population was 49,2±10,95 years. Hg, platelet, pdw, and platelet-lymphocyte ratio was statistically significant between patients with benign breast mass and with malignant breast mass (p<0.05). Within all models, a model of “PLR*Age/PDW*Hg” was provided best AUC for differentiation of benign and malignant breast lesions [AUC: 0.701 (95% CI, 0.624 - 0.778), p = 0.0001]. The sensitivity, specificity, positive and negative predictive values using a cut-off value of 31.4 were 63.6, 71.8, 81.7, and 50% respectively.

503

Conclusion: This study shows that a formula of “PLR*Age/PDW*Hg” can be utilized as an adjunct to other diagnostic tests in order to differentiate benign breast lesions from malignant lesions of breast.

504

PO 078Malignant peripheral nerve sheath tumor in the anterior mediastinum in Elderly: A case report

Agus Sudarso1, Noto Dwimartutie1

Division of Geriatric Department of Internal Medicine, Faculty of Medicine University of Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

Background. Malignant peripheral nerve sheath tumor (MPNST) is a rare tumor, found in only 5% of all soft tissue sarcomas. MPNSTs in the anterior mediastinum are rare. MPNSTs generally occur between the ages of 20 and 50 years of age, but rare above 60. MPNST has a poor prognosis. Five year survival rate is approximately 50% in patients with resectable tumor.

Case report. A 64-year-old man came to our hospital with swelling on the anterior wall chest since 4 months before. He complained pain, dyspnea, loss of body weight (6 kg), and sometimes fever. He felt fatigue, hopelessness, sad, and bedridden for most of the days. Physical examination revealed soft swelling on sternum region, reddish, and tenderness. The chest movement was asymmetric, breath sound was decrease with crackles on auscultation. There was also a pressure ulcer in sacrum region. Laboratory results showed pancytopenia and hypoalbuminemia. Chest x-ray showed right pleural effusion and pneumonia with atelectasis. Chest CT-scan revealed a solid mass in anterior mediastinum which extended to the anterior chest wall, destructed the sternum wall and costochondral junction. Histopathology result showed a lower grade sarcoma (first grade MPNS). Immunohistochemistry examination revealed 50% positive for Ki67. Tumor was unresectable, and only planned to get palliative chemotherapy. Performance status was less than 50% with Karnofski scale. Patient also suffered pneumonia, pleural effusion, malnutrition, hypoalbuminemia, immobility, second grade sacrum pressure ulcer, and depression. Other treatments given were improvement of nutritional status, infection control, physiotherapy, and supportive psychotherapy

Conclusion. A case of 64-year-old man with malignant peripheral nerve sheath tumor in anterior mediastinum had been reported. Other clinical conditions were pneumonia, pleural effusion, malnutrition, hypoalbuminemia, immobility, second grade sacrum pressure ulcer, and depression. This is a palliative case with interdisciplinary comprehensive management.

Keywords: MPNST, elderly, interdisciplinary

505

PO 079THERAPEUTIC LEUKAPHERESIS EFFECTIVENESS IN CHRONIC MYELOGENOUS LEUKEMIA: A SINGLE CENTER EXPERIENCE IN INDONESIA

Amrita Putu Niken, Diansyah MN, Savitri M, Bintoro UY, Sedana MP, Ashariati A

Division of Hematology and Oncology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Therapeutic Leukapharesis in Chronic Myelogenous Leukemia (CML), despite the era of tyrosine kinase inhibitor (TKI) agents, has been used in patients with leukostasis and hyperleukocytosis. However there are a few published clinical data on effectiveness of this procedures and CML patients follow up. This study determined the characteristics of CML patients underwent therapeutic leukapheresis, result and complication, and follow up the patients.

Material and Method: Retrospective data analysis on 20 CML patients underwent therapeutic apharesis in our center in 2013. Patients in Chronic Phase (CP) also received hydroxyurea and imatinib. We evaluate their characteristics, leukapheresis result and complication, and follow up the patients to 18 months and records their hematologic and molecular response to TKI treatment.

Result: The mean presenting WBC was 371.000 + 33.150 /mm3, 17 patients were in CP, 3 patients were in Blastic Phase (BP). One leukapheresis session were effective reducing mean absolut leukocyte 77.260 + 14.897 /mm3, and mean percentage reduction were 27,67 + 3,2 %. Mean leukapheresis session needed were 1.8 times per patient until leukostasis symptoms resolved and/or leukocyte counts have fallen below 100.000/mm3. In 16 patients (80%) leukostasis symptoms (tinnitus, cephalgia, blurred visison, dyspnea) were resolved. There were no early mortality and only one complication hematothorax due to catheter insertion. These patients were also given Imatinib. Four (25%) patients didn’t achieve complete hematological response on 3 months and 12 (60%) patients didn’t achieved MMR on month 12. Three patient died on follow up, all of them presented on blastic crisis phase.

Conclusion: Therapeutic leukapheresis were effective to reduce absolute neutrofil count. Leukapheresis were also effective to relieve leukostasis related symptoms. However in CML patients hydroxyurea and TKI treatment should also be given.

Keywords: therapeutic leukapharesis, Chronic Myelogenous Leukemia, leukoreduction

506

PO 080BORTEZOMIB COMPARED TO VAD REGIMEN AS AN INDUCTION CHEMOTHERAPY ON CD34+ COUNT IN MULTIPLE MYELOMA PATIENT UNDERWENT PBSCT IN SURABAYA-INDONESIA

Savitri Merlyna, Amrita PN, Diansyah MN, Bintoro UY, Sedana MP, Ashariati A

Division of Hematology and Oncology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: CD34+ count is essential marker of stem cells prerequisite for the Peripheral Blood Stem Cell Therapy (PBSCT) in Multiple Myeloma (MM) patient. Bortezomib and VAD regimen both can be used for induction chemotherapy in transplants candidates MM patients. Several guidelines suggested that Bortezomib were superior than VAD, unfortunately only VAD were covered by government health insurance (BPJS). The aim of this study is to compare Bortezomib to VAD as an induction chemotherapy and whether VAD is still acceptable based on CD34+ count result in MM patient.

Method: Eight MM patients underwent induction chemotherapy and achieved CR with plasma cell < 2.5% in Dr.Soetomo Hospital Surabaya during 2014-2016. Five patients had VAD (Vincristin 0.4 mg/m2, Doxorubicin 9 mg/m2, Dexamethasone 40 mg/day on d1-4, d9-12, d17-20) for 6 cycles, and 3 patients had Bortezomib (1.3 mg/m2 on d1, d4, d8, d11) for 6 cycles as an induction chemotherapy. We observed premobilization CD34+ count and adverse event in all of patients.

Results: The mean of CD 34+ count of 5 MM patients who had VAD as an induction chemotherapy was 84.24 75.30 cells/l while 3 patients who had Bortezomib the mean of CD34+ count was 119.33 115.78 cells/l. The T-test study revealed that there was no difference between VAD and Bortezomib as an induction chemotherapy on CD 34+ count (p = 0.616 ;p> 0.05). The adverse event in all of patients were tolerable (grade 0-2).

Conclusion: The CD 34+ count was relatively the same in MM patients who had Bortezomib or VAD as an induction chemotherapy before underwent PBSCT. VAD was still giving good result on CD 34+ count, and furthermore it was covered by BPJS in Indonesia.

Keyword: CD 34+ count, VAD, Bortezomib, PBSCT, Multiple Myeloma

507

PO 081STEM CELL MOBILIZATION USING HIGH-DOSE CYCLOPHOSPHAMIDE PLUS G-CSF IS SUPERIOR THAN G-CSF ALONE IN MULTIPLE MYELOMA PATIENTS UNDERWENT AUTOLOGOUS PERIPHERAL BLOOD STEM CELL TRANSPLANTATION

Hersana Widi, Noor Diansyah M, Savitri M, Amrita PN, Bintoro UY, Sedana MP, Ashariati A

Division of Hematology and Oncology, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Dr. Soetomo Hospital, Surabaya, Indonesia

Background: The best method for stem cell mobilization in multiple myeloma (MM) patients underwent autologous peripheral blood stem cell transplantation (PBSCT) remains controversial. Stem cell mobilization using G-CSF alone may be appropriate for a minority patients but high-dose myeloablative chemotheraphy using cyclophosphamide regiment reported with higher result of CD34+ cell count. Moreover these methods are complex because precise timing of stem cell collection is difficult to predict. This study was carried out to describe CD34+ cell count during stem cell mobilization using high-dose cyclophosphamide (HD-CY) plus G-CSF and G-CSF alone.

Material and Method: It was a retrospective study in Hematology and Medical Oncology Division, Department of Internal Medicine, Dr. Soetomo Teaching Hospital Surabaya. Secondary data collected from medical record of 8 MM patients underwent autologous PBSCT during September 2014 to February 2016. CD34+ cell count were measured before and after stem cell mobilization. Five patients were given HD-CY 4 g/m² i.v. followed by 7 days course G-CSF 10 µg/kg/day s.c., 3 patients were given 7 days course G-CSF 10 µg/kg/day s.c.. Stem cell apheresis can be performed at CD34+ count > 20 cells/µL.

Result: Mean age was 49.87±7.01 years (ranged 37 to 59 years). Average length of stay was 48.12±4.18 days. Five patients (62.50%) using VAD as induction regiment, 2 (25.0%) using bortezomib, and 1 (12.50%) using DVD. Five patients using HD-CY plus G-CSF had median CD34+ was 8.76 cells/µl (ranged 5.62-12.73 cells/µl) before stem cell mobilization, and 1058 cells/µl (ranged 433-2124 cells/µl) after stem cell mobilization. Three patients using G-CSF had median CD34+ was 7.32 cells/µl (range 3.37-8.62 cells/µl) before stem cell mobilization and 173 cells/µl (ranged 140-379 cells/µl) after stem cell mobilization.

Conclusion: Stem cell mobilization using HD-CY plus G-CSF is superior than G-CSF alone based on CD34+ cell count.

Keywords: Multiple myeloma, autologous PBSCT, high-dose cyclophosphamide, G-CSF.

508

PO 082COMPARISON OF HISTAMINE LEVEL IN CHRONIC MYELOID LEUKEMIA PATIENTS RECEIVING IMATINIB MESYLATE AND NILOTINIB IN HEMATOLOGY CLINIC OF PROF DR. R.D.KANDOU GENERAL HOSPITAL

Hartanto Wijaya, Harlinda HaroenInternal Medicine Department, Hematology-Oncology Medic Department,Faculty of Medicine University of Sam Ratulangi,Prof. Dr. R.D. Kandou General Hospital, Manado, North Sulawesi

Background : Chronic myeloid leukemia (CML) is a mieloproliferative disorder characterized by the presence of the BCR-ABL fusion gene. Imatinib mesylate and Nilotinib are drugs known as Tyrosine Kinase Inhibitors (TKI) that brings breakthrough and recommended as first-line therapy in patients with CML. Histamine is a marker of basophil cells which proved to be an indicator of disease progression and has prognostic value in patients receiving TKI therapy. However, until now there is no data which compare the effectiveness of this two drugs based on histamine levels in Indonesia. This study aims to compare and assess histamine levels in CML patients receiving Imatinib mesylate and Nilotinib therapy.

Methods : An analitic observational with cross sectional design study was conducted on CML patients receiving Imatinib mesylate and Nilotinib therapy for at least 3 months in Hematology- Oncology Medic outpatient clinic at Prof. Dr. R.D. Kandou General Hospital from April – June 2015. Histamine levels was measured using Enzyme Linked Immu-nosorbent Assay (ELISA). Univariate descriptive and comparative Mann - Whitney test were used to analysed , SPSS program version 22

Results : A total of 30 CML patients were participated in this study. Among them, 22 patients were receiving treatment with Imatinib mesylate with mean histamine levels of 4.7 + 15.8 ng / mL and 8 patients receiving Nilotinib with mean histamine levels by 0.6 + 0.5 ng / mL (p = 0.389).

Conclusion : The results of this study showed that there were no significant difference between mean histamine levels in patients receiving Imatinib mesylate therapy compared with mean histamine levels in patients receiving Nilotinib therapy.

Keywords : chronic myeloid leukemia , imatinib mesylate , nilotinib , histamine.

509

PO 083TREATMENT RESPONSE OF CHRONIC PHASE CHRONIC MYELOID LEUKEMIA PATIENT TREATED WITH TYROSINE KINASE INHIBITOR AT GENERAL HOSPITAL SANGLAH DENPASAR

Ni Made Renny AR, Losen A, TG Dharmayudha, Ketut Suega, IM BaktaDivision of Hematology and Medical Oncology, Department Of Internal MedicineMedical Faculty of Udayana

Background : The main of pathogenesis mechanism of Chronic Myeloid Leukemia (CML) is reciprocal translocation between chromosome 9 and 22, that produce chimeric oncogene called BCR-ABL, leads increasing of Tyrosine Kinase activity and the consequence is uncontrolled proliferation of myeloid cell. Tyrosine Kinase Inhibitor (TKI) inhibit BCR-ABL gene, and produce remission in CML patient.

Objective : To determine the treatment response (hematology and molecular response) of CP-CML patient who received treatment TKI for one year.

Method : This was a retrospective descriptive study in CP-CML patient at Division of Hematology and Medical Oncology, Department of Internal Medicine, Sanglah General Hospital. The response of TKI was evaluated at 3 months for hematology response and at 12 months for molecular response.

Result : Of the 29 patients, the range of age was 18-75 years, mean age of 36.76 ± 13 years. Nineteen patients (65.5%) were male. At the time of diagnosis, clinical symptoms were fever (68%), decrease of body weight (100%), syndrome of anemia (79.3%), bleeding (31%), splenomegaly (96.6%). The mean of hematology parameter prior to TKI therapy : WBC was 2279.59 ± 22.03 x 10³/mm³, hemoglobin was 9.68 ± 0.42g/dL ,thrombocyte was 458.32 ± 86.35 x 10³/mm³. Most of patient (72.4%) use Imatinib, only 8 patients (27.6%) use Nilotinib. Twelve patients (41.4%) achieved complete Hematology Response (CHR) at 3 months. Of 25 patients, the Molecular Response at 12 months was only achieved in 2 patients (8%).

Conclusion : The result of the study showed complete hematologic response was achieved in almost half of the patients (41.4%), but molecular response at 12 months is still low (8%).

Key Words : Chronic Myeloid Leukemia , Tyrosine Kinase Inhibitor, Treatment Response

510

PO 084Thrombophilia risk alleles and their association with venous thromboembolism in Czech Republic.

Jan Kvasnicka1,Petra Bobcikova1, Jaroslava Hajkova1, Zdenek Krska2, Tomas Kvasnicka2.Thrombotic Centre1 and Department of Surgery2 of General University Hospital, Prague, Czech Republic.

Venous thromboembolism (VTE) is the third most common life-threating cardiovascular condition in internal medicine. It is multifactorial disease with both genetic (with geographic distribution) and acquired risk factors. The aim of our study was to determine frequencies of the thrombophilia risk alleles known from published GWAS ( genome-wide association studies) in healthy persons a in patients with VTE and their clinically significances for potential opportunities for targeted prevention and personalized medicine in Czech Republic .

Methods. Mutations of F5 Leiden (FVL), F2 20210G>A, PAI-1 4G/5G, GP 6 ( rs 1613662), SERPIN C1 ( rs 2227589), fibrinogen gamma gene FGG polymorphism ( rs 6536024), F 11 ( rs 2289252) and in AB0 blood group ( rs 8176719) were tested in age and sex matched groups of healthy persons ( n 2637) and patients with VTE ( n 2630 ). The mutations were determined using PCR with subsequent melting curve analysis with specific fluorescently labelled hybridisation probes in a process called FRET. Specific primers and fluorescently labelled probes were designed in cooperation with TIB MOLBIOL (Berlin, Germany), where they were custom made. Odds ratio (O.R.) greater than 1.5 was considered as a value of clinically significant risk of VTE.

Results: Frequencies of risk alleles in healthy group and in VTE patients were: 4.55% and 19,86 % for risk allele A of F 5 Leiden ( O.R. 5.19; p < 0.001 ), 1.37 % and 4,52% for risk allele A of F2 G20210A ( O.R. 3.405; p < 0.001 ), 55.77 % and 55.89% for risk allele 4G of PAI-1( O.R. 1.00; p 0.92), 87.39 % and 87.99% for risk allele T of GP6 ( O.R. 1.057; p 0.45 ), 11.17% and 12.11% for risk allele A of Serpin C1 ( O.R. 1.092; p 0.22), 51.0 % and 56.6% for risk allele C of fibrinogen gamma gene polymorphism FGG, rs 6536024 ( O.R. 1.25; p < 0.001 ), 39.6% and 47. 2% for risk allele T of F 11, rs 2289252 (O.R. 1.39; p < 0.001) and 41.2% and 56.5% for risk allele G of AB0, rs 8176719 ( O.R. 1.85; p < 0.001 ).

Conclusion: Only F5 Leiden, F2 20210G >A and non 0 blood group were statistically significant (all p < 0,001) for determining of the VTE risk with O.R. above 1.5 in our study. We also confirmed the importance of F11 and FGG polymorphisms for VTE ( both p < 0,001).

Study was supported by research project RVO-VFN 64165

511

PO 085Antitrombin III In Patients With High Risk Thrombosis Andri Iskandar Mardia, Dairion GatotHematology & Medical Oncology Division, Internal Medicine DepartmentFaculty of Medicine Universitas Sumatera Utara

Abstract

Background: Antithrombin III (AT-III) is a small protein molecule that inactivates several coagulation system. AT-III is one of the natural anticoagulant that inhibits thrombin (IIa), factor Xa and also inhibits factor IXa, Xia, XIIa, kallikrein and plasmin. Patients with high risk hrombosis often require venous thromboembolic prophylaxis with heparin administration. AT-III is required to optimize the work of the heparin. Hence this study aims to view the AT-III levels in patients with high risk thrombosis.

Methods: This is a cross-sectional study in 55 patients with high risk thrombosis. High risk thrombosis was characterized by Caprini score ≥ 3 then the AT-III level was examined. Data were assigned to one of two groups; Normal AT III with admission AT-III 75-125% and Low AT-III with admission AT-III <75%. Differences in variables between two groups were evaluated using chi-square test for categorical variables and independent samples T test for continuous variables. The study was conducted in RS Adam Malik from January-June, 2016.

Result: Of all patients with high risk thrombosis, 50.9% showed low AT-III and 36.4% experienced Deep Vein Thrombosis (DVT). Of the patients who developed DVT, 40% presented low AT-III. The mean of AT-III in the low AT-III group was 42.99 ± 20.95% and was significantly different from the normal AT-III with a mean value of 92.94 ± 11:22%(p=0.001). There were no differences in hemoglobin, platelets, creatinin, albumin, coagulation status, and fibrinogen between the two groups with p-value 0.779; 0.285; 0,517; 0.327; 0.149; 0,353 respectively. The D-dimer level was higher in the group with low AT-III level (1845.7 ± 1464.7) than in the normal AT-III group (1102.8 ± 1194.2) with p value = 0.005.

Conclusion: Decrease in AT-III level seems quite frequent in patients with high risk thrombosis. DVT occurred in 36.4% of patients with high risk thrombosis.

Keywords: Antithrombin III, Thrombosis, DVT, Caprini

512

PO 086Acquired Hemophagocytic lymphohistiocytosis: a Case series report

1Fifi Akwarini., 1Pandji Irani Fianza., 2Uun Sumardi., 1Rismauli Doloksaribu. 1Subdivision of Hematology and Medical Oncology Department of Internal Medicine 2Subdivision of Tropical Infection Departement of Internal Medicine

Faculty of Medicine Padjadjaran University/ Hasan Sadikin HospitalBandung-Indonesia

Abstract

Acquired Hemophagocytic Lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation, occurring as a sporadic condition, in association with a variety of triggers such as infections, malignancies, or rheumatologic disorders. HLH, which is immune dysregulatory disorder, is prominently associated with cytopenias and a unique combination of clinical signs. The predominant clinical findings of HLH are fevers (often hectic and persistent), cytopenias, hepatitis and splenomegaly.

Here in, we present 3 patients who were diagnosed acquired HLH.

Case 1: A 47-year-old man was admitted to our hospital with prolonged fever with anemia, thrombocytopenia, and hyperferitinemia. The patient was diagnosed with bacterial infection and myelodisplasia syndrome The bone marrow apiration showed activated macrophages/histiocytes and Staphylococcus Haemolyticus (MRCoNS) was found from bone marrow culture. He was given vancomycin, platelet and red cell tranfusion. On the twenty fourth day of hospitalization, he passed away because of intracranial bleeding.

Case 2 : A 68-year-old woman was admitted to another hospital with prolonged fever with hepatomegaly, splenomegaly, anemia, thrombocytopenia, hyperferitinemia, hypertrigliserida. Abdominal CT scan found multiple lympadenopathy in paraorta and parailiaca. Bone marrow smear showed histiocytes with hemophagocytosis. The patient was diagnosed as HLH ec mycobacterium avium complex. She was given dexametason with moxifloxacin.

Case 3: A 37-year-old man was admitted to another hospital with prolonged fever with anemia and lekopenia. HIV test was positive and we found that activate macrophage/histiocytes on bone marrow smear. He was given corticosteroid and anti retroviral virus.

Conclusion: Acquired HLH can be found in variety disease such as bacterial infection, mycobacterium avium complex infection, HIV infection, and haemotology malignancy.

Key words:hemophagocytic lymphohistiocytosis

513

PO 087GAMBARAN ANEMIA PADA PASIEN PENYAKIT GINJAL KRONIK DI RUMAH SAKIT MOHAMMAD HOESIN PALEMBANG

Meiliana, Adhitya Wicaksana, Reysginawathie, Mediarty Syahrir

Divisi Hematologi Onkologi Departemen Penyakit DalamRS Mohammad Hoesin/FK UNSRI Palembang

Pendahuluan: Anemia defisiensi besi timbul karena cadangan besi kurang yang akhirnya menyebabkan pembentukan hemoglobin berkurang, ditandai dengan anemia hipokrom mikrositer dan cadangan besi yang kosong pada hasil laboratorium. Pada anemia penyakit kronik, penyediaan besi untuk eritropoesis berkurang karena pelepasan dari sistem retikuloendotelial berkurang, sedangkan cadangan besi masih normal.

Tujuan: Mengetahui gambaran anemia pada pasien penyakit ginjal kronik yang menjalani hemodialisa di RSMH.

Metode Penelitian: Jenis penelitian ini adalah cross sectional. Sampel berasal dari data sekunder yaitu pasien penyakit ginjal kronik baik yang sedang atau belum hemodialisa yang dirawat di kelas tiga bagian penyakit dalam RSUP Mohammad Hoesin Palembang pada bulan Januari-Februari 2016. Metode pengumpulan sampel adalah consecutive sampling.

Hasil Penelitian: Jumlah sampel penelitian adalah 40 orang yang mendapat transfusi PRC, pria sebanyak 35% dan wanita sebanyak 65%. Umur rata-rata 50 tahun. Rata-rata Hb 7,28 gr/dl, eritrosit 2,66 juta/ul, Ht 21,83 %, leukosit 14,500/ul, MCV 82,9 fl, MCH 27,7 pg, MCHC 33,4. Gambaran darah perifer lengkap paling banyak adalah anemia hipokrom mikrositer (55%), anemia normokrom normositer (45%) dan anemia makrositer (0%). Rata-rata ureum 178 mg/dl, kreatinin 11,08 mg/dl. Penyebab anemia pada penyakit ginjal kronik adalah anemia penyakit kronik (80%) dan anemia defisiensi Fe (20%).

Sampel yang menjalani hemodialisa kurang dari 1 tahun 55%, 1-2 tahun 35%, lebih dari 2 tahun 10%. Anemia defisiensi Fe yang termasuk anemia hipokrom mikrositer 50% sama dengan anemia normokrom normositer.

Kesimpulan: Penyebab anemia terbanyak pada pasien penyakit ginjal kronik adalah anemia hipokrom mikrositer yang terdiri dari anemia penyakit kronik sebanyak 80% dan anemia defisiensi Fe sebanyak 20% dengan lama hemodialisa terbanyak adalah kurang dari 1 tahun yaitu sebesar 55%.

Kata Kunci : Anemia penyakit kronik, anemia defisiensi Fe, gagal ginjal kronik

514

ANEMIA IN CHRONIC RENAL FAILURE PATIENTS AT MOHAMMAD HOESIN GENERAL HOSPITAL (RSMH) PALEMBANG

Meiliana, Adhitya Wicaksana, Reysginawathie, Mediarty SyahrirDivision of Hematology-Medical Oncology Department of Internal Medicine Faculty of Medicine Sriwijaya UniversityMohammad Hoesin Hospital Palembang

Background: Iron deficiency anemia occurred when there is depletion in iron stores causing decreased hemoglobin production, marked by hypochromic microcytic anemia and zero iron stores in the laboratory findings.

In anemia of chronic disease, reduction in iron stores in erythropoetic system due to decrease in iron released by reticuloendothelial system, while the iron stores are still in normal limits.

Objectives: To describe the types of anemia in hemodialized chronic renal failure patients admitted to RSMH and the patients’ characteristics.

Methods: The cross sectional data was collected from hemodialized chronic renal failure patients admitted to third class internal medicine ward at RSMH from January to February 2016.

Results: The data included 40 patients who already got transfused, 35% (14/40) male with average age of 50 years. Mean hemoglobin level was 7.28 g/dl, hematocrit level of 21.83% and red blood cell count of 2.66 million/Ul. The mean of MCV level was 82.9 fl, MCH level was 27.7 pg and MCHC level was 33.4. The duration of hemodialysis of the patients was less than 1 year in 55% (22/40) of the patients, between 1 to 2 years in 35% (14/40) and more than 2 years in 10% (4/40).

The most common type of anemia was hypochromic microcytic anemia (55%, 22/40), followed by normochromic normocytic anemia (45%, 18/40). The average ureum and creatinine level were 178 mg/dL and 11,08 mg/dL. The most common causes of anemia in chronic kidney disease patients were anemia of chronic disease (32, 80%), followed by iron deficiency anemia (8, 20%). Only half of iron deficiency anemia presented as hypochromic microcytic anemia. The other half presented as normocytic normochromic anemia.

Conclusion: The most common cause anemia in chronic renal failure are hypochromic microcytic anemia which consist of anemia of chronic disease and iron deficiency anemia. Majority of chronic renal failure patients are on hemodialysis less than 1 year. Half of iron deficiency anemia presented as hypochromic microcytic anemia and half as normocytic normochromic anemia.

Keywords: Anemia of chronic disease, iron deficiency anemia, chronic renal failure

515

PO 088RISK FACTORS OF ANEMIA IN HIV/AIDS PATIENTS WITH ZIDOVUDINE THERAPY

Ade Yonata1, Yvonne Yolanda Fransiska2, Novita Carolia 3

1 Department of Internal Medicine, Faculty of Medicine, University of Lampung2 Faculty of Medicine, University of Lampung3 Department of Pharmacology, Faculty of Medicine, University of Lampung

Background: Anemia is a hematological disorder which increases morbidity and mortality in HIV/AIDS patients. Zidovudin, as a therapy for HIV/AIDS infection, has been known to cause anemia. The goals of this study is to find the associations between body weight, clinical stage of HIV/AIDS and duration of the use of Zidovudine with anemia in HIV/AIDS patients with Zidovudin therapy.

Methods:This study was an observational-analytic study with cross-sectional approach. Data collecting was done in November, 2015. This study used secondary data that was collected from medical reports of HIV/AIDS patients in Voluntary, Counselling and Testing clinic, Public Hospital in Bandar Lampung Indonesia. There were only 42 medical reports which had complete data, and the samples were taken with total sampling technique.

Results: There were 211 patients in the period of January 2014 - August 2015 consumed regimen containing zidovudine. The result of this study showed that there were 26 patients (61,9%) of Zidovudine consumers had anemia. Factors associated with anemia in Zidovudin consumers were body weight (p: 0,010) and clinical stage of HIV/AIDS (p: 0,010) while duration of the use of Zidovudin was found not significant (p: 0.421).

Conclusion: There were associations of body weight and clinical stage of HIV/AIDS with anemia in HIV/AIDS patients consuming Zidovudine.

Keywords : AIDS, Anemia, HIV, Zidovudine

516

PO 089Comparison between M2 Pyruvate Kinase and Immunochromatographic Fecal Occult Blood Test For Colorectal Cancer Screening at Moehammad Hoesin Hospital Palembang

Mulyadi Joyo Santoso (Indonesia)

517

PO 090PERFORMANCE OF IMMUNOCHROMATOGRAPHIC FECAL OCCULT BLOOD TEST AS SCREENING TOOL FOR COLORECTAL CANCER Devid Ergan, Erti Sundarita, Suyata

Department of Internal Medicine, Faculty of Medicine, University of Sriwijaya Palembang

ABSTRACT

Background: immunochromatographic fecal occult blood test (iFOBT) may be used as screening tool for colorectal cancer (CRC). But currently, there is no data about the performance of iFOBT in detecting CRC in Mohammad Hoesin Hospital Palembang. The aim of this study was to evaluate the ability of iFOBT as a diagnostic biomarker of CRC.

Methods: patients who were referred for elective colonoscopy recruited in this study. Fecal samples were examined with iFOBT qualitative sticks test. The iFOBT results were then compared with the histopathologic findings of the colorectal biopsies.

Results: of 59 subjects who underwent colonoscopy examinations, 27 (45,8%) were men and 32 (54,2%) were women. Based on histopathologic examinations, 38 subjects had CRC. Of all patients with colonic malignancies, 29 (76,3%) subjects had adenocarcinomas, 5 (13,2%) subjects had intramucosal carcinoma, 3 (7,9%) subjects had signet ring cell carcinoma, and 1 (2,6%) subject had large cell neuroendocrine tumor. Sensitivity, specificity, positive predictive value and negative predictive value of the iFOBT test were 50%, 71%, 76%, and 44%, respectively.

Conclusions: iFOBT test has low sensitivity for detecting CRC. iFOBT seems to be a poor performance diagnostic biomarker for colorectal cancer. We believe that the marginal performance characteristics demonstrated by iFOBT assay do not warrant its application as a screening tool of colorectal cancer.

Key words: Colorectal cancer, iFOBT, diagnostic biomarker and screening.

518

PO 091A case of sporadic neuronal intranuclear inclusion disease diagnosed by MRI finding and skin biopsy

A Tanaka, M Ishiguro, M Izuta, E Nishino, M Sadohara

Kishiwada Tokusyukai Hospital, Osaka, Japan

Case: A 63-year-old man sudden was referred to one hospital because of amnesia and abnormal behavior, such as absentmindedly sleeping in his wife’s bed and do not remember that things. He was seen to a nearby clinic complaining a headache the day before referred. At the age of 46 years, he had abnormal behaviors, such as he could not leave the room in his workplace. He was seen to neurosurgery, but obvious abnormality was pointed out at that time. At the age of 61 years, he had that view is lacking, but it had resolved immediately. The patient’s past medical history is migraine and high blood pressure and arrhythmia. Family history is that his mother is Alzheimer’s type dementia. He had no obvious neurological findings, exert of cognitive function Cerebrospinal fluid examination was no abnormality. Hasegawa dementia scale was slightly decreased with 20/30 points. A brain MRI with DWI of the brain showed linear high-intensity areas at the white matter below the cerebral cortex or under the corpus callosum. Therefore, we suspected Neuronal intranuclear inclusion disease (NIID). By skin biopsy, eosinophilic intranuclear inclusion body was found in the fat cells.

Conclusion: We experienced a case of NIID, diagnosed by characteristic finding of brain MRI and skin biopsy. NIID is a rare neurodegenerative disorder characterized pathologically by the presence of eosinophilic intranuclear inclusions in neuronal cells. Because of the variety of neurological finding and clinical features, skin biopsy is useful for diagnosis of adult onset NIID.

519

PO 092Nonagenarian man with breast cancer, hypercoagulable state and diabetic nephropaty

Indriyani H, MediartyHematology and Medical Oncology Division, Department of Internal MedicineSriwijaya University, Dr. Mohammad Hoesin General Hospital Palembang

Introduction: About 1 percent of all breast cancer cases in the U.S. occur in men. It may sound like a small number, but that’s still more than 2.000 new cases expected each year. In addition, more than 400 men in the U.S. are expected to die from breast cancer this year.

Case report: A 91-year old man came with chief complain of palpable mass in right breast when he visited his internist office for diabetes mellitus, hypertension and heart disease. The palpable mass was found to be 3 cm in the nipple. Fine needle aspiration was performed which evaluation of the specimen revealed malignant cells which may represent carcinoma. Total mastectomy was performed and the surgical pathology of the tumor showed invasive ductal carcinoma with grade III comedonal necrosis of no special type (ductal, NOS) with positive estrogen receptor, progesterone receptor and Ki 67. Echocardiography revealed ejection fraction of 51%, with SWMA. Laboratory tests showed fasting blood sugar was 105 mg/dL, 2 hours post prandial blood glucose was 177 mg/dL, HB1Ac was 6.8%, BUN was 39, serum creatinine 2,38. Valsartan 1x80 mg, aspilet 1x80 mg, gliquidone 2x30 mg and Letrozole 1 X 2,5 mg was initiated. Three months after starting the therapy, the clinical condition of the patient is improving. The Ca 15-3 and CEA were found to be 9.9 (normal is less than 30) and 2.63 respectively.

Discussion: At least 8 out of 10 breast cancers in men are invasive ductal carcinoma which may be alone or mixed with other types of invasive or in situ breast cancer. Because male breast is much smaller than female breast, all male breast cancers starts relatively close to the nipple. Therefore, they are more likely to spread to the nipple as seen in this case. Since most breast cancers in men are hormone-receptor-positive, hormonal therapy with tamoxifen or letrozole, depending on the stage, is often used.

Conclusion: are reporting a case of a 91 year old man with right breast cancer which has been managed by total mastectomy and hormonal therapy. Three months after starting the treatment, the patient’s clinical condition is improving.

Key word: breast cancer, nonagenarian.

520

PO 093Obesity Contribution on synthesis and degradation of cartilage marker through inflammation pathway in osteoarthritic patients : Analisis of adiponectin, Leptin, YKL-40, Cartilage Oligomeric Matrix Protein (COMP) Synovial Fluids

Abd.Rahman Umar, FaridinRheumatologic Division, Department of Internal Medicine, Faculty of Medicine, Hasanuddin University.

This study aimed to determine the role of obesity in OA through inflammation pathway by analyzing joint cartilage synthesis and degradation markers in synovial fluid.

We performed observational study with cross sectional approach on 70 knee OA patients. Obesity was determined based on waist circumferences, whereas central obesity when waist circumferences > 90 cm in male and >80 cm in female. Knee OA was diagnosed based on 1986 American College Rheumatology (ACR) criteria. We examined leptin as inflammation marker, YKL-40 as cartilage synthesis marker and COMP as cartilage degradation marker in synovial fluid using ELISA.

Our study found, from 70 knee OA patients, 61 subjects had central obesity and 9 subjects had non-central obesity. In central obese OA group, waist circumferences were correlated with adiponectin and leptin levels, and consequently adiponectin levels were correlated with YKL-40 levels, and leptin levels were correlated with COMP levels. In non-central obesity group, waist circumference didn’t correlated with adiponectin levels, but adiponectin levels were correlated with YKL-40, while leptin levels were directly correlated with COMP levels. In partial correlation test, we found adiponectin levels were associated with age.

We concluded that obesity was contributed in central obese OA group on destruction of joint cartilage through inflammation. While in non-central-obese OA group, the damage of joint cartilage was directly correlated with waist circumference without involving inflammation pathway.

Keywords : Osteoarthritis, obesity

521

PO 094STEROID INDUCED AVASCULAR BONE NECROSIS IN PATIENT WITH NEPHROTIC SYNDROME

Lukman Pura1, Afiatin1, Dicky Mulyadi2

1. Nephrology and Hypertension Division, Department of Internal Medicine, Faculty of Medicine Padjadjaran University / Dr.Hasan Sadikin General Hospital Bandung, West Java - INDONESIA

2. Reconstruction Division, Department of Orthopaedics and Traumatology, Faculty of Medicine Padjadjaran University / Dr.Hasan Sadikin General Hospital Bandung, West Java - INDONESIA

-------------------------------------------------------------------------------------------------------

Background: Non-traumatic osteonecrosis or avascular necrosis (AVN) is known as a cause of pain, loss of function and joint deformity. The causation of avascular necrosis is remain unclear. However, a sequence of venous thombosis, increased bone venous pressure, reduced arterial flow, and hypoxia seems to be important in the development of ischemic osteonecrosis. The steroid is recognised as one of determinant of AVN. With increased steroid use in the treatment of some diseases such as nephrotic syndrome, it become the clinical awareness. We report a case of avascular necrosis hip joint bilateral in nephrotic syndrome patient at Dr.Hasan Sadikin General Hospital Bandung West Java - Indonesia.

Case Report: A 21years old man was diagnosed as nephrotic syndrome with steroid therapy for 1 year and the last 6 months continuously. The patient’s complains are pain, stiffness and limited range movement at bilateral hip joint. The symptoms started as pain since 4 months ago. The symptoms initially occured when the patient weight on the affected joint, and later it was worsened and occurs even while resting. The patient was admitted to the hospital and followed some examination. The radiographic finding show the narrowing of hip joint space and sclerotic sign at caput joint. Magnetic resonance imaging revealed suspicion of labrar tear. At second week was diagnosed as avascular bone necrosis. Total hip joint replacement (THR) was performed by orthopaedic surgeon and the pain was relieved. The bone was performed pathological anatomy examination.

Conclusion: These rare side effect of long term steroid therapy shoul be taken into account when pain arise as a symptom.

522

PO 095SECONDARILY GENERALIZED TONIC-CLONIC SEIZURE MANIFESTATION IN TEENAGERS WITH CEREBRAL SYSTEMIC LUPUS ERYTHEMATISUS: A CASE REPORT

Firas Farisi Alkaff1, Dinda Mutiara Annisa1, Ricardo Adrian Nugraha1, Michael Jonatan1,

Awalia2

1Faculty of Medicine, Universitas Airlangga – Dr. Soetomo General Hospital2Rheumatology Division, Internal Medicine Department, Dr Soetomo General Hospital – Faculty of Medicine, Universitas AirlanggaEmail: [email protected]

Introduction: Neuropsychiatric involvement is one of the SLE manifestations with the frequency range between 14-75%. Seizure, one of the manifestations in NPSLE, occurs in 8-18% of the patients.

Case Decription: An eighteen years old girl from NTB presented with focal secondary generalized tonic-clonic seizure. Her focal seizure lasts in two minutes before getting worse in five minutes for the generalized seizure. After the seizure episode she was fully alert. MRI scan shows multiple brain edema without increased intracranial pressure. She also had a history of the same seizure type. Beside her seizure, she also complained history of non-erosive arthritis, painless oral ulcer, non scarring alopecia, malar rash, and positive ANA test.

Discussion: Seizure is one of the most serious neuropsychiatric manifestations of SLE. It is a marker for an overall poor prognosis because it represents a marker of disease activity and severity in SLE. It can occur at any time in the course of SLE and even before the diagnosis of lupus has been made or other manifestations of the disease are present. They can occur as the only manifestation of CNS involvement or as a complication of the cerebrovascular manifestations.

Conclusion: Central nervous system symptoms occur in a substantial portion of patients with SLE. It is necessary to consider APS in patients with unexplained generalized tonic-clonic seizure and/or blurry vision and/or cerebral infarction especially in young women.

KEYWORDS: Seizure, SLE, Neuropsychiatric Manifestation, Antiphospolipid

523

PO 096Prevalence of Diabetes Mellitus, Hypertension and Dyslipidemia in Systemic Lupus Erythematosus Patients

KY Fong1,2, J Thumboo1,2

1Department of Rheumatology and Immunology, Singapore General Hospital, 2Duke-NUS Medical School

Objective : To determine the prevalence of diabetes mellitus, hypertension and dyslipidemia in a cohort of patients with systemic lupus erythematosus (SLE).

Methods : Two hundred patients with SLE were studied. The data were collected through chart review based on the following definitions : Diabetes - either (a) with symptoms of polyuria and polydipsia with a random blood glucose level > 11 mmol/l or a fasting blood glucose level of > 7 mmol/l or (b) an asymptomatic patient with 2 blood glucose levels of greater than the values stated, Hypertension - > 160/90 mmHg on 3 separate occasions and Dyslipidemia - total cholesterol > 6.2 mmol/l or LDL cholesterol > 4.1 mmol/l. The prevalence was compared to the national prevalence derived from the Singapore Burden of Disease Study 2010 for each condition, for which the definitions are as follows : DM - 2-hour plasma glucose during an oral glucose tolerance test ≥ 11.1 mmol/l, Hypertension - ≥ 140/90 mmHg, and Dyslipidemia - total cholesterol ≥ 6.2 mmol/l

Results : The gender ratio is 185:15 (Female : Male) with a mean age at diagnosis of 33 years and mean disease duration of 97 months. The prevalence for diabetes, hypertension and dyslipidemia are 5.5%, 23.5% and 25.5% respectively (national prevalence : 8.2%, 24.9% and 18.7%). The higher prevalence of dyslipidemia could be due corticosteroids ingestion and renal involvement. The prevalence for diabetes and hypertension were comparable to the general population.

Conclusion : Chronic lupus patients have comparable prevalence of diabetes or hypertension but have higher prevalence of dyslipidemia. Hence it is important to include lipid levels as part of regular medical review.

524

PO 097SCLERODERMA

T. Dian Permatasari, Zuhrial Zubir

Pulmonology Allergy Immunology-Departement of Internal MedicineMedical Faculty of North Sumatera University Adam Malik General Hospital

INTRODUCTION: Systemic sclerosis (SSc / scleroderma) is an autoimmune disease that is characterized by the distinctive pathogenetic triad of microvascular damage, dysregulation immunity, and generalized fibrosis in multi¬ple organs.A striking feature of systemic sclerosis in patientis variable, and heterogenity has been observed in clinical manifestations, autoantibody pro¬files, tempo of disease progression, response to treat¬ment and survival. On the basis of the extent of their skin involvement, patients are grouped into limited cutaneous systemic sclerosis (lcSSc) and diffuse cutaneous systemic sclerosis (dcSSc) subsets. In lcSSc, skin fibrosis is restricted to the fingers (sclerodactyly), distal extremities and face, whereas in dcSSc, the trunk and proximal extremities are also affected.

CASE: A female, 45 years old with the main complaints limitation of motion and hard to open mouth, stiffness and painful joints in the hands and feet, thickening on the skin in the chest for 8 years, purplish red spots on arms and legs intermittent for 8 year.Patients Hospitalized with stable haemodynamic. On physical examination found sclerosis lesions, sclerodactily on fingers and toes, telangiectasias in the region of the antebrachii and cruris. Laboratory examination :CBC, RFT, Glucose normal. CRP quantitative : 0.7 , ANA test: 10.7 Anti DsDNA: 123. Skin biopsy confirmed as scleroderma. Cor and pulmo normal. GIT: Gastritis Antrum+ GERD. Patient treated with Methylprednisolon 125mg/12h, Methotrexat 2,5 mg 1x3 tab/week and Lansoprazole1x30mg.

CONCLUSION: We reported a rare case based on clinical features and clinical laboratory. Patients given immunosuppressant therapy+ proton pump inhibitors, patient is getting better and recommended for outpatient treatment. Although skin fibrosis is the distinguishing hallmark, the pathological changes in the lungs, gastro¬intestinal tract, kidneys and heart determine the clini¬cal outcome.

Keywords : Systemic sclerosis or scleroderma, autoimmune disease, fibrosis.

525

PO 098Inhibition of Transmembrane Activator and Calcium-Modulating Cyclophilin Ligand Interactor as A Targeted Therapy for Remission and Prevent Exacerbation in Systemic Lupus Erythematosus: A Literature Review

Firas Farisi Alkaff1, Ricardo Adrian Nugaha1, Michael Jonatan1, Awalia2

1 Faculty of Medicine Universitas Airlangga – Dr. Soetomo General Hospital2 Rheumatology Division, Internal Medicine Department, Faculty of Medicine Universitas Airlangga – Dr. Soetomo General Hospital


Introduction: Nowadays, the definitive therapy to cure SLE has not been found yet, where present therapy is not capable to accelerate the remission state. Most therapy for now are using immunosuppressive drugs such as glucocorticoid, rituximab, and Belimumab, are not effective enough to induct SLE remission. Transmembrane Activator and Calcium-Modulating Cyclophillin Ligand Interactor (TACI) is an immunology based target therapy that expected to give a better result in induct remission.

Aim: Analyze the possibility of TACI inhibition as a targeted therapy for SLE management, in order to accelerate the remission period and prevent exacerbation.

Methodology: We look up for scienctif article comprehensively in Medline, Science Direct, Mbase, and Cochrane Database with limitations on English –published article only. We found 12 article based on bibliography and keywords from the database.

Result: TACI expression is elevated in B cells from patients with SLE. Inhibition of TACI cause an inhibition to B cell differentiation, and also decrease the amount of plasma cell, which cause a decreasing quantity of autoantibody which circulate in the blood such as rheumatoid factor, anti-dsDNA, anti ribonuclear protein, anti-Smith antigen, IgA, IgM, IgG, IgG2b, IgG2c. Inhibition of TACI will fully protects the animals against autoantibody production, without having any impact on B cell survival, because TACI is not the receptor for the B cell survival. This inhibition also delays the onset of proteinuria, albuminuria, basement membrane thickening, tubulointerstitial fibrosis, kidney capillary occlusion, and glomerulosclerotic disease. It also inhibits only the T-cell independent responses and T-cell dependent (IgA), but it will maintain T-cell dependent protective B-cell functions. Moreover, it delays the expression of TLR7, which plays role in autoimmune disease.

Conclusion: Inhibition of TACI shows a better outcome compared to current therapy. However, the study for now is only limited in mouse.

Keywords: BAFF, SLE, TACI, Immunology Based Targeted Therapy

526

PO 099The Quality of Life of SLE Patients in Hasan Sadikin Hospital

Gusti Fungani Harti, Laniyati Hamijoyo, Andri RezaInternal Medicine Faculty of Medicine Padjadaran Rheumatology

A good quality of life (QOL) is one of Systemic Lupus Erythematosus (SLE) treatment goals. Many factors affecting QOL of SLE patients, such as disease activity, organ involvement and psychosocial aspects.The Short-form 36 (SF-36) is one of the tools that can be used to measure QOL in SLE patients. The aims this study to show the quality of life using the SF-36 score and disease activity level using the SELENA-SLEDAI Score in SLE patients in Dr. Hasan Sadikin General Hospital..

This is was a descriptive, cross-sectional study. All inpatients and outpatients SLE in Dr. Hasan Sadikin General Hospital from August to December 2015 were assigned to this study. The demographic data and disease activity evaluated with SELENA-SLEDAI were obtained.

A total 110 patients were enrolled to this study. Most of the subjects were female (103, 93,6%) with median age of 35 (25-43) years. The median duration of disease was 4(2-8) years. The median of SLE disease activity according to SELENA-SLEDAI was 4 (0-8). The percentage of patients showing no disease activity, low, moderate, high and very high disease activity were 27,3%, 35,5%, 20,0%, 10,0% and 7,3% respectively. The median of physical component was 45,2 (38,1-51,3) and mental component was 47,7 (40,2-53,4).The median quality of life scores for physical component from each category were highest among the university education level (47,9 (14,5-57,1)), labour group (50,2 (30,5-56,8)), good adherence level (45,5 (14,5-59,3)), and high income (55,25 (43-57,1)). The median quality of life scores for mental component from each category were highest among junior high school education level (49,2 (25,7-63,5)), housewife (49,05 (24,4-67)), good adherence level (48,6 (24,4-67)) and high income (51,2 (43,5-56,8)).

The characteristic of quality of life in SLE patients showed that the physical component of quality of life is lower than the mental component. The physical and mental component of QOL were highest in pasient with no disease activity.

Keywords : SELENA SLEDAI, Short-Form 36, Systemic Lupus Erythematosus

527

PO 100CASE STUDY: HYPERTROPHIC MENINGITIS WITH MULTISYSTEM INVOLVEMENT AS INITIAL PRESENTATION OF BEHCET’S DISEASE

G Kughan1, GB Eow2, CF Cheah2

1 Department of Medicine, Penang General Hospital, Penang, Malaysia2 Department of Neurology, Penang General Hospital, Penang, Malaysia.

Introduction: Behçet’s disease (BD) is a multisystem recurrent vasculitic disorder of unknown origin, which manifests as recurrent oral and genital ulcers, skin and eye alterations. Hypertrophic pachymeningitis is a rare disease characterized by localized or diffuse thickening of the dura mater of brain associated with infections, systemic autoimmune/vasculitic disorders, malignancy and meningioma.

Case Report: A 35-year-old gentleman presented with two-year history of bilateral trismus and jaw pain which did not resolve, despite oral surgery was done. He also had fever, headache, blurring of vision with restricted left eye movement for three months. CT Brain and Orbit with contrast showed extensive pachymeningeal enhancement, bilateral retrobulbar mass and right infratemporal fossa lesion. MRI of Brain and Orbit showed diffuse pachymeningeal enhancement and inflammation of left recti muscles, right infratemporal and masticator spaces. Patient was empirically covered with antibiotics for meninigitis. Subsequently, he was started on anti-tuberculous treatment(anti-TB) due to high ESR and unresponsiveness to antibiotics. CSF results(cell count, biochemistry, C+S, acid-fast bacteria, MTB PCR, viral screening, GeneXpert) were not suggestive of infection. Despite being on anti-TB for eight months, fever did not resolve. Therefore, he was given trial of oral steroids(Tab Prednisalone) and his general condition improved. Due to worsening restriction of extraocular movement of left eye, left orbitotomy and retrorbital mass incisional biopsy were done. Left periorbital and orbital fat sent for histopathological examination showed neutrophilic vasculitis suggestive of Behcet’s disease. Currently, patient is started on Tab Azathioprine and being followed-up as outpatient.

Discussion and Conclusion: There should be high degree of suspicion about Behcet’s disease in patients with hypertrophic pachymeningitis with multisystem involvement although certain typical features such as recurrent oral and genital ulcerations are absent. Such atypical isolated cases has been reported worldwide. Early treatment with steroids are essential to halt progression of the disease and prevent serious complications.

528

PO 101The Correlation Between Serum Anti-Clq Antibody Levels and Disease Activity (based on SELENA-SLEDAI score) in Patients with Systemic Lupus Erythematosus at RSUP Dr Hasan Sadikin Bandung

Ferdian F, Hamijoyo L, Pramudiyo RInternal Medicine DepartementFK Unpad/RSUP Dr.Hasan SadikinBandung

Antibody to complement C1q (Anti-C1q Antibody) can be found in Systemic Lupus Erythematosus (SLE) patients. Complement C1q plays a role in the clearance of apoptotic cells and immune complexes. Anti-C1q cause complement C1q become inactive so that the clearance decreases. Decrease in clearance seen with many inflammatory response. SELENA-SLEDAI use to evaluate disease activities in lupus patient. The aim of this study is to correlate anti-C1q level with disease activity, so that antibody C1q can be used as an objective indicator of inflammation along with SELENA-SLEDAI

This is an analytic descriptive study with cross sectional design. Anti-C1q levels were measured in 52 SLE patients who are hospitalized and treated routinely in Rheumatology Dr.Hasan Sadikin Hospital Bandung from October 2015 to December 2015. Patient were excluded if pregnant, with hepatitis B or C infection, severe medical or psychiatry condition

Most of the study subjects were women (94%), with a median age of 33 years (17-54 years). There are 13 new patients (25%), 42 patients (80%) were treated routinely in Rheumatology Dr.Hasan Sadikin Hospital, Bandung. The median SELENA-SLEDAI is 6 (0-32). Subject with no activity (11.5%), low disease activity (34.6%), medium disease activity (25%) high disease activity (15.4%) and very high disease activity (13.5%). Median antibody C1q level was 3.92 U/mL range 0.6-100.2 U/mL. Anti-C1q levels were positively correlated with SLE disease activity based on SELENA-SLEDAI scores (r=+0.304; p=0.014)

Anti-C1q levels correlated with lupus disease activity based on SELENA-SLEDAI score

Keywords : Anti-C1q, SLE, SELENA-SLEDAI.

529

PO 102Bone Mineral Density Profile of Patient with Autoimmune Disease in Rheumatology Clinic at Dr.Hasan Sadikin Hospital, Bandung

Benny Budiman1, Sumartini Dewi2

1Internal Medicine Department, 2Rheumatology Division Internal Medicine Department, dr.Hasan Sadikin Hospital, Padjajaran University, Bandung

Inflammatory autoimmune disease such as rheumatoid arthritis (RA), systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) are frequently associated with bone loss. In chronic inflammatory conditions, the inflammatory cytokine network induces bone resorption and reduces bone formation that results in significant bone loss. The aim of this study is to assess the bone mineral density (BMD) profile of patient with autoimmune disease (RA, SSc or SLE) at dr.Hasan Sadikin Hospital (RSHS) Bandung from May 1st 2015 to April 30th 2016.

This is a retrospective observational study with cross-sectional design using BMD dual energy x-ray absorptiometry (DEXA) data. Subjects are RA, SSc or SLE patients with BMD results in rheumatology clinic RSHS Bandung from May 1st 2016 to April 30th 2016. The bone densitometry is assessed with World Health Organization (WHO) criteria for diagnosis of osteoporosis.

From 46 patients with autoimmune disease in rheumatology clinic from May 1st 2015 – April 30th 2016, there are 9 (20 %) patients with RA, 23 (50 %) patients with SSc and 14 (30%) patients with SLE. Overall, there are 11 (24 %) patients with normal BMD, 20 (43 %) patients with osteopenia BMD and 15 (33 %) patients with osteoporosis BMD. Majority of patients with osteoporosis BMD are SSc patients.

In our study, majority of the patients have osteopenia BMD. Early intervention is needed to avoid osteoporosis and it’s complication in patient with autoimmune disease.

Keywords : rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, bone mineral density, osteopenia, osteoporosis

530

PO 103Post-Chloroquine Administration Dyskinesia to Patient with Systemic Lupus Erythematosus: a Case Report

Darmawati Dwi, Ayu Paramaiswari, Dedy Nurwachid, Nyoman Kertia

Background: Anti malarial agents like chloroquine (CQ) and hydroxychloroquine (HCQ) have been recommended in Systemic Lupus Erythematosus (SLE) therapy regimen.1 Dyskinesia is involuntary movement resembling Parkinson and has been reported in patients with 4-amino-quinolone therapy especially CQ and amodiaquine.2

Case: A 30-year old woman presented to Rheumatology Clinic, Department of Internal Medicine, RSUP Dr. Sardjito with chief complaints tremor of both hands and anxiety around 48 hours after CQ 250 mg consumption. Patient was an SLE patient which was also treated with metilprednisolone, calcium, vitamin D3, and curcuma. Physical examination revealed anxiety, clear communication, vital signs within normal range, malar rash on face, discoid rash on arms, and tremor on both hands. Complete blood test showed normal renal function, ANA, and thyroid hormone level. However, slight elevation of hepatic enzymes was observed. Anxiety and tremor gradually stopped after CQ therapy was terminated.

Discussion: Dyskinesia is a movement disorder, marked with involuntary muscular movements such as tremor. Chloroquine is reported to trigger dyskinesia.4 CQ are reported to bind with tissues containing melanin, which is originated from 3-hydroxy-tyrosine (phenylalanine tyrosine dopaquinone melanin). Therefore, CQ is thought to form bond with dopaminergic receptor-rich tissues, as well. If this happens in nigrostriatal system, dopaminergic transmission will be blocked, resulting in involuntary movements resembling Parkinson.5 Some argued that the movements are caused by the decrease of catecholamine level in the brain and neural calcium uptake disruption. This hypothesis is supported by CQ-induced dyskinesia improvement after the administration of benzodiazepine.4,6

Conclusion: A tremor dyskinesia case on SLE patient was reported. Complaints disappeared after the treatment was stopped.

Keywords: Dyskinesia, chloroquine, Systemic Lupus Erythematosus

531

PO 104Severe Hypokalemia secondary to Type1(distal)RTA Secondary to Primary Sjogren’s Syndrome

Faisal Bashir Butt - Singapore

57 years old Chinese female ADL independent,community ambulant,married no children.

No PMHX /not on any long term medications. Not known to have any drug allergies.Admitted with generalized weakness&difficulty getting up from sitting position,Unable to dress herself and unable to do household chores.She has no recent history of any viral URTI/GE symptoms/weight loss.On examination she was alert,hemodynamically stable with full GCS,on neurological.examinationPower 2/5 all 4 limbs reflexes 1+UL and LL,Unable to assess cerebellar signs because of weakness,Plantars down goingNo sensory deficit.Blood investigations shows FBC normal,renal panel Na 135mmol k 1.1mmol/l Cr.103umol/l Ca 2.54mmol/l,TFT normal.EKG shows ventricular bigemny shows ventricular bigemny patient was put on telemetry monitoring.Further investigations were done including ABG’s tht shows PH 7.23 PCO2 23 PO2 90 HCO3 13 ,with Anion gap 6(Metabolic acidosis with normal anion gap)Urine anion gap +18,

WBC 8.1 PH 7.23

HB 11.5 PCO2 23

PLT 215 PO2 90

Na 135 Hco3 13

K 1.1 Anion gap 6

Creat. 103 Urine anion gap +18

Urinary K/Cr

Anti RO(SSA)

Anti La(SSB)

4.55

169RU/ml

61RU/ml

ANA

(speckled)

ESR

640

70mm/hr

532

Initial Impression: Severe Hypokalemia likely secondary to dRTA

Distal RTA characterised by impaired H+ secretion in the distal nephron because of decreased net activity of the proton pump – hence:The daily acid load cannot be excreted, resulting in progressive H+ retention and a NAGMA (serum HCO3- levels can sometimes fall below 10)Urine pH cannot be reduced below 5.5

Distal RTA may also be associated with nephrocalcinosis:Acidaemia promotes stone formation both by increased calcium phosphate release from bone during bone buffering of retained acid and by direct reduction in the tubular reabsorption of these ions

Two other factors also contribute importantly to stone formation

Persistently high urine pH favours precipitation of calcium phosphateReduced citrate excretion (since acidaemia enhances proximal citrate reabsorption) – urinary citrate is normally a potent inhibitor of calcium stone formation

Us KUB &X KUBNo evidence calculi/nephrocalcinosis

533

On further history she has been using eye drops on and off for eye discomfort last few months”Eyes dry”.

• Schirmer’s testRight Eye 0mmLeft Eye 1mm

• Refer to RAISymptomatic treatment for sicca symptomsLip Biopsy consistent with focal lymphocytic sialadenitis

• In summary this patient has • Ocular symptoms• Oral symptoms• Ocular signs: positive Schirmer’s test• Histopathology: Consistent with focal lymphocytic sialadenitis• Autoantibodies: anti-Ro(SSA) and anti-La(SSB) positive

Likely primary Sjögren’s syndromeFinal DiagnosisSevere Hypokalemia secondary to Type1(distal)RTA Secondary to Primary Sjogren’s SyndromeSymptomatic treatment for sicca symptoms Hydroxylcholoroquine 200mg OM and arrange for eye screening.

534

PO 105A rare case of lymphadenomegaly: Kimura Disease

Musa Salmanoğlu, Yusuf Hançerli, Barbaros Başbuğ, Yalçın Önem, Mustafa Kaplan, Ramazan Arıkan, Emrullah Solmazgül.

Background: Kimura disease is a rare, soft tissue angiolymhoproliferative disease and more common in young and middle-aged men. It is seen 6 times more in men than women. Clinically, it is usually seen in the head and neck regio, rarely in oral mucosa. Painless, subcutaneous nodules or masses are seen and there are body itching, lacerations and the involvement of regional lymph nodes. There may be peripheral blood eosinophilia and increased serum IgE in the patient with Kimura disease.

Case: About 1 year ago, 20 year old male patient has left inguinal swelling. Excisional biopsy was performed in outer center. It was resulted Kimura disease by histopathological findings and eosinophilia. About 6 months ago another biopsy of swelling in the left axilla has been reported as Kimura disease again. Currently he has noticed 2 new swellings in the left axillary region and was admitted to our hospital. The laboratory findings were CRP:1.79mg/L, sedimentation:6 mm/h, total IgE:427IU/mL, ALT:64U/L, AST:22U/L, peripheral blood eosinophilia:12.8% (778 /µL). Other laboratory findings were normal. 2 lymphadenomegaly(LAM) in left axillary region were seen at 50 and 18 mm in diameter in ultrasound and the histopathological examination of them was consistent with Kimura lymphadenopathy. There was a hepatomegaly in abdominal CT. Liver biopsy was resulted minimally reactive changes. Clinically, he had no complaints including itching. As the result, Kimura disease was confirmed in the patient and steroid was given at the dose of 1 mg/kg and he is still under treatment.

Conclusion: There are many reasons for LAM. Malignancies, especially lymphomas are in the list of differential diagnoses. However, Kimura disease which is rare and benign etiology of LAM should be kept in mind in a patient with LAM, and the disease assessments should be performed in such patients.

535

PO 106NEW INSIDE ON RHEUMATOID ARTHRITIS PATHOGENESIS: GENE ANALYSIS

Ramezan Ali Ataee*1 Gholam Hossein Alishiri2 and Mohammad Hossein Ataee3

1. Department of Medical Microbiology, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran.

2. Department of Rheumatology, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran.

3. Applied Microbial Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.

Background: Microbial Superantigens as major biomarkers may have an important role on rheumatoid arthritis pathogenesis. The aim of this investigation was to experimental and bioinformatically analysis the most common superantigens with a subclass MHC class II gene and analysis.

Methods: In this study, the related sequence SEQ NM_002118.4 and SEQ NM_006120.3 of Homo sapiens major histocompatibility complex and ent A, ent B gens, mycoplasma superantigen gens were amplified from synovial fluid of RA patients and subjected to sequencing. Then, multiple sequence alignments were performed using Clustal W and DNA Max trail software of European Bioinfor¬matics Institute website to find some common fragment epitopes in all the sequences. Then, Anti¬genic sequences within the genes were selected. The finding data was descriptively analyzed.

Results: The results of this assay revealed that the matched portion of the encoded site (rich XXX) by these superantigens sequences were fund the highly similarity between different microbial superantigens in RA patients.

Conclusion: However, there were no exact definite etiology for RA and different causative agent had mentioned. The results of this study could explain the similarity of the causative active site. This finding may be help to redefinition of autoimmunity of RA and proper to study and design vaccine strategies for RA disease.

Keywords: Rheumatoid arthritis, superantigens gene, MHC Class gene. Bioinformatics analysis

536

PO 107Title: SWEET’S SYNDROME CO-EXISTING WITH LEUKOCYTOCLASTIC VASCULITIS IN A 28-YEAR OLD FILIPINO MALE

Jestoni V. Aranilla MDDela Salle University Medical Center, Cavite, Philippines

Background: Sweet Syndrome is an uncommon inflammatory disorder, only two reported cases published in the Philippines, characterized by the abrupt appearance of painful, edematous, and erythematous papules, plaques, or nodules on the skin and on biopsy, a diffuse infiltrate consisting predominantly of mature neutrophils that are typically located in the upper dermis. Sweet’s syndrome presents in three clinical settings: Classical (Idiopathic), malignancy-associated, and drug-induced. The pathogenesis of Sweet’s syndrome may be multifactorial and still remains to be definitively established. Systemic corticosteroids are the therapeutic gold standard for Sweet’s syndrome.

Objective: To present a case of Sweet’s Syndrome who presented with facial lesions and debilitating arthralgia.

Setting: De La Salle University Medical Center, a tertiary hospital in Dasmarinas, Cavite.

Case: A 28 year-old Male, Filipino, with no known co-morbidities, presented with a two-week history of palpable purpura on both lower extremities and fever followed by debilitating arthralgia and myalgia of the lower extremities and papules and vesicles on the face, treated for one week with antibiotics and analgesics without improvement. Skin biopsy of the lower extremities revealed a diagnosis of Leukocytoclastic Vasculitis and skin biopsy of the face was histopathologically consistent with Sweet’s Syndrome. He had a complete recovery after a two-week course of oral corticosteroids.

Significance: This report will add to the literature that Sweet’s syndrome may co-exist in an individual with Leukocystoclastic vasculitis.

537

PO 108A Case of Systemic Lupus Erythematosus-Autoimmune Hepatitis Overlap Syndrome with Spontaneous Intraparenchymal Hemorrhages and Pulmonary Tuberculosis in A 29-Year Old Filipino Male

Jestoni Aranilla (Philippines)

Background: Systemic Lupus Erythematosus (SLE) is an autoimmune disease affecting multiple organ systems. One of its rare but highly fatal complications is intracerebral hemorrhage. SLE-Autoimmune Hepatitis (AIH) overlap syndrome is also a rare entity with only 35 cases reported worldwide. This case is reported, with the patient’s consent, to contribute to knowledge about unusual and complicated presentations of SLE.

Case: A 29-year old Filipino male presented with one year history of malar erythema, photosensitivity, and joint pains. He was hospitalized for nonproductive cough, intermittent fever, dyspnea but normal chest radiograph and no response to oral antibiotics. On admission, he had oral candidiasis, leukopenia with absolute neutrophil count of 598, cardiomegaly and bibasal infiltrates. He was given broad spectrum antibacterial and antifungal drugs and intravenous glucocorticoids. With the suspicion of lupus myocarditis and acute interstitial pneumonitis, he received methylprednisolone pulse for 3 days. Cough, dyspnea, and fever persisted but leukopenia resolved, platelet count remained normal, and sputum AFB was negative. On the tenth hospital day he had drowsiness, disorientation, and perseveration. Cranial CT scan revealed a massive bleed on the left temporo-parietal region. His sensorium improved after decompression using Mannitol.Broncho-alveolar lavage was positive for tuberculosis and multi-drug resistant Enterobacter aerogenes. Meropenem was shifted to cefepime but initiation of anti-tuberculosistherapy was delayed due to marked elevation of liver enzymes. Viral hepatitis profile and liver ultrasound were unremarkable but anti Smooth muscle antibody was positive. AIH was considered as a co-existing disease. Antibiotics and high dose glucocorticoids were continued with tapering after normalization of liver enzymes in 3 weeks. He completed six months of anti-tuberculosis therapy with almost complete clearing of right lung infiltrates. On last follow-up, 7 months after hospital discharge, all his previous clinical manifestations have resolved, laboratories are normal, and he is able to return to his work as a driver.

538

PO 109Successful Colchicine Therapy for Recurrent Pericarditis in A Patient with Long-Standing Rheumatoid Arthritis: A Case Report

Akitake Suzuki (Japan)

Pericarditis is the commonest complication of RA and one fourth of patients have recurrent acute pericarditis, tamponade or chronic pericarditis. The course of severe pericarditis is unfavorable and the potential beneficial impact of the biologic therapy on the extra-articular complications remains unclear. Herein, we report a case of recurrent rheumatoid pericarditis which could be successfully relieved by colchicine without increase of maintenance glucocorticoid. An 85-year-old female with 40 years history of anti-CCP antibody positive RA developed pericarditis 8 years ago. She was started with 30mg of dairy prednisone (PSL) with prompt effect and PSL was maintained thereafter. One year prior to admission, abatacept was started for disease control. Our patient developed persistent fever and chest discomfort 3 days before admission and admitted to our hospital. A laboratory evaluation revealed WBC of 10,700/μl and CRP of 6.91 mg/dl. ESR was elevated to 61 mm/hr. Interferon-gamma assay for tuberculosis was negative. The articular symptom was in low disease activity and a CT scan of the chest revealed marked pericardial effusion and thickened pericardium. The diagnosis of recurrent rheumatoid pericarditis was made and 1mg of dairy colchicine was started. Our patient’s condition improved rapidly within one week and she discharged from our hospital on 12th day. Although colchicine has been widely used in treating refractory and recurrent idiopathic and viral pericarditis, its use for connective tissue disease-related pericarditis has been still anecdotal. Our case may lead to confirm its beneficial effects for rheumatoid pericarditis.

Keywords: Rheumatoid arthritis; Recurrent pericarditis; Colchicine

539

PO 110GOUT PROBLEMS IN PATIENTS WITH CHRONIC KIDNEY DISEASES

Bagus P.P.Suryana, Atma Gunawan, Nur Samsu, Charisma Dian, Lya Rosita, Asri Nugraheni, Rizal Syarifudin, Bastianto Kusumajaya

Department of Internal Medicine, Saiful Anwar General Hospital – Brawijaya University, Malang, Indonesia

ABSTRACT

Background: Uric acid excretion decreased in Chronic Kidney Disease (CKD). This condition lead to hyperuricemia, a major cause of gout. There is evidence that gout and hyperuricemia may independently impair kidney function. The objective of this study is to identify gout problem, uric acid level, correlation between duration of CKD with number of gout attack per year, number of joints involved and correlation between estimated glomerular filtration rate (GFR) with serum uric acid (SUA) level.

Methods: A retrospective study was conducted in Nephrology Centre of Saiful Anwar General Hospital Malang with subject CKD patients in year 2016. Severity of CKD determined using GFR estimate by Cockcroft-Gault equation. Results: A total of 123 patients consist of 49.6% male with age 51.5+12.5 years, and 22 patients (17.9%) have gout problem. Most of patients (97.6%) have CKD stage IV and V, requiring regular dialysis including 89.4% with hemodialysis and 3.3% with peritoneal dialysis. SUA level mean are 8.39+1.93 mg/dL and 78% of patients are hyperuricemia (SUA>7.0 mg/dL). Only 43.1% of patients take allopurinol routinely with average dose 100 mg every other day to 100 mg/day. Joint pattern involved including knee (64%), ankle (27%), metatarso-phalangeal (MTP) joint I (18%), wrist (9%), and hand joints (9%). Duration of dialysis is statistically significant and positively correlated with number of joints involved (p=0.026; r=+0.201), but not statistically significant with number of attack per year (p=0.063; r=+0.168) nor with SUA level ((p=0.895; r=-0.012). GFR statistically significant and negatively correlated with SUA levels (p=0.019; r=-0.211). UA level not statistically significant with number of attack per year (p= 0.44) and also with number of joints involved (p= 0.329) Conclusion: Gout and hyperuricemia are more frequent in CKD. GFR is significantly correlated with UA level. Duration of dialysis significantly correlated with number of joints involved in gout attack in CKD.

540

PO 111A Population Based Study Examining Calcaneus Quantitative Ultrasound in Cipatujah Sub-District, Tasikmalaya West Java Indonesia in Conjunction of Universitas Padjadjaran Community Services Program 2015

Andri Reza Rahmadi (Indonesia)Rheumatology Division, Internal Medicine Department, Universitas Padjadjaran, Indonesian Research, Technology and High Education Ministry

Background. Osteoporosis and its related fractures are now becoming, and increasingly important worldwide public health problem, including in Indonesia. Fracture prevention for high risk population is very significant to prevent heavy economic burden. Some osteoporosis studies are using urban area population, but in rural areas like in West Java province in Indonesia are not been done before.

Methods. The gold standard used for diagnosing osteoporosis is Bone Mineral Density Dual X-ray Absorptiometry (BMD DXA), but it is expensive and impossible to do in rural area. Alternative simple and inexpensive method is Quantitative Ultrasounds (QUS), which also can detect density. The present QUS study was a part of Universitas Padjadjaran Community Services Program at Cipatujah Sub-District Tasikmalaya West Java Indonesia in August 2015.

Result. A prevalence 38,6% osteoporosis, and 40,3% osteopenia was found in population. Osteoporosis found in 88,2% women and 11,8% men. Mean age of osteoporosis is 62,64 years old (SD:9,31), osteopenia is 50,94 (SD:13,56). According to village location, osteoporosis found 26,5% in Cikawunggading, 10,0% in Derwati, and 3,5% in Pameutingan village. Some risk factor are found, for example: age more than 50 (92,6%), women (88,2%), menopause (80,9%), family with osteoporosis (10,3%), low calcium diet (61,8%), inactive daily activity (54,4%), and drink some medicine which can cause osteoporosis (26,5%).

Conclusion. Osteoporosis also found in rural area. Mostly found in old women. Calcaneus QUS can also detect osteoporosis and it can be an important screening method for rural areas.

Keywords : osteoporosis, quantitative ultrasound, screening.

541

PO 112THE RELATION BETWEEN AGE OF ONSET AND DISEASE DURATION WITH THE THICKNESS OF CAROTID INTIMA MEDIA IN PATIENT WITH SPONDYLOARTHRITIS

M.Trihatmowijoyo Bundjali, Joewono Soeroso, Lita Diah Rahmawati

Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Patient with SpA has higher risk of cardiovascular event that non-SpA patient. But that opinion has been against by other group of researchers. They’ve claimed that the evidence of increased risk of cardiovascular event in SpA is not significant enough, and they’ve also concluded that cardiovascular disease in SpA is more influenced by the condition of cardiovascular itself than SpA disease. So that, the increased risk of cardiovascular disease in inflammation process in SpA is still debated, the question that appears is that CIMT might have correlation with the age of onset and disease duration of SpA. The aim of this study is to know the relation of disease onset and disease duration with the thickness of carotid intima media on patients with SpA.

Methods: size of samples are 30 spondyloarthritis patients at Rheumatology Outpatient Clinic Dr.Soetomo Hospital Surabaya. Inclusion criteria based on the criteria SpA of ASAS 2009 and the informed consent signed by the patients. The data analysing use double linear regretion.

Results: In this research, mean of age of research subjects is 56 years old, 80% is women. Mean of age of onset is 49,700 (±10,971) years. Mean of disease duration is 76 (±88,369) months. Pearson correlation test results shown the correlation between SpA’s disease onset with CIMT right-CCA, CIMT left-CCA, and mean CIMT CCA are 0,310; 0,195; and 0,279. Whereas, the correlation of SpA’s disease duration between CIMT right-CCA, CIMT left-CCA, and mean CIMT CCA are 0,035; 0,024; 0,032. The large of relation between of SpA’s age of onset and SpA’s disease duration with CIMT is 0,382.

Conclusion: SpA’s age of onset and SpA’s disease duration is not strong enough to use for detecting the ateroscleroting process.

Keywords: SpA, chronic inflamation, SpA’s age of onset, SpA’s disease duration, and the thickness of carotid intima media.

542

PO 113ASSOCIATION OF HIGHLY SENSITIVE C-REACTIVE PROTEIN SERUM LEVELS WITH LEQUESNE INDEX IN KNEE OSTEOARTHRITIS

Astri Ulia Rahmawati, Joewono Soeroso, Awalia


Background: The recent theory in osteoarthritis pathogenesis involves inflammation process in synovial membrane (synovitis), not merely “wear and tear” process. Nevertheless, low grade inflammation in osteoarthritis is not easily recognized by classic signs of inflammation. There is increasing interest in biologic marker to identify inflammation in osteoarthritis. Thisstudy assessed the association between hsCRP serum levels and Lequesne Index in knee osteoarthritis.

Method: HsCRP serum was measured from 30 patients who visited Outpatient Clinic of Rheumatology Dr.Soetomo Hospital and were diagnosed as having knee osteoarthritis according to ACR criteria. HsCRP serum was processed with particle enhanced immunoturbidimetry. The clinical severity of knee osteoarthritis was measured by Lequesne Index. Correlation between hsCRP serum levels and Lequesne Index was determined by the Spearman rank correlation test. Patients with uncontrolled diabetes mellitus and hypertension, chronic kidney disease, hepatic cirrhosis, cardiovascular disease, smoking, infection, malignancy, inflammatory rheumatic disease, and intra articular steroid injection in the last 3 months were excluded.

Result: 80% of the patients were women and the mean age was 57,53 ± 5,1 years old. The mean BMI was 27,55 ± 5,09 kg/m2, median hsCRP was 2,0 mg/L (0,2-8,3 mg/L), and the mean Lequesne Index was 7,98 ± 4,49. The result of Spearman rank correlation test indicated significant negative correlation between hsCRP serum level and Lequesne Index (p = 0,000; r = -0,764).

Conclusion: Low grade inflammation in osteoarthritis measured by the increasing of hsCRP serum levels tended to be found in patients with lower Lequesne Index score.

Keywords : highly sensitive c-reactive protein, lequesne index, knee osteoarthritis

543

PO 114A MAN WITH SLE AND ANTI-PHOSPHOLIPID SYNDROME IN LIMITATION OF DIAGNOSTIC AND THERAPEUTIC OPTION (Case Report)

Cahyo Wibisono, Joewono Soeroso


Background: Anti-phospholipid antibody syndrome is defined by the presence of thromboembolic complications and/or pregnancy morbidity in the presence of persistently increased titers of antiphospholipid antibodies. Its clinical presentation can be diverse and any organ can be involved, with a current impact in most surgical and medical specialties.

Case: The author presents the case of a 17-year-old man presented with thrombosis of the abdominal and femoral artery in a setting where diagnostic and therapeutic options are limited and costly. The aim of reporting this case is because of its challenging diagnosis and the limitation of available treatment options.

Summary: The authors conclude that clinicians need to have a high index of suspicion of APS in patients who present with a thrombotic episode – clinicians should investigate for the presence of antiphospholipid antibodies, as early diagnosis may influence the course of the disease. Furthermore, resources for the detection of antiphospholipid antibodies should be made readily available in resource-limited settings. Finally, patient education on the importance of drug compliance, periodic monitoring, and prevention of thrombosis is indispensable.

Keywords: thrombosis, anticardiolipin antibodies

544

PO 115Kikuchi-Fujimoto disease: Report of 4 cases and review of the literature

Z. Tazi Mezalek, M. Bourkia, W. Ammouri, L. Lamzaf, M. Maamar, H. Harmouche, M. Adnaoui

Mohamed V University - Ibn Sina hospital - Internal medicine/hematology department - Rabat - Morocco

Introduction: Kikuchi-Fujimoto disease or histiocytic necrotizing lymphadenitis is a benign disease of unknown origin predominantly affecting young women and presenting in the form of cervical lymphadenopathy and/or prolonged fever.

Material and methods: The authors report 4 cases of Kikuchi-Fujimoto disease diagnosed in the Internal Medicine Department of Ibn Sina university hospital in Rabat between 2009 and 2010.

Results: These 4 women with a mean age of 27 ± 8.6 years [16–37] were admitted with febrile syndrome and cervical lymphadenopathy. The diagnosis was based on histological examination of a lymph node biopsy. The disease was associated with systemic lupus erythematosus in one case and actinomycosis in another case. A favorable course was observed in response to corticosteroid therapy in two patients, antibiotic therapy in one patient and antipyretic treatment alone in the fourth patient.

Conclusion: In the light of these four cases, the authors discuss the diagnostic difficulties, the modalities of treatment of Kikuchi-Fujimoto disease and its clinical course.

545

PO 116Late onset systemic lupus erythematosus: Retrospective study about 22 cases Z. Tazi Mezalek, M. Maamar, W. Ammouri, M. Bourkia, H. Harmouche, M. Adnaoui

Mohamed V University - Ibn Sina hospital - Internal medicine/hematology department - Rabat - Morocco

Objectives Systemic lupus erythematosus (SLE) is a multisystem inflammatory disease predominantly occurring in females of childbearing age. This disease is uncommon after the age of 50 years and has different clinical and laboratory characteristics. Method

We conducted a retrospective study to analyze characteristics and outcome of patients with late-onset SLE in a Moroccan tertiary referral center and compare them with those of younger patients with SLE.

From 1996 to 2012, 22 patients were identified as having late onset SLE defined as SLE diagnosed at or over the age of 50 years. These patients were compared with a group of 337 patients aged younger than 50 years at SLE diagnosis. We compared clinical characteristics, laboratory data, therapy and outcome.

Results

The female to male ratio is 4.5; mean age at disease onset is 59.5 + 6 years (51- 78 years). Articular involvement is the most frequent lupus-related symptom present in 95 % cases, followed by cutaneous manifestations in 90 % cases. Renal involvement was noted in 7 cases (glomerulonephritis class III in 4 cases and class IV in 3 cases). Some manifestations occurred less frequently in late onset SLE ; nephropathy (28.5 vs 46.8% p<0.005), auto-immune hemolytic anemia (19% vs 37.2% p <0.005) and lymphopenia (66.7% vs 81.7%). Serositis and thrombopenia occurred more frequently (42.8% vs 26.7% and 38 vs 28% respectively). Antinuclear antibodies are present in 96%, anti-DNA antibodies in 71.4% and anti-Sm dans 28.5%. Anti-phospholipid antibodies are present in five patients. There was no difference between the two groups for the immunological data. SLE was associated with Biermer disease in two cases, thyroiditis in one case. One patient has hepatitis C viral cirrhosis and two patients have myelodysplastic syndrom. Steroids were administrated in eighteen as oral prednisone between 0.5 and 1 mg/kg per day preceded by a pulse of methylprednisolone in 2 cases. Hydroxychloroquine was administrated in all cases. Three patients received immunosuppressive drugs. Two patients died of septic shock. The 5 years overall survival was 90.4% versus 94.5% in early-onset SLE.

Conclusion The clinical pattern of late onset is characterized by a lower disease severity especially with regard to renal involvement. Prognosis is related to comorbidities and infectious complications.

546

PO 117Risk Factors Associated with Low Back Pain in Malang Population

Fajar S1, M. Ananto1, Camelia Q1, M. Ansory1, Dyah S1, A. Zainuddin1, Lia S1, Harun Al Rasyid2, C. Singgih Wahono3, Handono Kalim3

1.Resident of Internal Medicine Departement - Saiful Anwar General Hospital, Faculty of Medicine, Universitas Brawijaya. 2. Supervisior of Public Health Departement, Universitas Brawijaya. 3. Supervisor of Rheumatology and Allergy Immunology Division, Internal Medicine Departement - Saiful Anwar General Hospital, Medical Faculty Universitas Brawijaya

Background : LBP contributes to disability and economic aspect worldwide. Many studies suggest that biologic, psychologic, socio-economic, environmental and cultural factors contribute to the development of LBP. As a part of the prevention strategy, it is required to understand risk factors of LBP.

Aim: To evaluate the risk factors of LBP in Malang population

Design and methods: This is a survey research with cross-sectional approach. We used multi-stage random sampling and used modified WHO-ILAR COPCORD questionnaires to identify risk factors that included demographic and habitual factors. We analysed the data using Chi Square to asses variables, and multivariate logistic regression to determine the strongest association.

Result : From 2067 subjects, there were 262 subjects with LBP. In male grup, bivariate analysis showed that low educational, heavy work and smoking (p= < 0.05), whereas multivariate analysis showed that BMI ≥ 23 kg/m2 and heavy work contributed to development of LBP ( p= < 0,05) (OR= 1.61, 95% CI= 1.05-2.46; OR= 2.98, 95% CI=1.87-4.74; respectively). In female grup, bivariate analysis showed that marital status, older age, body height ≤ 151.4 cm, and low educational status ( p= <0.05), whereas multivariate analysis suggested that marital status, older age, and lower body height contributed to development of LBP (p= < 0,05) (OR= 5.45, 95% CI= 3.09-9.62; OR= 1.64, 95% CI= 1.08-2.48; OR= 1.45, 95% CI= 1.20-2.08; respectively). Male had a higher risk to suffer LBP than female ( OR= 1.32; 95% CI= 1.02 – 1,72; p= 0.038).

Conclusion : Low educational status, heavy work, smoking and BMI ≥ 23 kg/m2 were risk factors of LBP in male. Marital status, older age, low educational status, and body height ≤ 151.4 cm were risk factors of LBP in female. Male had a higher risk to suffer from LBP than female.

Key words : risk factor, LBP

547

PO 118The Prevalence and Risk Factors of Soft Tissue Rheumatism in Malang, East Java, Indonesia

Camelia Qusnul C.*, Fajar Sariningsih*, Mohammad Ananto*, Diyah Saraswati*, Muhammad Anshory*, Achmad Zainuddin*, Lia Sasmithae*, Harun Alrasyid**, C.Singgih Wahono***,

Handono Kalim***

*Departement of Internal Medicine, **Departement of Public Health, ***Rheumato-Immunology Division, Departement of Internal Medicine, Faculty of Medicine, Universitas Brawijaya Malang, Indonesia

Background. Soft Tissue Rheumatism(STR) constitute a group of clinical entities affecting the appendicular musculoskeletal (MSK) system as the most frequent causes of rheumatic complaints with prevalence 0.7% to 15% worldwide. STR leading causeof activity limitation and work absence causes an economic burden on individuals, family, and goverments.

Objective. To assess the prevalence and risk factors of STR in Malang, East java, Indonesia population.

Methods. A multistage, randomized method, a cross sectional survey performed on adult residents (>15 yrs) (n=2067). This study using the Modified COPCORD screening methodology. Chi Square describes factors that associated with STR. Adjusted Odds Ratio (OR) and 95% confidence Interval (CI) were estimated by using logistic regression.

Results. The overall prevalence of STR was 8.46% (175). Bivariate analysis showed that age, sex, marital status, Level of education, Body Mass Index /BMI, physical activity associated with STR (p <0.05). Women (OR 1.241 95% CI 0.890-1.731), married (OR 1.888 95% CI 1.252-2.848), Active physical activity (OR 1.436 95% CI 1.045-1.972), age <55 yrs (OR 1.476 95% CI 1.035-2.104), BMI 23 kg/m2 (OR 1.536 95% CI 1.092-2.160), high education (OR 1.466 95% CI 1.107-2) were more caused STR. Multivariate logistic regression for risk factors of STR was marital status (OR 1.767 95% CI 1.169-2.673 p 0.007), BMI (OR 1.548 95% CI 1.098-2.183 p 0.013), physical activity (OR 1.384 95% CI 1.003-1.910 p 0.048) and education (OR 0.705 95% CI 0.515-0.966).

Conclussion. Age(<55 years old), sex (women), Body Mass Index /BMI (23kg/m2), married, high education, active physical activity associated with STR. And the most dominant risk factor that associated with STR was marital status.

548

PO 119 The Relationship of Risk Factor For Musculoskeletal Pain With Duration, Intensity Of Pain And Disability In Malang, Indonesia

Lia Sasmithae, Fajarsariningsih, Camelia Q. C, M. Ananto, M. Zainudin , Diyah S*,Handono kalim**,C. Singgih Wahono**,Harun Alrassyid***

*Department of Internal Medicine,** Department of Public Health ***Rheumato-Immunology Division, Department of Internal Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia

Background. To estimate relationship between of risk factor for musculosceletal pain with duration, intensity of pain and disability in malang.

Objective. To assess the nature and extend of musculosceletal pain complaints in Malang area using the Community Oriented Program for the Control of Rheumatic Disease (COPCORD) by ILAR and the WHO

Subject and Methods. All members of community of 2067 subjects over the age of 15 years were offered a quistionnaire base interview. The validated Indonesia version of the WHO-ILAR COPCORD core questionnaire was used in a survey.

Result. A total 122 subject were diagnosed with musculosceletal pain. The Incidence of musculosceletal pain was 5.90% (95%CI, 0.78-1.53). Gender,age,body mass index,and marital status,physical activity, were asscociated with musculosceletal pain (p<0.05). The pain higher in women (63.11%) than in men (36.88%). Men and women differ in regard to body size and fuctional capacity and,perhaps, in factors such as mix of fast and low-twitch muscle fiber,cardiovascular endurance,and other physiologic variables. The complaint rate increased with age up 22.9% in the group age >35 years. The metacarphopahalangeal joint 1 (MTP 1) was responsible for 40% of all complaints pertaining to the joints. The incidence increased with increasing body mass index (62.91±12.05 kg),and with being houswife.

Conclussion. The risk factor for musculosceletal pain in our population were increasing by gender,age, body mass index,and being housewife.

Keywords: Joint pain,COPCORD,Risk factor

549

PO 120The prevalence and risk factors of knee osteoarthritis in Malang, Indonesia

M Ananto* Camelia Q* Fajar S* Dyah S* Lia S* M Anshory* Achmad Z* Handono K** C. Singgih W** Harun A****Internal Medicine Resident, ** Supervisor Rheumatology Division, *** Staff of Public Health Department, Faculty of Medicine, Brawijaya University, Malang, Indonesia

Background : Osteoarthritis is a leading cause of pain and disability and leads to reduced quality of life

Objectives : To determine the prevalence and risk factors of knee osteoarthritis in the community of malang, indonesia

Methods : A cross sectional study, using multistage randomized method in 2067 population over the age of 15 years old. Data collection was direct observation with interview and questionnaire, researchers will collect subjects in Malang City. Bivariate analysis, adjusted odd ratio and 95% CI were estimated by using logistic regression

Results : Respondents completed 2067 questionnaires. Of these 296 (14.32%) respondents had knee osteoarthritis. Age, gender, body mass index, level of education, physical activity and smoking were associate with knee osteoarthritis (p<0.05). Age more than fifty five higher risk for knee osteoarthritis than below fifty five OR 5.28 (95%CI 3.80-7.338). Woman was higher risk for knee osteoarthritis than men OR 1.85 (95% CI 1.39-2.45). Body mass index more than 23 was higher risk than below 23 OR 2.11(95%CI 1.58-2.80). Low level of education was higher risk than high of education OR 1.943(95%CI 1.490-2.533). Active physical activity was higher risk than inactive OR 0.495 (95%CI 0.368-0.667). Non smoking was higher risk than smoking OR 2.29(CI95% 1.62-3.24). Age was the most influence risk factors for knee osteoarthritis in multivariate analysis OR 5.139 (95% CI 2.73-4.86). Age was the main risk factor for knee osteoarthritis.

Conclusion : In this study, we found a knee osteoarthritis prevalence of 14.32%. The risk factors of knee osteoarthritis in our population were increasing by age, gender, body mass index, non smoking and low level of education.

550

PO 121FEMALE WITH EARLY DERMATOMYOSITIS: A CASE REPORT

Suriani Alimuddin, *Alvina Widhani, *Nanang Sukmana

*Division of Allergy-Immunology, Department of Internal Medicine

University of Indonesia

Background : Dermatomyositis is one of rare chronic autoimmune diseases which is characterized by weakening of proximal muscles, skin lesions, and positive specific autoantibody. The morbidity and mortality caused by this disease is relatively high. Early diagnosis and immunotherapy treatment are very important to prevent muscle atrophy and delay handicap of the patients.

Case Report : A 47-year old female with chief complaints were itching and redness of the skin since 3 years ago. The skin lesions were expanding start from the face, back, and extremities with no history of allergy. The patient also felt muscle weakness while combing or walking. From physical examination, we found normal vital sign and other examinations. Dermatology status showed purplish red plaques all over the body. Laboratory findings showed positive ANA test (titer >1/1000), dsDNA 62 IU/ml, LDH 512 U/l, low CK level, normal complement levels, and negative viral markers for syphilis and hepatitis. The immunofluorescence test from skin biopsy showed no immunoglobulin, C3, or fibrinogen sedimentation. From electromyography test we found myogenic lesion with spontaneous activity from proximal muscles of all extremities and also median nerve slowing at her right wrist. The patient was diagnosed as early dermatomyositis and given methylprednisolone 8 mg twice daily, azathioprine 50 mg twice daily, loratadine 10 mg, and cavit D3. Significant improvement was seen after 2 months intensive therapy.

Conclusion : Dermatomyositis is a rare disease with many sign and symptoms which are different from patients. Early diagnosis and proper treatment with steroid and immunosuppressive drugs will reduce patient’s symptoms and delay impairment.

Keywords : Early dermatomyositis, ANA test, steroid, immunosuppressive drug

551

PO 122Dermatomyositis: Evolution of a Diagnosis

Kun S1,Yulyani W2, Arief N2, Zainal A2

1.Resident of Internal Medicine, Department of Medicine in the Faculty of Medicine, Sebelas Maret University, Dr. Moewardi Surakarta Hospital2.Division of Rheumatology,Department of Medicine,Faculty of Medicine, Sebelas Maret University, Dr. Moewardi Surakarta Hospital

Introduction: Dermatomyositis is one of the idiopathic inflammatory myopathies,chronic autoimmune condition characterized by the subacute onset of symmetrical proximal muscle weakness and muscle inflammation, accompanied by distinctive skin lesions and specific autoantibodies. Incidence 2-10 cases/1 billion,has a female predominance, and peak incidence in 5th decade of life.

Case description : Our initial diagnosis in this patient was SLE, treated with methylprednisolone 48 mg daily for 4 years. No improvement during treatment. Since 2 years ago patient complaint weakness in the lower muscles. Patients felt weakness on lower extremity , with difficulty rising from a squat or low chair or in climbing stairs. Skin rash,with a purplish,dusky appearance, on the eyelids,cheeks and neck.Periorbital oedema(+).Poliarthralgia(+).Decreased tendon reflexes.Laboratorium findings: SGOT110,SGPT 68 ,LDH 350u / l,CKMB 530Ug/ ml, HBsAg (-),antiHCV (-),HIV test (-),ANAtest (+),antiDsDNA (-),ANA profile(-).Skin biopsy results: epidermal hyperkeratosis,foliker plugs,falt rete ridge,the proliferation of basal cells, dermis: there is infiltration of lymphocytes around the vessels.Improved general condition (sit) and outpatients.

Discussion: Patient with similiar clinical manifestation like SLE. There are malar rash but not involved nasolabial folds. After distinguish from differential diagnosis like bacterial and viral infection,metabolic myiopathies,other endocrine abnormalities we diagnosed this patient with dermatomyositis because from clinical examination,laboratory findings and skin biopsy are match.We could not do EMG due to wound in his leg.

552

PO 123The Relationship of Risk Factor of Musculoskeletal Pain With Health Seeking Behaviour in Malang, East java, Indonesia

Achmad Z. A, Lia Sasmithae, Fajarsariningsih, Camelia Q. C, M. Ananto, Diyah S*,Handono kalim**, C. Singgih Wahono**, Harun Alrassyid***

*Department of Internal Medicine,** Department of Public Health ***Rheumato-Immunology Division, Department of Internal Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia

Objective. To assess health seeking behaviour of people with musculoskeletal pain complaints in Malang area using the Community Oriented Program for the Control of Rheumatic Disease (COPCORD) protocol by International League of Associations for Rheumatology (ILAR) and the World Health Organization (WHO).

Subject and Method. 2067 member of the community over the age of 15 years were randomly offered a questionnaire base interview in phase 1 of the study. Frequency of musculoskeletal pain, disability and health seeking behaviour assessed using the validated Indonesian version of the WHO-ILAR COPCORD core questionnaire.

Result. Total 1018 subject (49%) with musculoskeletal pain assessed for health seeking behaviour. Modality of health seeking behaviour using non steroid anti-inflammatory drugs (NSAIDs) found in 275 subjects (27%), massage 107 subjects (10%), herbal medication 126 subjects (12%), NSAIDs and herbal combination 197 subjects (19%), other modality 39 subjects (3%) and no treatment 274 subjects (27%). Gender, age, education, occupation, marital status, duration of pain, pain recurrence and disability were significantly affect health seeking behaviour (p=0.023, OR=1.02; p=0.000, OR=0,442; p=0.000; OR 1,72; p=0.007; p=0.000; p=0,000; p=0.049; p=0.000). Education had the most significant influence for health seeking behaviour (p=0.006; OR 2.214), followed with duration of pain (p=0.34; OR=0.899), gender (p=0.025, OR=0.725), disability (p=0.018, OR=0.651), age (p=0.001; OR=0.522).

Conclusion. Musculoskeletal pain is a major health problem in the community and the major treatment modality were NSAIDs. Health seeking behaviour was most influenced by education status, followed with duration of pain, gender, disability and age.

Keywords. Musculoskeletal pain, COPCORD, Health seeking behaviour

553

PO 124Predictors of Rheumatoid Arthritis Disease Control after Six Month of Conventional Disease Modifying Anti Rheumatic Drugs Monotherapy

Suryo Anggoro (Indonesia)

554

PO 125INTERACTION BETWEEN CHRONIC NEUROINFLAMMATION AND PAROXYSMAL SYMPHATETIC HYPERACTIVITY IN HYPERTENSION

Yogi Agung Prima Wardhana[1], Ricardo Adrian Nugraha[1], Michael Jonatan[1], Radityo Bagus Wicaksono[1], Rina Judiwati[2]

1. Faculty of Medicine, Universitas Airlangga – Surabaya2. Department of Biomedics, Faculty of Medicine, Universitas Airlangga – Surabaya


Introduction. There is a strong relationship between autonomic nervous system and immune systems playing a prominent role in the initiation and maintenance of hypertension and significantly contributes to cardiovascular mortality. Hypertension is associated with neuroinflammation and increased sympathetic tone. Studies have shown consistent association between hypertension, proinflammatory cytokines and the cells of the innate and adaptive immune systems. Overactivity of the renin-angiotensin system, oxidative stress, and cyclooxygenases (COX) in the brain are implicated in the pathogenesis of hypertension.

Methods. We appraised several trials from Pubmed and Cochrane database to examine sources of heterogeneity, including difference in clinical outcomes and exposure measurements. For studies that used similar sources of data over concurrent periods and similar age range, only the study with the largest data set was included in the meta-analysis.

Results. Hypertensive stimuli, such as angiotensin II, DOCA-salt, and norepinephrine, cause T cells and monocytes/macrophages to accumulate in the brain and their vascularization. These cells release inflammatory cytokines, such as IL-6, interferon-γ, and IL-17, that promote vascular hypertrophy. In rat models, hypertension exhibited significantly higher levels of TLR4 in the hypothalamus, especially in Paraventricular Nuclei (PVN). TLR4 inhibition within the PVN attenuated MAP, improved cardiac hypertrophy, reduced TNF-α, IL-1β, iNOS levels, and NFκB activity in SHR but not in WKY rats. These results were associated with a reduction in plasma NE and HMGB1 levels and an increase in IL-10 levels in SHR. We also found that hypertension, induced by either angiotensin II or l-NG-nitro-l-arginine methyl ester, is accompanied by microglial activation as manifested by microgliosis and proinflammatory cytokine upregulation.

Discussion. Inflammation of forebrain and hindbrain nuclei controlling the sympathetic nervous system (SNS) outflow from the brain to the periphery represents an emerging concept of the pathogenesis of neurogenic hypertension. Angiotensin II (Ang-II) and prorenin were shown to increase production of reactive oxygen species and pro-inflammatory cytokines (interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α)) while simultaneously decreasing production of interleukin-10 (IL-10) in the paraventricular nucleus

555

of the hypothalamus and the rostral ventral lateral medulla. Peripheral chronic inflammation and Ang-II activity seem to share a common central mechanism contributing to an increase in sympathetic neurogenic vasomotor tone and entailing neurogenic hypertension. Both hypertension and obesity facilitate the penetration of peripheral immune cells in the brain parenchyma. We suggest that renin-angiotensin-driven hypertension encompasses feedback and feedforward mechanisms in the development of neurogenic hypertension while low-intensity, chronic peripheral inflammation of any origin may serve as a model of a feedforward mechanism in this condition.

Conclusion. Hypertension alone can facilitate the penetration of peripheral immune cells in the brain parenchym. We suggest that renin-angiotensin-driven hypertension encompasses feedback and feedforward mechanisms in the development of neurogenic hypertension while low-intensity, chronic peripheral inflammation of any origin may serve as a model of a feedforward mechanism in this condition.

Keywords: Angiotensinogen, Hypertension, Neuroinflammation, Hypothalamus

556

PO 126Secondary membranous nephropathy associated with guillain-barré syndrome

Betul Yildirim, Betul Erismis, Hakan Kocoglu, Bahar Ozdemir, Yildiz Okuturlar, Mehmet Hursitoglu, Ozlem Harmankaya, Abdulbaki Kumbasar

Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul

Introduction: Membranous glomerulonephritis (MGN) is the most common form of nephrotic syndrome in adults. It can be idiopathic or associated with secondary causes (30%). M-type phospholipase a2 receptor (PLA2R) has been identified as a major target antigen in the idiopathic MGN in adults (70-80%positive). In a study, a significant increase in the production of IgG4 in the presence of interleukin 4 was observed in the idiopathic MGN group but not in the secondary. Approximately 25% of the MGN cases were associated with malignancy, infection or rheumatologic disorders like systemic lupus erythematosus. We present here a case of nephrotic syndrome secondary to Guillain-Barré syndrome (GBS). Case: A 33-year-old female admitted to our clinic with a history of fatigue. She had pletoric face, palpable right axillary mass and pitting edema. Complete blood count, coagulation studies and electrolytes were all normal. Her serum creatinine, albumin, and acute phase reactants were normal. Twenty-four hour urinary protein excretion was 7257 mg/day. Biopsy of right axillary lymph node (measured 28x11mm by ultrasonography) did not provide any diagnostic findings. Also thoracoabdominal CT scan showed no evidence of malignancy. During the second week of admission to hospital, patient experienced weakness of both lower extremities. Electromyography showed demyelinating motor and sensory polyneuropathy. There was albuminocytologic dissociation in the spinal fluid sample. Renal biopsy showed MGN stage 1 (IgG4 stain was negative). There was no relevant cause of this secondary MGN (other than the associated GBS). So the patient started on plasmapheresis, five day course of iv immunoglobulin and steroid therapy. After 1 year of treatment and follow-up, patients muscular weakness was resolved. As expected, urinary protein excretion decreased to 520 mg/dl (non nephrotic level). Conclusion: Although rare, GBS could be a cause of secondary MNG that regress with the treatment of the underlying etiology.

557

PO 127 Oral Glucose Tolerance Test and Serum C-peptide Levels in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Background: The aim was to evaluate the state of glucose intolerance in non-diabetic peritoneal dialysis (PD) patients.

Methods: The 75 gram oral glucose tolerance test (OGTT) was done in 41 PD patients without history of diabetes mellitus (22 males, 19 females, aged 53.8 ± 13.2 years (mean ± SD)). The results of the 75 gram OGTT were compared to that of the normal group (n=41) with normal renal function.

Results: Among 41 patients, nine (22%) had IGT and three (7.3%) were newly diagnosed with diabetes. There was no difference in fasting glucose levels between the PD (95.4 ± 7.9 mg/dl) and the normal group. (93.1 ± 7.2 mg/dl, P=0.473). Glucose levels checked two hours after oral glucose intake (pp2hr) were significantly higher in the PD group (135.7 ± 38.5 mg/dl) compared to those of the normal group (103.0 ± 14.8 mg/dl, P=0.000). Fasting C-Peptide levels were significantly higher in PD patients (7.0 ± 3.1 ng/mL) compared to those of the normal group (2.2 ± 1.5 ng/mL, P=0.000) and pp2hr C-peptide levels were also higher PD group (14.6 ± 3.3 ng/mL) compared to those of the normal group (7.2 ± 2.1 ng/mL, P=0.000). There was no significant difference of HbA1C levels between two groups.

Conclusion: Our results demonstrated that most PD patients were non-diabetics, but they showed higher pp2hr glucose levels compared to those of the normal group. Significantly higher fasting and pp2hr C-peptide levels were also observed in the PD group compared to the normal group.

558

PO 128The Association of Visceral Fat Area with Renal and Cardiac Function in a Population with Normal or Mildly Impaired Renal Function

Eunjin Kang (South Korea)

559

PO 129Evaluation of Combination of Peritoneal Dialysis and Hemodialysis in Kaohsiung, Taiwan

Hugo You-Hsien Lin1,2,3, Sheng-Wen Niu1,2,3, I-Ching Kuo1,2, Chi-Chih Hung2, Shang-Jyh Hwang2, Hung-Chun Chen2

1 Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital; 2 Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, 3Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University

Background: Although peritoneal dialysis (PD) is recommended as one of the first-line treatments for end-stage renal disease (ESRD), the efficiency of PD gradually worsens over time. The most common reasons for PD failure are inadequate dialysis and or ultrafiltration failure. Combined therapy with PD and hemodialysis (HD) was first introduced in the 1990s. It is a treatment choice for PD patients who cannot achieve adequate fluid and/or solute removal by PD alone. To evaluate the clinical benefit of this modality in Taiwan, we evaluate of the adequacy of renal replacement therapy in hospitals of Kaohsiung, Taiwan.

Methods: From 2011 to 2016, we evaluated the patients with end stage renal disease (ESRD) in Kaohsiung Municiapal Ta-Tung Hospital, which is one of the social hospitals of Kaohsiung. There are 132 patients, excluding 2 patients admitted due to unstable vital sign, enrolled this study.

Results: There are 110 patients receiving HD therapy; 19 patients receiving PD therapy; 1 patient receiving combination PD and HD therapy. Age, body weight, serum hemoglobin, albumin, potassium were significantly higher in patients with HD compared to PD. Serum triglyceride, phosphate were significantly higher in patients with PD compared to HD. In patient with combination PD and HD therapy, anemia, hypoalbuminemia, hyperphosphotamia, residual renal function, KT/V, weekly Ccr and the normalized protein catabolic rate (nPCR) was significantly improved after combination therapy.

Conclusion: In this study group, combination PD and HD therapy may improve clinical condition than PD alone. Further study with larger patient scales is needed to clarify the indications for and consequences of switching from standard PD alone to combination therapy.

Key words: combination, peritoneal dialysis, hemodialysis

560

PO 130DESCRIBING AZOTEMIA AS A RARE ASSOCIATION WITH PURPLE URINE BAG SYNDROME.

Objective: Describing azotemia as an association with purple urine bag syndrome(PUBS).Purple urine bag syndrome is a rare entity and causes significant alarm to patients and their care givers. Its association with chronic debilitation, constipation, long term in-dwelling catheter and recurrent urinary tract infection (UTI) have been reported in literature. Here we describe azotemia as a less reported association of PUBS.Case Information: A 79 year old female, presented to us with vomiting for three days. She had multiple co-morbidities, of note were epilepsy, previous right cerebellar stroke, diabetes and hypertension. She was hemodynamically stable on presentation. However her GCS was 14 and she had marked lethargy and drowsiness. Systemic examination was unremarkable. Of note was the unique appearance of the in-dwelling catheter which collected purple urine in the urine bag (Fig 1).

Her initial investigations showed: Azotemia, Hyponatremia and elevated CRP. Urine examination showed pyuria, with a WBC count of 360/UL. Chest radio graph was normal. She was empirically treated for UTI with IV Co-amoxiclav based on her previous positive urine cultures . Urine culture 48 hours later showed growth of Pseudomonas aeruginosa which was sensitive to penicillins, ciprofloxacin and aztreonam . IV Co-amoxiclav was continued and her urinary catheter was changed, resulting in clearing of the purple coloured urine. She was discharged well after 5 days of uneventful hospitalization with one week of oral antibiotics, with plans to be followed up later. Indwelling catheter care was reinforced to the care givers.

Discussion-

561

PUBS is very rarely reported that there is no MESH name in the National Library of Medicine [Ref 1]. It is seen in about 9.8 % of patients who were in long term wards [Ref 2]. Its association with old age, female gender, constipation, chronic urinary catheterization, urinary tract infection, alkaline urine, use of polyvinyl catheter has been reported in literature [Ref 1]. Azotemia as an association has not been reported in literature before and we postulate an association between the two.

Azotemia results in increased levels of tryptophan metabolites. [Ref 4]

In PUBS, Purple colored urine occurs due to the accumulation of indigo and indirubin, which are the end products of tryptophan metabolism due to the action of sulfatases and phosphatases formed by bacteria like Providencia, Citrobacter, Enterobacter, Klebsiella etc.

Pathophysiology of PUBS:

In bowel intestinal bacteria metabolizes Tryptophan --------> Indole (promoted by constipation, Dysmotility, bacterial overgrowth) [Ref 2]

hepatic conjugation leads conversion of Indole ------------> Indoxyl sulphate (Indican)

In urine, conversion of Indican ---------> Indoxyl takes place by the action of bacterial phosphatases and sulphatases produced by Gram Negative Bacilli. [Ref 5 ]

Indoxyl oxidizes to Indirubin(red) and Indigo (blue) which reacts to plastic catheter and urine bag leading to purple discoloration of urine in urine bag. [Ref 4, 5, 6]

Our patient was an elderly with dementia, was bedridden, and had chronically catheterization as a typical case of PUBS. In fact, in most cases, multiple risk factors are present and act synergistically to the occurrence of PUBS. In our patient azotemia played an important role and acted synergistically with other factor such as infection to cause PUBS.

A case series in this regard would help trend the strength of this association further, hence making it easier to predict PUBS, when patients have significant association factors as described above. It could also help in educating patients and care givers regarding PUBS, reducing their stress and alarm arising from PUBS.

References

1. A Case of Purple Urine Bag Syndrome in a Patient with an Ileal Conduit - Ryan Don Aycock, Washington Hospital Center, Washington, DC, USA

(Int J Nephrol Urol, 2010; 2(4): 580-583)

2. Case analysis of purple urine-bag syndrome at a long-term care service in a community hospital- Su FH, Department of Family Medicine, Cardinal Tien Hospital, Hsin Tien,

562

Taipei, Taiwan, ROC. Chang Gung Med J

2005 Sep;28(9):636-42.

3. Tryptophan and indolic tryptophan metabolites in chronic renal failure- The American Journal of Clinical Nutrition 33: JULY 1980, pp. 1402-1406. Akira Saito et al

4. Determination of indoxyl sulfate in plasma of patients with renal failure by use of ion-pairing liquid chromatography- clin chem une 1986 vol. 32 no. 6 938-942- by Stanfel LA,Gulyassy PF, G Jarrard EA .

5. Enzymatic degradation of urinary Indoxyl sulfate by Providencia stuartii and Klebsiella pneumoniae causes the purple urine bag syndrome- j Clin Microbiol 1988 Oct;26(10):2152-6 by Dealler SF, Hawkey PM, Millar MR

6. purple Urine Bag Syndrome: a case report of an alarming phenomenon. Hippokratia. 2014 Jan-Mar; 18(1): 92–94 by DI Agapakis,EV Massa, I Hantzis , E Paschoni and E Satsoglou

563

PO 131The Association Between Levels of Erythropoietin and Levels of Asymetric Dimethylarginine in Renal Failure Patients Trhee Months After Kidney Transplantation

Linda Armelia (Indonesia).

POSTER

THE ASSOCIATION BETWEEN LEVELS OF ERYTHROPOIETIN AND LEVELS OF ASYMETRIC DIMETHYLARGININE IN RENAL FAILURE PATIENTS TRHEE

MONTHS AFTER KIDNEY TRANSPLANTATION

Linda Armelia1, Endang Susalit2, Maruhum Bonar HM2 1. Department of internal Medicine, Faculty of Medicine Universitas YARSI, Jakarta, Indonesia 2 Division of Nephrology, Departement of Internal Medicine, University of Indonesia, Cipto

Mangunkusumo Hospital, Jakarta, Indonesia Abstract Aim: to determine association between elevated levels of erythropoietin (Epo) and level of asimetrik dimetilarginin (ADMA) in patients 3 months after kidney transplantation. Methods: a cross-sectional prior and 3 months after kidney transplantation in patients with renal failure who underwent a kidney transplant in RSCM. The study included 21 subjects who enrolled from July 2013 to February 2014. Blood samples prior and 3 months after kidney transplantation were collected to evaluate the level of Epo and level of assymetric dimethylarginine (ADMA). Statistical analysis was performed using Pearson or Spearman correlation test. Results: the results of the study showed that prior to kidney transplantation, level of Epo was increased but not statistically significant (p>0.05) and the ADMA level was significantly decreased (p<0.05). Three months after transplantation showed a no association between the elevated level of Epo and the decreased level of ADMA. Conclusion: three months after kidney transplantation showed an elevated level of Epo and the decreased level of ADMA. However, there was no association between the elevated level of Epo and the decreased level of ADMA in patients 3 months after kidney transplantation. Key words: asymetric dimethylarginine; erythropoietin; kidney transplantation

564

PO 132A Novel RET Mutation Identified in a Patient With Pheochromocytoma and Renal Cell Carcinoma

Eui Dal Jung – South Korea

Pheochromocytomas might be sporadic or genetic. Genetic pheochromocytoma is associated with multiple endocrine neoplasia (MEN) type 2A, MEN type 2B, and von Hippel-Lindau (VHL) disease. RET mutations are identified in more than 90% of index cases of MEN2 and familial medullary thyroid cancer and in about 4–12% of apparent sporadic cases. Here, we report a 54-year-old man presenting with pheochromocytoma and renal cell carcinoma, who was identified as having a novel missense RET mutation.

565

PO 133Epidemiological, Clinical Profile and Management of Hypertensive Crisis in General Hospital in Tangerang, Banten, Indonesia

Nata Pratama Hardjo Lugito1, Andree Kurniawan1, Theo Audi Yanto1, Ivan Onggo Saputro2

1 Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University2 Faculty of Medicine, Pelita Harapan University

Background. Hypertensive crisis that comprises of hypertensive emergency (HE) and hypertensive urgency (HU) is a severe clinical condition. Although the incidence is only 1%, it is an important and common event in emergency unit. This study aimed to describe the epidemiology, clinical profile and management at Emergency Unit of General Hospital in Tangerang, Banten, Indonesia

Methods. The descriptive study was conducted from January 2014 until December 2015 at Emergency Unit of General Hospital in Tangerang, Banten, Indonesia. Data collected from patients were age, sex, history of hypertension, symptoms and signs, systolic and diastolic blood pressure, target organ damage and duration to achieve the blood pressure target. Chi-square test was used to compare categorical variables and Student’s t-test was used to compare quantitative variables.

Results. There were 62 hypertensive crisis patients (HE 41.94% and HU 58.06%). In the HE and HU group there were more female compared to male (57.69% vs. 42.31% and 66.67% vs. 33.33%; p=0.470). The largest age group of HE was 51-60 years (34.62%) compared to HU which was 41-50 years (36.11%). History of hypertension in HE compared to HU patient was 35.48% vs. 54.84% (p=0.196). Hemiparese and dyspneu were the most prevalent symptoms in HE compared to HU (19.35% vs. 0.0%; p=0.000 and 30.77% vs. 16.67%; p=0.190). The mean systolic and diastolic blood pressure in HE were higher compared to HU (219.6923 mmHg vs. 203.9167 mmHg; p=0.0035 and 119.3077 mmHg vs. 115.9722 mmHg; p=0.2749). The most prevalent target organ was kidney (30.77%). Mean duration of achieving the blood pressure target in HE compared to HU was 4.76 + 6.79 vs. 1.74 + 1.63 hour (p=0.0147)

Conclusions. Prevalent presentation of HE were hemiparese and dyspneu, prevalent target organ of HE was kidney. Blood pressure of HE was higher and target was more difficult to achieve.

Key words: hypertensive crisis, hypertensive emergency, hypertensive urgency.

566

PO 134The Effectiveness of The Questionnaire for Cerebrovascular Diseases Detection in Hypertensive Patients in Primary Health Care

I.V. Kim 1, E.V. Bochkareva1, Yu.Ya.Varakin2

1. National Research Center for Preventive Medicine, Moscow, Russian Federation2. Research Center of Neurology, Moscow, Russian Federation

Background. The role of general practitioner can be significant in assessment and management of hypertensive patients with cerebrovascular disease (CVD). We developed a 17-item questionnaire for CVD detection (QCVD) in primary health care. Previous studies have shown that QCVD was valid and reliable questionnaire for the CVD assessment. The present study aimed to improve CVD detection among hypertensive patients in outpatient clinic environment.

Methods. This cross-sectional study included 257 consecutive patients aged 40-70 years with arterial hypertension (stages I-III) who visited eight general practitioners in a Moscow outpatient clinic by any reason. All subjects answered QCVD for detection of clinical forms of CVD: chronic brain blood supply insufficiency syndrome, hypertensive encephalopathy, hypertensive cerebral crises, transient ischemic attack and stroke. Results of questioning were verified by neurologist, cardiologist. ECG-exercise method, 24-hour Holter monitoring, duplex ultrasound scan of carotid arteries, computer tomography, magnetic resonance brain imaging were performed if necessary.

Results. 53.3% of patients were male and mean age was 58.3±6.6 years, 46.7% were female, mean age was 58.3±6.6 years. It was shown high prevalence of CVD: 57.6%. Newly diagnosed CVD was revealed with the QCVD in 52 (20.2%) patients: 48 of them had chronic brain blood supply insufficiency syndrome and hypertensive encephalopathy, 4 had history of stroke or TIA. 76 of the 257 subjects (29.6%) had hypertensive cerebral crises. Only 5.3% of these had previous history of crises, 94.7% were newly diagnosed with the QCVD and were confirmed by the neurologist.

Conclusion. The new 17-item QCVD is a reliable and responsive tool for evaluation of CVD in outpatient clinic environment. It was shown that internists do not know about chronic insufficiency of brain blood supply, hypertensive encephalopathy and hypertensive cerebral crises symptoms in patients with arterial hypertension. The new 17-item QCVD can be effectively used for CVD detection in hypertensive patients in primary health care.

567

PO 135Correlation between Fibroblast Growth Factor-23 Serum and Fractional Excretion of Phosphate Urine in Predialysis Chronic Kidney Disease

Vika Wirdhani, Yenny Kandarini, Wiradewi LestariInternal Medicine Department. Faculty of Medicine Udayana University / Sanglah Teaching Hospital Denpasar

Background: Fibroblast Growth Factor-23 (FGF-23), has role in regulating phospate homeostasis and could be an early marker of Chronic Kidney Disease (CKD) mineral and bone disorders. Fractional excretion of phosphate (FEPi) urine is the proportion of phosphate which is filtrated by kidney and excreted through urine. There is an increasing FGF-23 serum level and FEPi urine in predialysis CKD. Currently, there is no study reported in evaluating a correlation between FGF-23 serum level and FEPi urine in Indonesian setting. This study aimed to find correlation betwen FGF-23 serum level and FEPi urine in predialysis CKD.

Methods: An observational and cross-sectional study was conducted in Sanglah Hospital from October 2014 until April 2015. The investigator recruited 75 predialysis CKD patients by consecutive sampling. Criteria inclusion of this study were predialysis CKD stage 2,3, and 4 patient aged range 18-65 years old. Patients who got vitamin D, phosphate binder, calcimimetic therapy, and have been diagnosed with malabsorption syndrome and malignancy were excluded from this study. All participants were taken informed consent. The correlation between FGF-23 serum level and FEPi urine was analyzed using Spearman correlation test.

Results: Fifty four out of 75 samples were male (72%) and 21 (28%) were female. Nineteen (25,3%) were CKD stage 2, 43 (57,3%) were CKD stage 3, and 13 (17,3%) were CKD stage 4. Median FGF-23 levels was 108,7 (13,6-1226,2) RU/ml. Median FEPi urine was 24,3 (4,04-65,9)%. This study showed positive and significant correlation between FGF-23 and FEPi urine (r = 0,44; p < 0,001).

Conclusions: FGF-23 serum level has positive correlation with FEPi urine in predialysis CKD.

568

PO 136Direct Medical Cost Burden among Hypertensive Patients at a Public Hospital in East Java Province

Bobby Presley1,2, Fauna Herawati1,2, Siti Maghfiroh2, Raisah Ismi Indraswari21. Centre of medicine information and pharmaceutical care2. Department of Clinical & Community Pharmacy, Faculty of pharmacy University of

Surabaya

Background: Hypertension had been known as one of the most problematic chronic disease all around the world, including in Indonesia. Patients with uncontrolled hypertension or comorbidities were usually admitted to the hospital for intensive treatment. Little is known about the real cost per patient admission. This information was ultimately needed for the government to allocate the funding in the era of universal coverage, namely “Jaminan Kesehatan Nasional/JKN”. This study aimed to identify and describe the direct medical cost of hypertensive patient at hospital.

Method:This retrospective non experimental study involved 179 hypertensive inpatients (patient with a government health insurance program [JKN]; and patient with out of pocket payment [non-JKN]) at a public hospital in East Java province. Each patient billing statement was the primary data source. Direct medical cost which collected in this study including room charges, drugs, laboratory tests, medical supplies and health professional services. Patient perspective was used and inflation rate was not accounted for in this study.

Results:The mean of direct medical cost among patients covered by JKN (81 patients) and non-JKN (98 patients) were Rp. 2.667.324 and Rp. 2.247.494, respectively. The three highest proportion of the cost was drug costs (44.64%) followed by laboratory tests (17.43%) and room charges (16.08%). This study found that cost percentage for antihypertensive drugs compared with total drug cost were only 10.57% in JKN patients and 5.48% in non-JKN patients. Diltiazem and nicardipine were contributed in 49.55% and 38.92% of total antihypertensive drugs cost respectively.

Conclusion: Analysis based cost to charge ratio need to be performed in order to reflect the real economic burden for hypertensive patient. By doing so, government would be able to evaluate the allocated funding for hypertension related diagnosis in INA CBGs.

569

PO 137Frequency of Hypertension in Our District, Erbaa, A Black Sea District

Fatih Mehmet Cilingir Bafra State Hospital Internal Medicine,Samsun

Hypertension is the number one risk faktor in the causes of death in the world that can be prevented.

As of 2000 years, 26.4 % of the adult population in the world has hypertension and In 2025, this ratio was expected to rise to 29.2 %. Hypertension is a very common problem in our country.

According to demographic data from 2000 years there are about 15 million hypertensive individuals in our country.

22133 patients was examined who admitted to hospital between May 2014 - February 2016. In these applications 18 years and over 4880 patients had hypertension. The number of hypertensive patients participated in the study were 1555 men (31.8 %) , 3325 female (68.2 %).

21 patients were (0.43 %) in 18-29 years of age, 112 patients were (2.30 %) in 30-39 years of age, 359 patients were (7.35 %) in 40-49 years of age, 1047 patients were (21.4 %) in 50-59 years of age, 1558 patients were (31.9 %) in 60-69 years of age, 1252 patients were (25.6 %) in 70-79 years of age, 531 patients were (10.88 %) in the age of 80 years and older.

According to Turkish Hypertension Prevalence Study (PatenT) prevalence of hypertension in Turkey was found to be 31.8 %. The prevalence of hypertension in women (36.1 %) was higher than men (27.5 %).In PatenT2 study in total population (18 years and older) prevalence of hypertension was found to be 30.3 %, in men 28.4 % and in women 32.3 %. Hypertension prevalence in our study, in men was 7 %, in women was 15 %, in all groups was 11 %. In PatenT2 study hypertension prevalence was found to be 30.7 % in Middle Anatolian region. In our study hypertension prevalence was found to be 11 % in a Black Sea district, Erbaa

Key words: Erbaa, hypertension, prevalence

570

PO 138Quality of Life of End State Renal Disease Patients Receiving Hemodialysis in General Hospital in Tangerang, Banten, Indonesia

Nata Pratama Hardjo Lugito1, Neneng Suryadinata2, Andree Kurniawan1, Margaret Mer-lyn Tjiang1, Hans Kusuma Muliadi3, Andhica Saputri4, Soejono Indra4, Imelda Yacinta4

1 Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Tan-gerang, Banten2 Faculty of Medicine, Pelita Harapan University, Tangerang, Banten3 Internal Medicine, Siloam General Hospital, Tangerang, Banten4 Resident Medical Officer, Siloam General Hospital, Tangerang, BantenIntroduction. End state renal disease (ESRD) is a global health problem, including Indonesia. Studies found that ESRD patients receiving chronic HD had low quality of life. Prevalence of ESRD patients receiving hemodialysis (HD) in Indonesia is increasing. In 2011 there were 6,951 patients already on chronic HD and 15,353 new patients receiving HD. Studies in this field in Indonesia is very limited. This study aimed to describe the association betweeen QoL of ESRD patients receiving chronic HD in Hemodialysis Unit of General Hospital in Tangerang, Banten, Indonesia with epidemiological and clinical profiles.

Methods. This cross sectional study was conducted from April-May 2016. Datas collected were QoL using KDOQL-SFTM 1.3, age, sex, education level, marital status, duration of HD, and comorbidities. Data was analyzed using Statistical Package of Social Sciences (SPSS) version 19.1. Student’s t-test and Pearson or Spearman correlation was used to compare QoL and variables.

Results. Out of 58 ESRD patients receiving chronic HD that participated in the study, median age was 52 y.o (range 21-75 y.o). Frequency of male was 53.45%, median duration of HD was 16.5 months (range 1-108 months). Mean QoL in were as follows: physical component summary (PCS) 57.59 + 18.92, mental component summary (MCS) 80.22 + 17.68, symptoms / problem lists 78.52 + 13.53, effect of disease 69.02 + 19.84 and burden of disease 65.19+28.14. In PCS, duration of HD less than 12 months and diabetes have lower QoL (p<0.05). In MCS, male and diabetes have lower QoL (p<0.05). Diabetes was associated with lower QoL in PCS, MCS, symptoms/problem lists and effect of disease (p<0.05). Age and education level was not associated with QoL.

Conclusion. Diabetes was associated with lower QoL. Different epidemiological and clinical profiles were associated with different domains of ESRD patients’ QoL.

Keywords: quality of life, end state renal disease, hemodialysis

571

PO 139Different Impact of Aspirin on Renal Progression in Predialysis Advanced Chronic Kidney Disease Patients with or Without Previous Stroke

Kuang-Chih Hsiao, Jing-Yang Huang, Chun-Te Lee, Tung-Wei Hung, Yung-Po Liaw, Horng-Rong Chang

Background: The benefit-risk between stroke reduction and renal progression associated with antiplatelet therapy among patients with advanced chronic kidney disease (CKD) is controversial.

Methods: From January 1, 2002, through June 30, 2009, 1301 adult patients with advanced CKD treated with erythropoiesis stimulating agents (ESA) were enrolled when they initiated receiving ESA therapy from 2005 Longitudinal Health Insurance Database in Taiwan. They were followed up until primary endpoint was the development of ischemic stroke, secondary endpoints included hospitalization of bleeding events, cardiovascular mortality, all-cause mortality and renal failure, or end of study (DEC 31, 2011). The adjusted cumulative probability of events was calculated by multiple COX proportional regression.

Results: The incidence (per 104 person months) of ischemic stroke was significantly higher in aspirin users (29.36; 95% CI, 20.53-42.00) than in nonusers (15.92; 95% CI, 12.89-19.67). Adjusted survival curves showed usage of aspirin was not associated with ischemic stroke, hospitalization of bleeding events, cardiovascular mortality and all-cause mortality, however, aspirin use was significantly associated with renal failure. In the subgroup analysis, aspirin use was associated with renal failure in never stroke patients (HR, 1.41; 95% CI, 1.14-1.73), and there was borderline interaction effect between previous stroke and aspirin on renal failure (interaction p = 0.0565).

Conclusions: For the overall patients with advanced CKD who receive aspirin therapy exhibit no significant benefit for ischemic stroke prevention and associated with risk of renal failure in the subgroup without previous stroke.

Keywords: Aspirin; Ischemic stroke; Advanced chronic kidney disease; Renal failure.

572

PO 140

Cardio-Metabolic Risk Factors Among Chronic Kidney Disease Patients Admitted at Princess Marina Hospital, Gaborone, Botswana: Cross-Sectional Case Matched Study

Godfrey Mutashambara Rwegerera, Musa Bayani, Erasmus Kago Taolo, Dereje Habte

Background/Rationale: Cardiovascular disease (CVD) is the leading cause of death among patients with chronic kidney disease (CKD).CVD is mostly precipitated by both traditional and non-traditional cardiometabolic risk factors. This study was conducted to determine the burden of cardiometabolic risk factors among patients with CKD, and also do a comparison to non-CKD patients matched by age and gender.

Methods: A cross-sectional study was carried for three months between March 2014 to June 2014 involving 86 cases and 86 matches. Chronic kidney disease (CKD) was defined as either patient known to have CKD during study period or GFR less than 60 ml/min/1.73 m2.Both traditional and non-traditional risk factors were compared between cases and their matched counterparts. A p-value of less than 0.05 was considered statistically significant.

Results : History of smoking, Hypertension, Diabetes mellitus and anaemia among cases of CKD was 24.4%, 67.4%, 25.6% and 87.2% respectively compared to 37.2%, 20.9%, 5.6% and 34.9% respectively among matches. The prevalence of proteinuria, abnormal mean arterial pressure and Trigerycides/HDL ratio among cases was 82.5%, 40.7% and 80.2% respectively, compared to 4.1%, 18.6% and 55.8% respectively among matches. The difference was statistically significant for all variables (p-value ≤ 0.001). Among the CKD patients, only proteinuria was significantly higher as GFR decreased (p-value=0.000);-other variables were similar across different stages of CKD.

Conclusion: There is a significant high burden of cardiometabolic risk factors among cases of CKD that is independent of CKD stages. Among matches a higher proportion of risk factors are observed making them to be at risk of CKD in the future. There is a need to carry a longitudinal study in the community to verify these findings, also need to devise preventive mechanisms to control the burden of cardiometabolic risks among both cases and their matched counterparts.

573

PO 141A Case of Autosomal Dominant Polycystic Kidney Disease Presented with Acute Pancreatitis.

Zeynep Altin (Turkey)

Introduction: Polycystic kidney diseases (PKD) can be inherited as autosomal recessive (ARPKD) or autosomal dominant (ADPKD) traits. ADPKD is a renal disease which is associated with cysts in the liver and pancreas ( %50-60; %7-10 respectively). We report a case of ADPKD presented with acute pancreatitis.

Case description: A 51 year-old-female presented to the emergency department with abdominal pain , vomiting. She had hypertension and positive family history for ADPKD. On examination her upper abdomen was diffusely tender. Patient laboratory data revealed the following: serum lipase and amilase were elevated at 471 U/L and 764 U/L respectively. Serum creatinine 2.4 mg/dl, lactate dehydrogenase (LDH) level 585 U/l, glutamic-pyruvic transaminase (ALT) level 78 U/l, glutamic-oxalacetic transaminase (AST) level 175 U/l, glucose 143 mg/dl, C-Reaktif protein 7.4 mg/dl ,white cell count 12.7 × 109/L. An Abdominal ultrasonography showed multiple cysts with the widest diameter approximately 3 cm located in liver and bilateral kidneys that caused corticomeduller irregularity and nephromegaly. Also ultrasonography revealed multiple cysts (mean diameter ≤1.0 cm) in the head and corpus of pancreas. Patient was diagnosed as acute pancreatitis due to pancreatic cysts, and chronic renal disease caused by ADPKD. The Ranson score was 2 . arterial blood gases showed metabolic acidosis. The patient recovered over 48 hours with clear oral fluids and supportive medical treatment including intravenous fluids and analgesia as required. The patient’s condition markedly deteriorated, with serum amilase, lipase lowered and acidosis corrected with an increase in urine output .

Discussion: We report a case with acute pancreatitis due to pancreas cysts in a newly diagnosed ADPKD patient. We suggest that after the succesfully treatment of acute pancreatitis, patients may have further examination for recurrent pancreatitis and ADPKD on follow-up visits.

574

PO 142Normalization of Blood Pressure Circadian Rhythm in Kidney Donors within 12 Weeks Post Nephrectomy

Hasan Basri, Endang Susalit,Dharmeizar

Departement of Internal Medicine, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Correspondence Mail : Division of Nephrology, Departement of Internal Medicine, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital, Jl. Diponegoro No. 71 Jakarta 10430, Indonesia, email: [email protected]

Latar Belakang : Isu yang berkembang pada donor ginjal hidup adalah penurunan fungsi ginjal dan terjadinya hipertensi setelah dilakukan nefrektomi. Satu minggu setelah nefrektomi pola tekanan darah sirkadian berubah menjadi non dipper. Selanjutnya terjadi kompensasi sehingga fungsi ginjal akan stabil dalam 12 minggu. Namun belum diketahui apakah perbaikan fungsi ginjal akan di ikuti oleh pola tekanan darah sirkadian kembali menjadi dipper.

Tujuan : Untuk mengetahui perubahan pola sirkadian tekanan darah donor ginjal hidup setelah 12 minggu nefrektomi unilateral.

Metode Penelitian : Studi Pre-experimental dengan before and after design. Subyek sebanyak 18 orang donor ginjal hidup sehat yang berusia 18-50 tahun . Peneltian dilakukan di RS Cipto Mangunkusumo pada bulan Januari 2015 sampai dengan Mei 2015. Tekanan darah diukur dengan 24 jam Ambulatory Blood Pressure Monitoring{ABPM} . Pemeriksaan kreatinin darah, eLFG epi dan uACR dilakukan sebelum nefrektomi, pada 1 minggu dan 12 minggu setelah nefrektomi.

Hasil :Terdapat 18 subyek yang memiliki pola dipper sebelum dilakukan nefrektomi unilateral. Tujuh belas subyek mengalami pola non dipper setelah 1 minggu nefrektomi. Pada 12 minggu setelah nefrektomi 16 diantaranya kembali menjadi pola dipper yang bermakna secara statistik (p<0.001).

Simpulan : Terdapat perubahan pola sirkadian tekanan darah non dipper kembali menjadi pola dipper pada donor ginjal hidup 12 minggu setelah nefrektomi unilateral.

Kata kunci : Pola sirkadian tekanan darah, dipper, non dipper, donor ginjal, 24 jam ABPM.

575

ABSTRACT

Background : The issue of post nephrectomy in living kidney donor is kidney function decrease and hypertension. One week after nephrectomy circadian pattern of blood pressure becomes non dipper. Then there will be a compensatory of renal function that becomes stable within 12 weeks after nephrectomy. However, whether the improvement of renal function is followed by the circadian pattern of blood pressure becomes dipper is still unknown.

Aims : To know the changes circadian pattern of blood pressure among living kidney donors 12 weeks after unilateral nephrectomy.

Methods : A pre-experimental study with before and after design. The subjects were 18 healthy living kidney donors aged 18 to 50 years old , conducted in RSCM hospital between January 2015 to May 2015. Blood pressure was measured by 24 hours ABPM. Serum creatinine, e-GFR epi and uACR were taken before nephrectomy, 1 week and 12 weeks after nephrectomy.

Results : There were 18 subjects had dipper pattern before unilateral nephrectomy. Seventeen of them exhibited a pattern became non dipper on one week after nephrectomy. Sixteen subjects showed the pattern returned to dipper after 12 weeks nephrectomy that statistically significant (p<0.01)

Conclusions : The circadian pattern of blood pressure returned to dipper from non dipper on living kidney donors after 12 weeks unilateral nephrectomy.

Keywords : Circadian pattern of blood pressure, dipper, non dipper, kidney donor, 24 hrs ABPM.

576

PO 143IMPACT OF ACUTE KIDNEY INJURY ON MORTALITY RATE OF PATIENTS WITH SEPSIS IN INTENSIVE CARE UNIT

Fatnan SH*, Jati A*, Prasetyo DH*, Kusumadewi RT**, Arifin***, Sumandjar T***, Purwanto MB*** Internal Medicine Department, Sebelas Maret University / Dr. Moewardi Regional Hospital, Surakarta, Indonesia ** Division of Nephrology and Hypertension, Internal Medicine Department, Sebelas Maret University / Dr. Moewardi Regional Hospital, Surakarta, Indonesia

*** Division of Tropical Medicine and Infectious Disease, Internal Medicine Department, Sebelas Maret University / Dr. Moewardi Regional Hospital, Surakarta, Indonesia

Background: Acute kidney injury (AKI) is a common complication in patients with sepsis admitted to the intensive care unit (ICU). It occurs in about 23% with severe sepsis and 51% with septic shock. And it is believed that mortality rate from sepsis with AKI is higher than other renal disorder.

Purpose: To report the patients characteristics and mortality rate of sepsis with AKI in ICU.

Methods: We performed a retrospective study among patients with sepsis admitted to the ICU in Dr. Moewardi Regional Hospital, Surakarta Indonesia from April 1st 2015 – April 30th 2016. Data were obtained from the database of medical records and interview. We analyzed age, sex, source of infection, length of stay and outcome, using Chi-Square test and Mann-Witney Test, with p< 0,05 is significant.

Results: A total of 311 patients were evaluated in this study. We identified 106 cases of AKI, 38 cases of End Stage Renal Disease (ESRD), and 167 cases of Non-Kidney Injury (non-KI). Median age of the population was 55 (range 17 to 92) years old. There were 160 males (51,4 %) and 151 females (48,6 %) patients. The source of infection in sepsis were pulmonary (43,4%) following to urogenital (37%), abdomen (14,5%), skin/soft tissue/bone (7,4%) and others (6,8%). The mortality rate were 80,18 % for AKI, 31,58 % for ESRD, and 52,1 % for non-KI (P < 0.02) and mean length of stay (LOS) were 9, 6 and 7 days respectively.

Conclusion: Patients with sepsis in ICU with AKI have a higher mortality rate and long periode of stay than those with ESRD and non-KI.

Keyword : Acute Kidney Injury, Mortality Rate, Sepsis, Intensive Care Unit

577

PO 1441H-Proton Magnetic Resonance Spectroscopy (1H-MRS) of Osmotic demyelination syndrome in a Uremic PatientTeguh Thajeb, MD, 1 and Peterus Thajeb, MD, DMedSci 2-4

1. Department of Internal Medicine, section of Nephrology, Landseed Hospital, Taiwan; 2. Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan;3. Biomedical Science, Graduate Division, John A Burns School of Medicine, UHM,

Honolulu, HI, USA;4. Lily Evergreen Neurology Clinic, Taoyuan, Taiwan, ROC

Correspondence: Peterus Thajeb, MD, DMedSci

Abstract

Osmotic demyelination syndrome (ODS) includes Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) are rare well-known neurological complications following rapid correction of hyponatremia. We herein report 1H-proton magnetic resonance spectroscopy (1H–MRS) of CPM and EPM in a diabetic and hypertensive elderly woman with old stroke, end-stage renal disease, and hyponatremia. Akinetic mutism, dysphagia, limb rigidity, focal dystonia, spastic tetraparesis, and myoclonic jerks of the extremities occurred 2 to 3 weeks following slowly correction of hyponatremia. MRI showed heterogenous signal intensity at right basal ganglion on both T1WI and T2WI suggesting an acute demyelination and petechial/hemorrhagic necrosis, and hyperintensity at the central pons and paraventricular white matter on T2WI suggesting demyelination. 1H-MRS shows decrease N-acetyl aspartic acid (NAA) to creatine (Cr) ratio and increase choline (Cho) to creatine ratio of the lesions in the thalamolenticular region suggesting neuroaxonal damage and cell membrane degradation. The metabolite changes in the bifrontal area are less conspicuous. Follow-up 1H-MRS 3 months later showed gradual normalization of the NAA/Cr. The dysphagia, limb rigidity, dystonia, and tetraparesis improve, and the lesions on neuroimages may resolve over time; however, permanent neurological sequel such as akinetic mutism and dementia remain even after 2 years of follow-up.

578

PO 145PLEUROPERITONEAL LEAK IN PATIENT WITH CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD)

Lukman Pura, Rudi Supriyadi, Ria Bandiara

Nephrology and Hypertension Division, Department of Internal Medicine, Faculty of Medicine Padjadjaran University / Dr.Hasan Sadikin General Hospital Bandung,

West Java - INDONESIA

-------------------------------------------------------------------------------------------------------

(CASE SERIES)

Background: Continuous Ambulatory Peritoneal Dialysis (CAPD) is one of modalities treatment for end stage renal disease (ESRD) patient. Advantages of CAPD such as simple, flexible, effective and rationale cost are suitable especially for the patients living in developing countries with geographical difficulties. Pleuroperitoneal leakage is a rare non-infectious complication of PD with incidence range 1.6 - 2 %. We report case series (2 cases) of pleuroperitoneal leakages in two years observation in PD patients population at Dr.Hasan Sadikin General Hospital Bandung West Java - Indonesia.

Case Report: Two serial cases of pleuroperitoneal leakage were observed in two years, in a 44-years-old woman and a 38-years-old man, with CAPD treatment for 2 months and 48 months respectively. Both patients presented with complaint of shortness of breath suddenly just after inflow 2 L PD fluid. There were no fever, cough or another sign of infection. The patients have significant right sided pleural effusion in chest X-ray. The effusion was managed initially with intercostal drainage insertion. Biochemistry examination of pleural fluid show transudate pleural effusion with high glucose level. Pleuroperitoneal leakage was then suspected. The first patient performed dynamic scintigraphy with SPECT/CT that showed pathological level of radioactivity in pleural fluid and confirmed hydrothorax secondary to pleuroperitoneal leakage. PD process was discontinued and shift to haemodialysis, however one case continue PD treatment with lower volume of PD fluid.

Conclusions: Pleuroperitoneal leakage is rare non-infectious complication in PD patients. Diagnosis can be made simply on typical clinical sign and to be confirmed with biochemistry examination of pleural fluid (high glucose level) and scintigraphy.

579

PO 146The Relationship of Serum Insulin-like Growth Factor-1 (IGF-1) and Insulin-Like Growth Factor Binding Protein-1 (IGFBP-1) with Nutritional Status of Peritoneal Dialysis Patient

Herman Trianto1, Atma Gunawan1, Nursamsu1, Putu Arsana1

1Nephrology Division, Faculty of Medicine Universitas Brawijaya dr. Saiful Anwar Hospi-tal –Malang – Indonesia

Background. Malnutrition is often found in patients with CAPD but underdiagnosed. 1/3 of patients with CAPD was diagnosed as Kidney Wasting Syndrome. Several factors, including insulin like growth factor-1/insulin like growth factor binding protein (IGF-1/IGFBP) axis, was allegedly played role as a secondary etiology of malnutrition.

Objection. To ascertain correlation of IGF-1/IGFBP-1 axis and nutritional status in pa-tients with CAPD.

Method. This study is a survey, held in CAPD Center RSSA, Malang in May-August 2014. 68 patients participated and performed history taking and physical examinations to de-termine baseline characteristics. Serum IGF-1 and IGFBP-1 was measured with Human Quantikinine ELISA. Nutritional status was identified by measuring anthropometry sta-tus (body height(BH), body weight (BW), body mass index (BMI), body surface area (BSA), upper arm circumference (UAC), mid arm muscle circumference (MAMC), triceps skinfold thickness (TST), subscapular skinfold thickness (SST)) and biochemistry marker (albumin, prealbumin, transferrin). Correlation of serum IGF-1, IGFBP-1 and nutritional status was analyzed statistically. Data analysis used Pearson, Spearman, and Point Bise-rial.

Result. Mean ± SD age of the patients was 47.82 ± 11.17 years old. Mean serum IGF-1 was 10.69 ± 4.85 μg/L and median serum IGFBP-1 was 7.16 (0.99-56.72) μg/L. An-thropometry measurement revealed mean BH was 158.15±7.92 cm, mean BW was 59.81±13.7 kg, median BMI was 23.55 (16.6-40.4) kg/m2, median BSA was 1.6 (1.2-2.1) m2, median UAC was 21.5 (7.5-36) cm, median MAMC was 17.25 (3.4-30.3) cm, median TSF was 12 (3-39) mm, and median SST was 17(2-33) mm. Biochemistry marker meas-urement revealed serum albumin was 2.85 (1.3-5.8) g/dL, prealbumin 31.6 ± 7 mg/dL, and transferin 127.33 ± 74.65 mg/dL. Adequacy wKt/V was positively correlated with BMI (r=0.510, p=0.008), MAMC (r=0.503, p=0.000), TST (r=0.333, p=0.006), SST (r=0.360, p=0.002), and albumin (r=0.317, p=0.008). Adequacy wCrCl was positively cor-related with BMI (r=0.260, p=0.033), MAMC (r=0.347, p=0.004), TST (r=0.244, p=0.045), and albumin (r=0.242, p=0.047). Serum IGF-1 was positively correlated with serum pre-albumin (r=0.296, p=0.014) and transferin (r=0.342, p=0.004), whether serum IGFBP-1 was negatively correlated with MAMC (r=-0.364, p=0.002).

580

Conclusion. Serum IGF-1 and adequacy improvement is correlated with nutritional sta-tus amelioration, whether increased serum IGFBP-1 is associated with reduction of nu-tritional status.

Keywords: CAPD, adequacy, IGF-1, IGFBP-1, nutritional status

581

PO 147ASSOCIATION BETWEEN PHOSPHATE AND FIBROBLAST GROWTH FACTOR 23 LEVEL IN PRE-DIALYSIS CHRONIC KIDNEY DISEASE PATIENTS

Nuri Susanti, Nunuk Mardiana, Widodo, Djoko Santoso, Mochammad Thaha, Chandra I Mohani, Aditiawardana, Artaria Tjempakasari


Background: Hyperphosphatemia and increasing of Fibroblast Growth Factor 23 (FGF23) due to mineral-bone metabolism disorders (MBD) are associated with increased risk of cardiovascular disease. MBD develop in a reduce of Glomerular Filtration Rate (GFR) <60ml/minute/1,73m2. FGF23 was elevated precedes detection of increased phosphate levels, thus FGF23 may be used as an early marker of MBD and as target for CKD-MBD therapy. This study clarified the association between Phosphate and FGF23 level in pre-dialysis CKD patients

Methods: In this cross sectional study, posphate was measured using Phosphorus-UV (normal range 2.5-4.5 mg/dl) and intact FGF23 was measured using ELISA methode. Association between Phosphate and FGF23 level was analyzed using Spearman Rank test.

Results: Forthy pre-dialysis CKD patients were enrolled in this study. The median phosphate was 4,5 mg/dl and median FGF23 was 124.87 pg/ml. Rank Spearman test showed significant association between phosphate and FGF23 (p<0.001, r = 0.7).

Conclusion: There was significant association between increased phosphate level and elevated FGF23 level . FGF23 was increased in CKD 4 precedes the emergence of hyperphosphatemia.

Keywords: mineral and bone disorders, chronic kidney disease, cardiovascular disease, hyperphosphatemia, FGF23

582

PO 148ASSOCIATION OF NEUTROPHIL TO LYMPHOCYTE RATIO WITH LEFT VENTRICULAR HYPERTROPHY IN HEMODIALYSIS PATIENTS

Artaria Tjempakasari, Nunuk Mardiana, Widodo


Background: Cardiovascular disease is the principal cause of morbidity and mortality in dialysis patients, and left ventricular hypertrophy (LVH) is an independent risk factor for mortality in hemodialysis (HD) patients. Inflammation plays an important role in left ventricular remodeling. Neutrophil to lymphocyte ratio (NLR) is defined as neutrophil count divided by lymphocyte count, is an inexpensive and readily available parameter, which may serve as inflammation marker This study was undertaken to determine the association of NLR with LVH in patients on regular HD.

Method: This cross sectional single center study (performed at Jemursari Islamic Hospital Surabaya) analyzed ESRD patients on twice a week hemodialysis for more than 3 months. Blood samples were taken after hemodialysis procedure to measure neutrophil and lymphocyte counts. Electrocardiography was performed to asses LVH. Spearman correlation test was used to determine the association of NLR with LVH.

Results: We analyzed 80 subjects (male:female 50:30), 36 patients had diabetes mellitus. Other factors that influence LVH is hypertension (30 patients). The mean of age was 54 years old (+10.76), median duration on hemodialysis was 24 months (5–84 months), median of NLR was 3.2 (0.93–12.12). There was no association between age, duration on hemodialysis, diabetes mellitus, hypertension with LVH (p=0.499, p=0.503, p=0.375, p=0.447). The Spearman correlation test showed no association between NLR and LVH (p=0,728).

Conclusion: This study showed no association between NLR with LVH in hemodialysis patients.

Keywords : Neutrophyl-lymphocyte ratio, LVH, hemodialysis

583

PO 149COMPARISON OF HIGH-SENSITIVITY C-REACTIVE PROTEIN LEVEL BETWEEN CHRONIC KIDNEY DISEASE STAGES

Tri Asih Imro’ati, Mochammad Thaha, Aditiawardana, Widodo, Pranawa, Chandra Irwanadi


Objective : To evaluate the hs-CRP level comparison between CKD stages in Dr. Soetomo General Hospital Surabaya.

Methods: An analytic observational cross-sectional study, evaluating the differences of hs-CRP level between CKD stages in 48 patients with CKD (mean age 55.81±7.83 years, the ratio between male:female was 1:1.08, mean BMI 24.32±3.44 kg/m2, 33.3% diabetics, 41.7% on ACEI/ARB, 22.9% on statin), recruited from Nephrology Outpatient Clinic, Dr Soetomo General Hospital, Surabaya, from January to May 2014. The stages were stratified according to the MDRD formula.

Results: The mean hs-CRP of CKD stage 3 was 2.29±2.86 and non-dialysis stage 5 was 2.09 ± 2.54. The analysis using Mann Whitney U test showed no significant differences among patients with CKD stage 3 and non-dialysis stage 5 (median 1.25 vs 1.05 mg/L; p=0.680). No significant differences of the serum hs-CRP level were detected between diabetics and non diabetics in stage 3 and non-dialysis stage 5 (p=0.673 vs 0.138); between patients with and without ACEI/ARB treatment (p=0.610 vs 0.671); and between patients with and without statin treatment (p=0.852 vs 0.309).

Conclusion: There was no significant difference between hs-CRP levels in CKD stage 3 and stage 5 non-dialysis. In this study, CRP levels did not represent the increase in CKD stage. Further research must be done on the relationship between hsCRP levels with CKD stage using cohort study and studies similar to this one should involve all stages of CKD (stage 1 to 5).

Keywords : chronic kidney disease, hs-CRP

584

PO 150ASSOCIATION BETWEEN MTHFR GENE POLYMORPHISM AND HYPERHOMOCYSTEINEMIA IN HEMODIALYSIS PATIENTS IN INDONESIA

Mochammad Thaha, Ardityo R Ardhany, Wenny P Nilamsari, Mochammad Yusuf, Widodo, Yasuhiko Tomino


Background: Growing evidence has demonstrated an association between renal failure and cardiovascular disease (CVD), although the exact mechanism is still obscure. Hyperhomocysteinemia (hHcy) is one possible mechanisms of CVD in chronic kidney disease (CKD) patients. Previous reports have revealed that the presence of methylene tetrahydrofolate reductase (MTHFR) gene polymorphism C677T is positively correlated with plasma homocysteine (Hcy) concentration. Until now, there was no data on the association of MTHFR gene polymorphism and plasma Hcy concentration in Indonesian hemodialysis (HD) patients.The objective of the present study is to investigate the association between MTHFR gene polymorphism and hyperhomocysteinemia (hHcy) in HD patients.

Method: A cross-sectional study was conducted on 15 HD patients and 15 healthy subjects with the following criteria: 1) aged 18–65 years old, 2) having undergone regular HD over the previous 3 months while remaining stable, 3) having hemoglobin (Hb) levels of more than 8 g / dL and serum albumin levels higher than 3 g / dL, and 4) who had not taken antioxidants in the previous one month. Patients who had received a blood transfusion prior to sampling were excluded from this study. All patients agreed with this study and completed an informed consent sheet. The Hcy assay was performed by HPLC, while the MTHFR gene polymorphism assesment were performed by PCR and DNA sequencing. The prevalence of the C677T mutation in the MTHFR gene was examined in 15 HD patients and in 15 healthy subjects.

Results: The mean plasma Hcy levels in HD patients were significantly higher than those in healthy subjects, i.e. 22.5 ± 4.9 vs. 10.3 ± 2.3 umol / L (p < 0.05). The distribution of the three genotypes in the healthy subjects was as follows: CC genotype, 80.0 %; CT genotype, 20.0 % ; and TT genotype, 0.0 %. In HD patients, the distribution was CC genotype, 60 % ; CT genotype, 33.3 %; and TT genotype, 6.7 %. The plasma level of Hcy in the TT genotype was higher than that in the CC genotype and CT genotype, but not statistically significant.

Conclusion: It is indicated that Hcy levels in patients with MTHFR gene polymorphism, i.e. the TT genotype, is substantially higher than Hcy levels in patient without MTHFR gene polymorphism in Indonesia. This study did not show a statistical association between MTHFR gene polymorphism and Hcy levels in HD patients. Since this study measured

585

only a small number of HD patients, an on going collaborative study in both Indonesia and Japan is being performed

Keywords: chronic kidney disease, cardiovascular disease, hyperhomocysteinemia, MTHFR gene polymorphism

586

PO 151Lectin-like oxidized low-density lipoprotein-1 related endothelial dysfunction in patients with white coat hypertension Yavuzer S1, Yavuzer H1, Cengiz M1, Erman H2, Altıparmak MR3, Korkmazer B4, Balci H5, Simsek G6, Yaldıran AL1, Karter Y1, Uzun H2

1. Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.

2. Department of Biochemistry, Cerrahpasa Faculty of Medicine, Istanbul3. University, Istanbul, Turkey.4. Department of Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University,

Istanbul, Turkey5. Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University,

Istanbul, Turkey.6. Central Research Laboratory, Cerrahpasa Faculty of Medicine, Istanbul University,

Istanbul, Turkey, 7. Department of Physiology, Cerrahpasa Faculty of Medicine, Istanbul University,

Istanbul, Turkey.Backround: White coat hypertension (WHT) may lead to cardiovascular target organ damage similar to sustained hypertension (HT). Endothelial dysfunction is one of the earliest manifestations of atherosclerosis. Lectin-like oxidized low density lipoprotein receptor-1 (LOX-1) was identified from endothelial cells as the molecule that induces endothelial dysfunction triggered by oxidized low-density lipoprotein (oxLDL). LOX-1 is viewed as a mediator and biomarker of endothelial or vascular dysfunction. Measurement of soluble LOX-1 (sLOX-1) may provide a novel diagnostic tool for the evaluation and prediction of endothelial dysfunction and vascular disease. We investigated the sLOX-1 levels in patients with HT and WCH, the association of sLOX-1 with oxLDL, endothelial nitric oxide synthase (eNOS) and carotid intima–media thickness (CIMT) between HT, WCH patients and healthy controls. Methods: The three groups, HT, WCH and controls, were comprised of 35 patients each. CIMT were measured on ultrasonography images. oxLDL, sLOX-1, total nitic oxide (NOx) levels and eNOS activity were measured from collected blood samples. All statistical comparisons were performed using the analysis of variance was used to compare multiple-group means. Results: oxLDL and sLOX-1 levels were significantly higher in the HT and WCH groups than in the control group (P<0.001, P=0.011; P<0.001,P=0.019 respectively). But sLOX-1 levels were significantly higher in the HT group compared with the WCH group. eNOS levels were significantly lower in the HT group than in the control group. There were no significant differences between the WCH and control group. CIMT measurements were significantly higher in the WCH and HT groups compared with control (p<0.001). There was a significant positive correlation between CIMT and sLOX-1. Conclusion: A possible endothelial impairment may act as a cardiovascular risk factor in WCH. We believe sLOX-1 level is strong biomarker for determining early endothelial damage in HT, and especially in WCH patients.

587

PO 152The Nutritional Status of Continous Ambulatory Peritoneal Dialysis (CAPD) Patients at CAPD Centre of Saiful Anwar General Hospital Malang East Java 1Etik Mertianti 2Atma Gunawan 3Nursamsu Division of Nephrology and Hypertension, Internal Medicine Department,Faculty of Medicine Brawijaya University, Saiful Anwar General Hospital Malang

Objective. End-stage renal disease (ESRD) has significantly increased in developing countries such as Indonesia. Continous Ambulatory Peritoneal Dialysis (CAPD) as an alternative dialysis therapy for ESRD is offered in 5 of the 13 centers in our country, in last 3 years, the CAPD program has been developing more rapidly. The purpose of this research is to assess the nutritional status of CAPD patients in our hospital and to assess the correlation between nutritional status with dialysis adequacy.

Method. A cross sectional study was performed on ESRD patients treated with CAPD at CAPD Centre of Saiful Anwar General Hospital Malang.The nutritional status of each patient was assessed using subjective global assesment (SGA), anthropometric parameters including body mass index (BMI), mid-upper arm circumference (MUAC), triceps skin fold (TSF) and biochemical parameters including albumin serum and total cholesterol levels. Dialysis adequacy (KT/V) was assessed by solute clearance measurement.

Results. It involved 66 adult CAPD patients. The mean age was 47.79±11.25 years, 58.8% were males and 41.2% were female. The mean BMI was 23.84±4.70kg/m2, mean MUAC was 17.6 mm, mean TSF was 13.2 mm, mean albumin serum was 3.17 gr/dL, while mean total cholesterol level was 194.9 mg/d . Based on SGA scores, 71.2% were well nourished, 19.6% were moderately undernourished, while 9.2% were severely malnourished. The mean adequacy dialysis (weekly KT/V) was 1.84 ± 0.56 (L/week). We noted significant correlation between adequacy and anthropometric parameters such as BMI, MUAC and TS. And siginificant correlation between adequacy and total kolesterol serum as a biochemistry parameter. There was no significant correlation between adequacy and albumin.

Conclusion. Malnutrition is uncommon in our CAPD centre, with a significant correlation between adequacy and the nutritional status.

Keywords : Nutritional status, SGA, Adequacy Dialysis, Anthropometric parameters

588

PO 153The Effect of Dhikr Method Majelis Zikir Al-Hidayah Pekanbaru towards the Decrease of Systolic Blood Pressure and Diastolic Blood Pressure

Dani Rosdiana 1, Eka Bebasari 2, Faradini 3

1Department of Internal Medicine Faculty of Medicine Riau University-Arifin Ahmad General Hospital Pekanbaru2Department of Physiology Faculty of Medicine Riau University3Faculty of Medicine Riau University BACKGROUND: Indonesia is the most populous Muslim country in the world, it reaches up to 87.2%. the measurement of Blood Pressure in 2013 showed that the prevalence of hypertension was 25.8% (aged over 18 years). Dhikr as a ritual of rememberance of God can be used as an Islamic meditation. Dhikr can facilitate the relaxation that affects the autonomic nervous system responding to the blood pressure. The practitioners of Dhikr apply the dhikr method by closing their eyes, reciting the sentence and interpretation the meaning of the dhikr itself. The purpouse of dhikr is to gain inner peace and to be more focused. This study aims to investigate the effect of dhikr method of Majelis Zikir Al-Hidayah Pekanbaru toward the decreasing blood pressure. METHODS: The study is a quantitative study with cross-sectional design in 62 respondents who confirmed the inclusion criteria and no exclusion criteria. The data was collected by using digital sphygmomanometer and questionnaires. The blood pressure of the respondents were measured before and after the practice of the dhikr . The data was analyzed by using statistic paired t-test. RESULTS: The results shows the majority of respondents are male (58%) with age >40 years (35%). The mean systolic blood pressure before and after the remembrance are 139.1 mmHg and 134.7 mmHg (a difference of -4.4 mm Hg). Based on Wilcoxon statistical test results obtained the difference in systolic blood pressure were significantly (p = 0.000). The Mean diastolic blood pressure before and after the remembrance are 83.5 mmHg and 81.5 mmHg (a difference of -2 mm Hg). Based on the result of T – paired statistical test, there was difference in diastolic blood pressure that significant with (p = 0.000). Conclusions: There are significant differences between the mean blood pressure before and after Al-Hidayah dhikr method.

Key words: dhikr method, blood pressure

589

PO 154Clinical Features And Quality Of Life In End Stage Renal Disease Patients Undergoing Hemodialysis Twice A Week Compared To Thrice A Week

Imelda F, Marbun MB, Susalit E, Rumende CM

Background: Hemodialysis (HD) is still the main choice for renal replacexment therapy in Indonesia. National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NFK-KDOQI) recommend HD thrice a week. Patients undergoing HD twice a week more than thrice a week. It is necessary to investigate the clinical features and the quality of life in End Stage Renal Disease (ESRD) patients undergoing HD twice a week.

Objective: To know the clinical features and the quality of life in ESRD patients undergoing hemodialysis twice a week.

Methods: This study is a cross-sectional study in ESRD patients undergoing HD at RSCM and some private hospitals. Laboratory examination and assessment of quality of life by using KDQOL-SF 36.

Results: There were 80 subjects and most age group over 50 years, the male subject is more common. Clinical features that differ between groups of patients undergoing HD two and three times weekly were IDWG 4.91 (SD 1.52) and 3.82 (SD 1.28) p=0.002. Albumin 4.05 (SD 0.26) and 3.86 (SD 0.48) p=0.027. Phosphate 5.82 (SD 1.68) and 5.82 (SD 1.68) p=0.026. TIBC 235.20 (SD 55.72) and 273.73 ( SD 58.29) p=0.004. Transferrin saturation 25.5 (12.0 to 274.0) and 21.95 (5.8 to 84.2) p=0.004. Approximately 68% of patients undergoing HD twice a week reached adequate HD (Kt/V >1.8), 93,3 % of the HD group thrice week achieve Kt/V >1.2.The quality of life did not differ significantly p=0.227 PCS, p=0.247 MCS and p=0.889 KDCS.

Conclusion: Some parameters of the clinical features significantly different between the two groups. The quality of life is found not significantly different between the two groups.

Key words: End Stage Renal Disease, hemodialysis frequency, quality of life.

590

PO 155Title: CLINICO-EPIDEMIOLOGICAL PROFILE OF PATIENTS WITH ATRIAL FIBRILLATION : A HOSPITAL BASED STUDY FROM EASTERN NEPAL

Authors: P Karki, D. Garg, B Pradhan, V Kattel.

Institute: Division of Cardiology, Department of Internal Medicine B P Koirala Institute of Medical Sciences, Dharan, NEPAL

Background: Atrial fibrillation (AF), one of the common cardiac morbidity and mortality, is associated with heart failure, frequent physicians or emergency department visit, hospitalization and significant economic consequences. Atrial Fibrillation (AF) causes a five-fold rise in the stroke. The prevalence of AF among stroke cases is 16.7%.

Objectives: Primary aim of the study is to describe the clinical profile and treatment pattern of patients with Atrial Fibrillation.

Methods: This was a descriptive cross sectional study. All patients of Eighteen years and above were enrolled, if AF was documented on an ECG during the index visit.

For descriptive statistics mean, median, standard deviation, inter-quartile range and proportion were calculated.

Results: Among 64 cases enrolled 54% were male, 48.4% belonged to the age group of 60-79 years (mean age 65.9±14.43). The prevalence of paroxysmal, persistent, and permanent AF was 31.25%, 21.87% and 46.87% respectively. Cohort Presenting with Congestive Heart Failure was 48.4%. Underlying heart disease was present among 60 patients (93.75%) most common being Dilated Cardiomyopathy (31.2%) followed by Coronary Artery Diseases (29.6%), Rheumatic heart disease (23.43%) and hypertensive heart disease (20.3%). Digitalis was prescribed among 62.8% followed by beta-blocker 11.6%, calcium-channel blocker 8.1% and amiodarone 6.25%. Oral anticoagulation (OAC) was prescribed among 10.9% only though the indication was among 84.3% by CHADS2 score (mean CHADS2 score 1.37).

Conclusion: Though the cases of stroke has not been reported in our study but follow up of this cohort might give higher prevalence of the stroke and stroke related mortality due to under use of OAC. Thus follow up of the cohort is recommended to assess the risk benefit ratio of OAC in AF.

Keywords: Atrial fibrillation, Oral Anticoagulant, Stroke.

591

PO 156Efficacy Of High Right Ventricular Septal Lead Placement For Prevention Of Subclinical Atrial Fibrillation

Tatsuo Misawa - Japan

To investigate the effect of atrial septal and high right ventricular septal pacing on the incidence of subclinical atrial fibrillation (AF), a follow-up survey was performed with regard to the atrial tachycardia response (ATR), a mode switching function of the pacemaker.

Methods:Fifty patients who had undergone dual-chamber pacemaker implantation with right atrial septal and high right ventricular septal pacing were assigned to two groups: the sick sinus syndrome (SSS) group with maximal atrial septal pacing and the atrioventricular block (AV block) group with maximal right ventricular septal pacing. We examined the ATR events to identify the incidence of AF.

Results:The SSS group consisted of 26 patients (mean age 78±7 years, 12 men) and was followed up for 167±98 days. The AV block group consisted of 24 patients (mean age 79±5 years, 12 men) and was followed up for 164±108 days. In the AV block group, the mean right ventricular pacing rate was significantly higher (91±20% vs. 10±20%; P<0.001) and the mean right atrial septal pacing rate was significantly lower (22±23% vs. 73±22%; P<0.001) than in the SSS group. Asymptomatic episodes of atrial fibrillation occurred in 16 patients in the SSS group and 15 patients in the AV block group. In the SSS group, 7852 ATR events were observed during the 4048-day follow-up period, and 8415 events were observed in the AV block group during the 3881-day follow-up period. The total ATR operation time in the SSS group was 2810 hours in the 97152 hours followed up (4048 days*24 hours) and that in the AV block group was 239 hours in the 93144 hours followed up (P<0.001). The duration of AF in the high right ventricular septal pacing group was significantly shorter than in the right atrial septal pacing group.

Conclusions:High right ventricular septal pacing reduced the risk of subclinical AF.

592

PO 157Pericardial drainage without catheter laboratory and echocardiogram, Is it Possible ?

Yudistira Panji Santosa, Mario Steffanus, Pramantha Liong, Marcella AdisuhantoDepartment of Internal MedicineAtma Jaya University, Jakarta, Indonesia

Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary edema, shock, and death. The fluid around the heart must be drained as quickly as possible. Pericardiocentesis is a procedure that uses a needle to remove fluid from the tissue that surrounds the heart

Here, we present 41 year-old men with dyspnea when he came into hospital. He has reduced body weight, prolonged fever. Physical examination revealed that tachypnea, tachycardia, sub febrile with hypotension. Electrocardiogram showed low voltage and Chest X ray showed hugged cardiac size. When patient want to delivered to diagnostic center for echocardiogram, suddenly patient unconsciousness and blood pressure drop. We do make ultrasound examination with abdominal probe in subcostal region; we see severe pericardial effusion with RV collapse. For emergency treatment, we do drainage pericardial fluid with abbocath no 14, 500 cc yellowish fluids were taken. After drainage, dyspnea disappears and tachycardia diminished. Blood pressure goes up to normal range. Patient delivered to ICU ward. Analyzed effusion revealed exudative fluid and no malignancy in sitology examination.

Pericardial tamponade is emergency situation. For emergency cases, removal of pericardial fluid is the definitive therapy for tamponade and can be done using large needle without echocardiogram and catheter laboratory

Key word : Pericardial tamponade, catheter laboratory, echocardiogram

593

PO 158Correlation between Asymptomatic Peripheral Arterial Disease and Severity of Stable Coronary Heart Disease

Abduh MS, Antono D. Panggabean MM. Harimurti K

ABSTRACT

Background: Atherosclerosis is a diffuse disease process; in which damaged of a blood vessel will predict abnormalities in other blood vessels. Ankle Brachial Index (ABI) and Toe Brachial Index (TBI) are non-invasive tests, which are proved to be sensitive and specific for detecting and assessing the severity of peripheral arterial disease. This study was aimed to determine the relationship between degree of asymptomatic peripheral arterial disease (PAP) and the severity of stable coronary heart disease (CHD)

Method: In this cross-sectional study the severity of coronary artery stenosis was measured by using a GENSINI scoring system, in which score>40 was considered severe and score<40 was considered mild to moderate. Peripheral arterial disease was evaluated by ABI and TBI tests with oscillometric method. Data were analyzed using Spearman’s rank correlation coefficient and Pearson correlation analysis.

Results: Seventy three patients with stable CAD undergoing coronary angiography were investigated. Asymptomatic CHD with stable PAP was seen in 47 patients (64.4%). The median value of ankle brachial index was 1.07 (range from 0.57 to 1.27), the mean score of Toe Brachial Index (± 0.155) and the mean score of GENSINI was 46.60 (± 33.64). There was no significant correlation between ankle brachial index and Toe Brachial Index and the GENSINI score with p=0.407 (r = -0.099) and p= 0.196 (r = -0.153), respectively.

Conclusion: The study showed that ABI and TBI with oscillometric method had no correlation with the degree of coronary artery stenosis defined by the GENSINI score. ABI and TBI did not have a good potential to distinguish patients with mild-moderate and severe stable CHD determined by GENSINI scores.

Keywords: Peripheral Arterial Disease, Coronary Heart Disease, Ankle Brachial Index. The Brachial Index. Gensini Score.

594

PO 159Correlation between FEV1 % Prediction and Mean Pulmonary Arterial Pressure by Echocardiography in Stable Chronic Obstructive Pulmonary Disease patients

Munadi1, Muhammad Yamin2, Anna Uyainah3

1.Fellow Consultant Cardiovascular Department of Internal Medicine, Faculty of Medi-cine. Indonesia University2. Cardivascular Division Department of Internal Medicine, Faculty of Medicine. Indone-sia University3. Pulmonary Division Department of Internal Medicine, Faculty of Medicine. Indonesia UniversityBackground: 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 either in COPD patients with exacerbations treated in intensive care unit. Data of pulmonary hypertension in stable COPD group is still relatively rare published. Alternatively to RHC, nowadays echocardiography is used to measure Mean Pulmonary Arterial Pressure in stable COPD group.Objective: To determine the correlation between forced expiratory volume in one second (FEV1 %) prediction and mean pulmonary arterial pressure. To determine the best clinically cut-off point between FEV1% prediction with mean pulmonary arterial pressureMethods: A cross-sectional study was conducted on fifty-eight stable male COPD patients (mean age : 67,6) under went spirometry. Mean pulmonary arterial pressure was measured using transthoracic echocardiography at short axis view in aortic level.Results: Mean value of FEV1% was 26,6 % (SD 4,7) with median value of mean pulmonary arterial pressure was 37,61 mmHg (range 18,3-59). 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 has a clinical value correlating to mean pulmonary arterial pressure, 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 chronic obstructive disease patients. The cut-off point FEV1 % prediction was 55,3% has a good capability to discriminate pulmonary hypertension in stable PPOK patient.

Keywords: Stable chronic obstructive pulmonary disease, echocardiography, FEV1 % prediction , mean pulmonary arterial pressure

595

PO 160NOT AN ORDINARY UTI: A CASE OF MULTIPLE MYELOMA STAGE III WITH NO BONE PAIN, HYPERCALCEMIA, OR OSTEOLYTIC LEISONS

Yue Shi, MS3; Zarah Lucas, MD; KavitaKalra, MDHematology/ Oncology, University of Maryland, Midtown Campus, Baltimore, MD.

Introduction: Multiple Myeloma (MM) is a cancer of abnormal plasma cells that accumulate in bone marrow, where they interfere with the production of normal blood cells. The typical clinical presentation of MM is summarized as “CRAB” features (hypercalcemia, renal insufficiency, anemia and lytic bone lesions). In MM, there is an increase in osteoclast activity caused by osteoclast activating factors (OAFs). The OAFs are known to be released by tumor plasma cells.

Case Description: A 63-year-old African American male was admitted for dysuria and brown-colored urine of 2 weeks’ duration. He had no fever but had on and off chills. He reported a 23-lb weight loss and decreased appetite. Work-up on admission revealed anemia with a hemoglobin of 7.5g/dL and renal insufficiency with creatinine as 1.67mg/dL. He was treated with intravenous ceftriaxone which relieved his dysuria and discolored urine. However, his renal insufficiency persisted despite hydration and antibiotics. Due to his anemia and renal insufficiency, multiple myeloma was suspected. Serum protein electrophoresis showed M protein of 4.4g/dL with Immunoglobulin G (IgG) kappa and free lambda on serum immunofixation. IgG was 6911 mg/dL. Kappa light chains were 622.3 mg/L with kappa/lambda ratio of 3.66. Subsequently, bone marrow biopsy showed 90% cellularity with 70-80% plasma cells that were kappa-restricted. The following cytogenetics by FISH were reported: CCND1-IGH fusion, extra signal for chromosome 9, and loss of one copy of 13q14. Interestingly, the patient denied bone pain and had no lytic lesions on skeletal survey. He also did not have hypercalcemia, instead he actually hadhypocalcemia with calcium level of 7.7mg/dL.

The patient was diagnosed with IgG kappa multiple myeloma, International Staging System Stage III, as his B2-microgobulin level is 10.3 mg/L. Since the patient had high risk disease, he was started on bortezomib, lenalidomide, and dexamethasone.

Discussion: This case illustrates a patient diagnosed withIgG kappa MM ISS Stage III with no lytic bone lesions or hypercalcemia, which is rarely reported in currentmedical literature. However, MM patients can present with a variety of complaints and collateral signs. Interestingly, the International Myeloma Working Group had revised the definition of multiple myeloma to include sixty percent or more plasma cells in the bone marrow as one of the myeloma-defining events regardless of the presence of CRAB features.

596

PO 161Predictors of Short Term Outcomes of Primary Percutaneous Coronary Intervention (PCI)

Farhana Ahmed - Bangladesh

Background: Acute myocardial infarction (AMI) is one of the leading causes of death and disability all over the world. Primary percutaneous coronary intervention (PCI) is the treatment of choice for patients with acute ST segment elevation myocardial infarction (STEMI). Primary PCI is being increasingly done in our country also. But the factor influencing the outcome of primary PCI in our setting are mostly unknown. The present study was conducted to investigate factors that influencing the short term outcomes of primary PCI.

Materials and methods: This prospective observational study was conducted from September 2014 to January 2016 in the Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka. 48 patients were selected by purposive sampling. Patients with acute STEMI treated with primary PCI were included in the study based on inclusion and exclusion criteria. Effect of factors including advanced age, male sex, diabetes mellitus, hypertension, dyslipidemia, serum creatinine, left ventricular ejection fraction, anterior myocardial infarction (MI), thrombolysis in myocardial infarction (TIMI) flow, multi vessel disease, angiographic severity score (Leaman score), thrombus aspiration, door to balloon time and total ischemic time on major adverse cardiac events (MACE) i.e. death, post procedural MI, target vessel revascularization (TVR), stroke as well as, on other adverse events like heart failure, cardiogenic shock, major bleeding, significant arrhythmia and stent thrombosis were studied.

Results: The overall incidence of MACE was 2.1%, major bleeding 2.1%, heart failure 4.2% and cardiogenic shock 2.1%. In multivariate analysis, the factors independently influencing the adverse short term outcomes (MACE and other adverse events) were diabetes mellitus (odds ratio (OR) 2.55, 95% confidence interval (CI) 1.180 to 4.124, p=0.02), anterior MI (OR 1.48, 95% CI 1.020 to 1.926, p=0.04), total ischaemic time (OR 1.49, 95% CI 1.044 to 2.444, p=0.04), multivessel coronary artery disease (OR 1.77, 95% CI 1.26 to 3.261, p=0.03) and Leaman score (OR 2.5, 95% CI 1.100-4.504, p=.03).

Conclusion: According to our finding, diabetes mellitus, anterior myocardial infarction, total ischemic time, multivessel coronary artery disease and high Leaman score are predictors of adverse short term outcomes of primary PCI.

597

PO 162Arterial Hypertension and Metabolic Syndrome: Focus on Circadian Profile of Central Aortic Pressure and Arterial Stiffness

Lyaisan ANDREEVA1, Ludmila PANCHENKOVA1, Khadizhat KHAMIDOVA2 Moscow University of Medicine and Dentistry, Russia

Objective: To evaluate the parameters of the central aortic pressure (CAP) and arterial stiffness during the day and night period in patients with arterial hypertension (AH) associated with the metabolic syndrome (MS).

Material and methods. The study included 48 subjects divided into 2 groups: 23 (47.9%) subjects with AH, 25 (52.1%) subjects with AH in the MS (AH+MS). Control group (CG) were 22 practically healthy subjects. All the subjects underwent examination ABPM with oscillometric sensor (BPLabVasotens, Russia) with assessment CAP and arterial stiffness (systolic blood pressure, SBPao; diastolic blood pressure DBPao; pulse pressure PPao; Augmentation index Alxao; amplification of pulse pressure, PPA, pulse wave velocity, PWVao; reflected wave transit time, RWTT; augmentation index, Aixao).

Results. Analysis of CAPao showed a statistically significant increase all parameters in the two groups examinees (day/night/daily – SBPao:121,44±10,95/111,66±9,25/119,24±10,15; DBPao: 84,16±8,27/74,12±7,64/1,84±7,73; mean BPao: 100,48 ± 9,76/90,16±8,12/97,88±8,86) and AH+MS (SBPao:122,48±1,29/113,13±17,18/119,83±11,87; DBPao: 84,52±6,37/74,48 ±8,2/81,78±6,13; mean BP:102,52±10,28/91,78±13,38/99,57±10,32) compared to the CG (SBP: 114,27±7,13/104,36±8,75/112,00±6,68;DBP:79,73±6,31/67,95±7,59/77,14±5,84; mean BP: 93,73±6,56/82,09±8,21/91,09± 6,02) [p<0,05, p<0,05, respectively]. No significant differences in parameters of PPao during the day in these groups, however, PPao was higher in AH+MS group compared to the group AH. Also in the group AH+MS showed significantly high levels of Alxao (-42,27±19,68/-36,95±23,19/-41,18±18,98), and PPA was significantly lower (126,39±9,84/125,32±7,64/124,61±9,56) compared to CG (136,23±7,46/126,18±5,92/134,14±6,87) [p<0,05] and a AH group (Alx:-32,24±18,50/-24,92±24,4/-27,68±19,57;PPA:134,56±9,91/125,32±7,64/132,32±9,03) [p<0,05], PWVao was significantly higher in AH+MS (11,03±1,99/10,74±1,57/10,32±1,45) compared to CG (8,77±1,66/7,54±1,44/7,82±1,38) [p<0,05] and a AH group (9,34±1,37/8,82±1,58/8,86±1,37) [p<0,05]. RWTT significantly lower in AH+MS (137,7±8,97/146,09±10,51/141,3±10,03) and AH groups (138,08±12,0/144,08±12,63/140,68±11,21) compared to the CG (145,77±13,19/154,05±13,23/148,55±12,53) [p<0,05,p<0,05, respectively].

Conclusion. Our study revealed high extent of arterial stiffness both day and night in hypertension subjects with metabolic syndrome. Measurement of central aortic pressure and arterial stiffness necessary for the risk stratification of cardiovascular events in subjects with comorbid conditions aiming to administration adequate therapy.

598

PO 163

EPIDEMIOLOGICAL TRENDS IN COLORECTAL CANCER IN CHINA

Jinzhou Zhu1,2, Kelseanna Hollis-Hansen2, Chaohui Yu1, Youming Li1 1 Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China

2 Department of Epidemiology and Environmental Health, University at Buffalo, The State University of New York, Buffalo, USA

Abstract Background: China has experienced rapid economic development and a considerable change of disease burden over the past decades. Due to the changes in lifestyle and dietary behaviors, the incidence of colorectal cancer (CRC) has been rapidly increasing in China. Aims and Methods: To present the trends of CRC in China over the past decade, using data from a series of nationally representative data including the National Central Cancer Registry of China (NCCR), the GLOBOCAN project and the Global Burden of Disease (GBD). Results: According to NCCR data, the age-standardized rate (ASR) of incidence increased from 12.8 in 2003 to 16.8 per 100,000 in 2011, while the ASR mortality rose from 5.9 to 7.8 per 100,000. The age group most effected by incident CRC cases were those aged 60-74 years old, whereas CRC death was most associated with those >74 years old. Furthermore, the east coast of China presented a higher ASR mortality rate (> 15 per 100,000 in men and 10-14.9 per 100,000 in women), while it was lower in central/west China (5-14.9 per 100,000 in men and 5-9.9 per 100,000 in women) (GBD 2013). Compared with other countries worldwide (GLOBOCAN 2012), China indicated lower rates of incidence, mortality, and 5-year prevalence than most other developed countries. However, China had a higher case-fatality ratio and mortality/incidence ratio than other developed countries. Lastly, Disability Adjusted Life Years attributed to CRC in China was 224.2 per 100,000, which closely resembles the US. Conclusion: This study revealed the domestic diversity of age, gender, and geography, and also presented the differences between China and developed countries. It might yield insights for national programs and policies. Key words: colorectal cancer, China, epidemiology.

599

PO 164Correlation of Epicardial Adipose Thickness with the Severity of Coronary Artery Stenosis in Stable Coronary Heart Disease Patient

Robert Noldy Ngantung (Indonesia)

Background: Epicardial adipose tissue (EAT) as part of visceral adipose tissue, has an integral role in the atherosclerotic cardiovascular disease. Previous studies have shown that EAT is thicker in those with coronary heart disease. This study is to determine the correlation of epicardial adipose thickness with the severity of coronary artery stenosis in stable coronary heart disease (CHD) patient

Method: A cross-sectional study was conducted on seventy stable CHD patient undergoing coronary angiography at PJT RSCM, Jakarta. Severity of coronary artery stenosis was evaluated using Gensini scoring system : > 40 (severe) and ≤ 40 (mild-moderate). Epicardial adipose tissue was measured using transthoracic echocardiography at end-systole from parasternal long-axis view.

Results: Mean value of epicardial adipose thickness was 5,96 mm (SD 1,76) and median value of Gensini score was 35,0 (range 2-126). The correlation test showed a significant strong-positive correlation (r = 0,768, p < 0,001). The best cut-off point of epicardial adipose thickness which has a clinical value correlating to severity of coronary artery stenosis based on Gensini scoring system was 6,15 mm with the sensitivity 85,29 %, specificity 83,33%, positive predictive value 82 %, negative predictive value 85 % and AUC of 0,893 (CI 0,814-0,971, p < 0,001)

Conclusion: picardial fat thickness is significantly correlated to the severity of coronary artery stenosis based on Gensini scoring system. The thickness cutoff point of 6,15 mm has a good capability in discriminating those stable CHD patient with Gensini score of > 40 and ≤ 40.

600

PO 165Stanford Type A Aortic Dissection May Present with Transient Loss of Consciousness

Yoshito Nishimura 1,2) Tomohiro Tsuda 2) Shinichi Nishina 2) Akiyoshi Omoto 2) Mahito Misawa 2) Hiroki Yabe 2) Toshihiko Nagao 2) Fumio Otsuka 1)

1. Department of General Medicine, Okayama University Hospital2. Ako Central Hospital

Background: Stanford Type A aortic dissection is a medical emergency which typically causes a severe chest and back pain. Although various symptoms can be assumed with the disease depending on the involved arteries, an atypical presentation still makes prompt diagnosis and treatment difficult. We report a case of transient loss of consciousness finally diagnosed with Stanford Type A aortic dissection, which suggest a clinical pearl to avoid overlooking the lethal condition.

Case: A 76 year-old male was brought to the emergency department presented with transient loss of consciousness (LOC). On the day of the presentation, he suddenly lost his consciousness while he was having breakfast. GCS was E1V1M4 and he was anisocoric at the time of contact by ambulance team. Upon arrival, his consciousness improved to E3V4M5 (approximately 10 minutes after the event). The blood pressure was 102/63 mmHg with no bilateral difference, the pulse was 74/min, the temperature was 35.4℃. He could not remember the event and had no complaints. His past medical history was unremarkable besides uncontrolled hypertension. Physical examination revealed right-sided anisocoria. Laboratory studies revealed no abnormalities including troponin I and CK-MB. Electrocardiogram revealed ST depression in II, III, aVf leads. Subsequent head CT and MRI revealed no abnormalities. After MRI, he said, “I feel slight chest pain”. Subsequent chest CT revealed Stanford A aortic dissection with cardiac tamponade. For immediate operation, he was transferred to another hospital.

Discussion: Stanford Type A aortic dissection must be taken into consideration in differential diagnosis of transient LOC. Early thrombosis of false lumen may prevent aortic tear to progress, making symptoms to be transient. Any trivial complaints of patients may be valuable to attain a diagnosis when you cannot find the reasonable explanation for them.

Poster Session

601

PO 166Beta-Blockers are Under-Prescribed in Patients with Chronic Obstructive Pulmonary Disease and Comorbid Cardiovascular Disease

Pieter Neef - Australia

Background: Cardiovascular morbidity and mortality is prevalent among patients with chronic obstructive pulmonary disease (COPD). International guidelines recommend the use of beta-blockers following acute myocardial infarction (AMI) and in heart failure with reduced ejection fraction (HFrEF). These guidelines no longer declare COPD a definite contraindication to beta-blocker therapy and there is mounting evidence for mortality benefits in this cohort. Despite this, the use of beta-blockers in patients with COPD and comorbid cardiovascular disease remains contentious. We sought to assess the rates of prescription in patients with COPD and a definite indication for beta-blocker therapy.

Methods: We conducted a retrospective cohort study across two tertiary metropolitan hospitals in Melbourne, Australia from July 2013 to June 2014. Patients were included in the study if admitted for acute exacerbations of COPD and an indication for beta-blocker therapy. Spirometry and echocardiography results were recorded, and beta-blocker use was analysed using admission medications. Data analysis was performed using χ2 test and Fisher’s exact test using two-tailed p-values.

Results: 1,071 patients were admitted for acute exacerbations of COPD with 453 (42%) identified as having an indication for beta-blocker therapy. Males accounted for 57% with a mean age of 75.4 years. A history of prior AMI was present in 373 patients (35%), 214 (20%) had HFrEF, with 114 (11%) had a history of both. In total, only 203 (45%) of these were receiving beta-blocker therapy on admission. Only 178 (48%) of patients with a prior AMI and 109 (51%) of patients with HFrEF were receiving beta-blockers.

Conclusion: Significant rates of under-prescription were evident in patients across all severities of obstructive airways disease. Given the potential mortality benefits of beta-blocker therapy in patients with COPD and comorbid cardiovascular disease, we strongly encourage clinicians to not overlook this cohort of patients and to optimise medical management of their cardiovascular disease.

602

PO 167The Evaluation of Plasma Viscosity and Endothelial Dysfunction in Smoking Individuals

Fatma Ates Alkana, Gulfidan Cakmakb, Denizhan Karisa, Zuhal Aydan Saglamc, Tayyibe Salerc, Levent Umit Temizd, Mustafa Yenigund, Meltem Ercana

a. Department of Biophysics, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey

b. Department of Respiratory Medicine, Haseki Education & Research Hospital, Istanbul, Turkey

c. Department of Family Practitioners, Haseki Education & Research Hospital, Istanbul, Turkey

d. Department of Internal Medicine, Haseki Education & Research Hospital, Istanbul, Turkey

Background: Smoking is considered to be one the of risk factors effecting atherosclerosis which is associated with the physical forces, biological and chemical stimuli occuring in vessel wall. The aim of this study is analysis of the biomechanical (plasma viscosity, PV) and biochemical effect (nitric oxide, NOX; asymmetric dimethylarginine, ADMA) of smoking on endothelial function.

Methods: One hundred-twenty two individuals were divided into three groups as ex-smokers, current-smokers and non-smokers. PV was measured by Harkness Capillary Viscometer at 37°C. Plasma NOX level was determined by enzymatic methods using commercial kits. ADMA concentration was determined by Elisa Plasma Assay. Physiologic spirometric-arterial gas parameters and pulmonary blood flow rate were measured in order to exclude chronic obstructive pulmonary disease.

Results: PV variables of ex-smokers were significantly higher than those of non-smokers (p<0.001). NOx levels were found to be statistically significantly higher when compared with current-smokers and non-smokers (p<0.001), and ex-smokers and non-smokers (p<0.05). The levels of fibrinogen was higher in current-smokers than non-smokers (p<0.05).

Conclusion: Smoking increases plasma viscosity that may lead endothelial damage. Plasma viscosity plays an important role as a biophysical mechanical marker on the behalf of hemodynamics. Biochemical markers as NOx and ADMA may show this damage. However, we observed that plasma viscosity can be consistent with biochemical markers. Thus, plasma viscosity may be useful for diagnosis, treatment and follow-up of smoking individuals.

Key words: Plasma Viscosity, Nitric Oxide, Asymmetric Dimethylarginine, SmokingThe present work was supported by the Research Fund of Istanbul University. Identification number 15364.

603

PO 168Comparison of Angiographic Patterns and Clinical Outcomes of In-Stent Restenosis between 1st and 2nd Generation Drug Eluting Stents in Real World Clinical Practice

Sangwook Kang1, Hyunok Cho2

Department of Cardiology, Daegu Veterans Hospital, Daegu, Republic of Korea1 Cardiovascular center, Andong medical group, Andong, Republic of Korea2

Backgrounds : The new, 2nd generation drug eluting stents (2nd-G DES) are characterized by improvements in stent platform, polymer, and drug, with the aim of minimizing the incidence of DES in-stent restenosis (ISR) and improving safety. However, the angiographic patterns and Clinical outcomes of ISR between 1st and 2nd-G DES in clinical practice have not been fully described yet.

Methods : A total of 573 consecutive patients with 738 coronary lesions treated with 1st-G DES (Cypher, Taxus, Endeavor, n=340) and 2nd-G DES (Promus, Xience V, Endeavor Resolute, n=233) were enrolled in this retrospective study between June 2008 to December 2011. We analyzed 57 ISR lesions after DES implantation, and compared the angiographic pattern and clinical outcomes of ISR of 1st-G DES with those of 2nd-G DES.

Results : Baseline characteristics were comparable between two stent groups. The angiographic ISR rate did not differ (9.2% in 1st-G DES vs 5.7% in 2nd-G DES, p = 0.084). Also, there were no significant differences in ISR pattern (focal 61% vs 68.8%, diffuse 39.0% vs 31.2%, p = 0.585). Among angiographic ISR lesions, ischemia-driven repeat revascularization was performed in 53.7% in 1st-G DES and 56.2% in 2nd-G DES (p = 0.86). Angiographic recurrent ISR after conventional treatment in consecutive patients were high, similarly (64.3% vs 60.0%, p = 0.58).

Conclusions : Angiographic patterns of ISR did not differ after 1st and 2nd-G DES implantation and recurrent ISR rate were similar following conventional treatment.

Keywords : drug eluting stent, in-stent restenosis

604

PO 169SODIUM LEVEL AS A PREDICTOR TO DETERMINING LENGTH OF HOSPITALIZATION IN ACUTE DECOMPENSATED HEART FAILURE

Ngakan Ketut Wira Suastika, Ni Wayan Meindra Wirtayani, Wayan Wita

Internal Medicine Departement, Udayana University Medical School/ Sanglah Hospital Denpasar, Bali, Indonesia

ABSTRACT

Hyponatremia can increase morbidity and mortality in patients with Acute Decompensated Heart Failure (ADHF). Hyponatremia was also independently associated with disease progression and decrease of survival in patients with ADHF. The study aims to determine the role of sodium level in predicting length of hospitalization in patients with ADHF. Subjects in this study were patients with ADHF who underwent treatment in Sanglah Hospital Denpasar. Sodium levels was examined when the patient admitted to hospital and then followed to determine the length of hospitalization. Multivariate linear regression analysis was used to determine the role of sodium and others factor in predicting lenghth of hospitalization. A total of 34 samples were included in this study. Through the Spearman correlation test, we obtained a significant negative correlation between sodium level and lenght of hospitalization (r = -0.478; p <0.001). Sodium levels can predict the length of hospitalization with the the regression equations: Length of hospitalization = 27.090 - 0.378(sodium level) - 0.361(hemoglobin) + 0.001(ureum level) + 0.063(serum creatinin) + 0.1(score Charlson Comorbidity Index). Based on this study, it can be concluded that sodium levels are independently associated with length of hospitalization in patients with ADHF.

Key words: sodium level, heart failure, length of hospitalization.

605

PO 170CURRENT PROFILE AND RISK FACTORS OF YOUNG PATIENTS WITH ACUTE CORONARY SYNDROME IN INDONESIA

Sally Aman Nasution1, Bhanu1, Devi Felicia1


Background: Premature Coronary Artery Disease (PCAD) is a term referred to patients less than 45 years of age suffering from coronary artery disease. It is estimated that 4-10% of individuals with CAD are in the age group of less than 45 years. The prevalence of CAD in younger subjects is difficult to establish accurately since it is frequently a silent process. Certain risk factors are thought to be mainly responsible in the development of PCAD such as hypertension and smoking habits.

Methods:The case records of patients admitted in the ICCU of Cipto Mangunkusumo Hospital, Indonesia presenting acutely with premature CAD during the period 2012-2015 were analyzed retrospectively. Data including risk factors, echocardiographic parameters, as well as vessel score and presence of left main disease were evaluated.

Results: 47 case records of PCAD were collected in this study. PCAD comprised of 3.95% from the total population. The mean age was 42.06 ± 3.17 years who were predominantly males (74.5%). PCAD had higher rates of hypertension (63.8%), dyslipidemia (51.1%) and smoking habits (55.3%) compared to diabetes mellitus (21.3%) and prior history of CAD (27.7%). In echocardiographic findings, 36.2% had ejection fraction lower than 55%, 23.4% had reduced TAPSE, 25.5% had enlarged LVDd, and 31.9% had enlarged left atrial dimension. Majority of patients had no diastolic dysfunction (55.3%) followed by mild dysfunction (40.4%). In angiographic findings, we found 2 cases (4.3%) with left main disease, vessel score evaluation showed majority of patients presented with 1 vessel disease (31.9%) followed by 3 vessel disease (29.8%).

Conclusion: In PCAD, presence of hypertension, dyslipidemia and habit of smoking identifies as a contributing factor in acquiring CAD. Echocardiographic findings showed no significant abnormalities while angiographic findings showed a predominant prevalence of CAD with 1-vessel disease followed by 3-vessel disease.

Keywords: PCAD, cardiovascular risk factors, echocardiography, angiography,

606

PO 171Clinical Profiles, Treatments Received, and Outcomes of Elderly and Non-Elderly Patients with Acute Coronary Syndrome Admitted at The Intensive Care Units of University of Santo Tomas Hospital

Eric John A. Marayag, M.D.1 Francis Marie Purino, M.D.2

1 Principal Investigator; Resident-in-Training, Department of Internal Medicine University of Santo Tomas Hospital2 Co-Investigator; Cardiologist, Section of Cardiology, University of Santo Tomas Hospi-talIntroduction: Across trials on Acute Coronary Syndrome (ACS), it has been proven that age is a powerful determinant of morbidity and mortality. However, the elderly group is underrepresented in clinical trials, which brings dilemma to many physicians whether to perform an aggressive procedure or resort only to conservative measures to prevent more harm to the elderly patient. This study compared the clinical profiles, treatments received and in-hospital outcomes of elderly and non-elderly patients with Acute Coronary Syndrome.

Methods: From June 1, 2015 to December 31, 2015, 100 patients had Acute Coronary Syndrome admitted at the Intensive Care Units of University of Santo Tomas Hospital and a total of 72 medical records were reviewed. These patients were divided into elderly ( ≥ 65 years old) and non-elderly (< 65 years old). Their clinical characteristics, treatments received, and in-hospital outcomes were compared.

Results: Of the 72 medical records reviewed; there were 42 males (58.3%) and 30 females (41.67%). Elderly females were more likely to develop Acute Coronary Syndrome. (p=0.0149) The elderly patients were less likely to receive in hospital diagnostic angiography and reperfusion (p=0.0003 for Angiography and (p= 0.002 for stenting). Treatment with Angiotensin Inhibitors was also less likely in the elderly group (p=0.038) due to a significantly lower Glomerular Filtration Rate. There was no significant difference in in-hospital mortality between the two age groups (p=0.08). However, elderly patients had a significantly higher incidence of in hospital Acute Respiratory Failure (p=0.03), Acute Kidney Injury requiring Renal Replacement Therapy (p=0.0157) and bleeding (p=0.0057).

Conclusion: Elderly patients with Acute Coronary Syndrome have significant in-hospital morbidity compared to non-elderly patients. Although adequately treated pharmacologically, elderly patients tend to be undertreated invasively.

607

PO 172A Case Of Thyroid Crisis Patients with Heart Failure and Atrial Fibrilation

Edward Putera, Rio Wironegoro, Ari Sutjahjo

Internal Medicine Department - Endocrinology DivisionMedical Faculty of Airlangga University - Dr.Soetomo General HospitalSurabaya, Indonesia

Background : A 53 years-old male was admitted to dr. Soetomo Hospital Surabaya with shortness of breath.

Case :A 53 years-old male was admitted to dr. Soetomo Hospital Surabaya with shortness of breath.The patient was diagnosed with hyperthyroid and heart failuresix months ago. Thionamide was administered for the patient,tness of but he failed to comply with all medications for the last four months due to weary of taking multiple medications at once. Shortness of breath was complaint since four months prior to admission alongside with swollen in both feet and scrotum; those complains were worsen one week prior to admission. Other complaints of thyroid are palpitations, decreased body weight regardless of diet, and intolerable to heat. Physical examinations shows irregular pulse, subfebrile 37.2 oC, dyspnea 24 times/min, increased jugular venous pressure, widening of cardiac left border, bibasal rales, and pretibial edema. TSH level was 0.018 mU/L with FT4 level of 2.17 ng/dL. Electrocardiogram shows atrial fibrilation with moderate ventricular response of 60-130 beats/minute. Chest radiography shows cardiomegaly and pulmonary congestion. Echocardiography shows dilatations of left and right atrium, left ventricle, moderate pulmonal hypertension with eccentric left ventricle hypertrophy and decreased ejection fractions of 52 %. Thyroid ultrasonography shows bilateral diffuse goitre nad non specific lymphadenopathy in left and right submandibula, submental and right supraclavicula. Burch and Wartofsky (BW) score was 50.

We started to treat the patient with hemodynamic and breathing stabilization, force diuretics, aldosterone antagonists, ACE inhibitors, thionamide, iodides one hour ofter thionamides, and corticosteroid. Beta blockers were postponed until pulmonary congestive subsided. After seven days of treatment, hyperthyroid, heart failure, and atrial fibrilation clinical sign and symptoms eased off, patient was discharged. We give the patient information and education to administer thionamide regulary in order to avoid future storm. We also suggest the patient to come to endocrinology outpatient department every 4 weeks for thyroid function monitoring.

Conclusion :A case of thyroid storm with precipitation factor of thionamide withdrawal. Although seemingly simple and often ignored, failure to give information and education to the patient could bring about atrocious complications.

608

PO 173Catheter ablation for atrial fibrillation with contact force catheters using automated annotation system (VisiTag™) : ablation lesion characteristics and short-term clinical outcome

Hyun-Ok Cho1, Hyoung-Seob Park2, Seongwook Han2, Yoon-Nyun Kim2, Sangwook Kang3

Andong Medical Group1, Keimyung University Dongsan Medical Center2, Daegu Veterans Hospital3

Background: The automated annotation system (VisiTag™ module, Biosense Webster, Inc., Diamond Bar, CA) displays ablation tags based on user-defined criteria and offers better assessment of parameters related to lesion formation during radiofrequency energy delivery. The purpose of this study was to evaluate ablation lesion characteristics and short- term clinical outcome after catheter ablation for atrial fibrillation (AF) with contact force (CF) sensing catheters using automated annotation system.

Methods: This study enrolled 30 patients (18 male [60.0%], mean age 59.9±9.7 years-old, 21 paroxysmal AF [70.0%]) who underwent circumferential pulmonary vein isolation (CPVI) for atrial fibrillation with CF sensing catheter (THERMOCOOL® SMARTTOUCH™

catheter, Biosense Webster, Inc., Diamond Bar, CA). CPVI was performed guided by automated annotation criteria with minimum time of 10 seconds, maximum range of 2mm, CF over time of 50% and minimum CF of 8g. The patients were followed for 6 months

Results: CPVI was obtained successfully without any complications in all patients. Ablation lesion analysis was performed on 5047 lesions. Mean CF during ablation was 12.8±1.5g and mean force-time integral (FTI) was 303.3±44.4 gs. Impedance drop during ablation weakly correlated with average CF (r = 0.155, P < 0.001) and FTI (r =0.222, P < 0.00). Following the 3-month blanking period, 4 patients (13.3%) patients experienced any atrial tachyarrhythmia recurrence.

Conclusion: AF ablation with CF sensing catheters using automated annotation system could be a good strategy to improve outcomes. Ablation lesion characteristics showed weak correlation between impedance drop and CF parameters.

609

PO 174THE IMPACT OF THE ECONOMIC RECESSION ON THE SURVIVAL OF OUT-OF-HOSPITAL CARDIAC ARREST VICTIMS ΙΝ A GENERAL HOSPITAL

Zisimangelos Solomos (Greece)

BACKGROUND: The aim of this study is to assess the impact of the austerity measures, implemented in the Hellenic Healthcare System, during the ongoing national economic crisis. Data from a Greek general hospital regarding the immediate and 24-hour survival of out-of-hospital cardiac arrest victims were collected.

METHODS : A retrospective study was conducted on all the patients who experienced an out-of-hospital cardiac arrest and were transferred to the emergency department of our hospital during an eight-year period (2007-2014). The cardiac arrests were divided into two four-year sessions (2007-2010 and 2011-2014). The first and the second quadrennium represented the pre-crisis and the economic crisis period respectively. Data concerning victims’ ROSC (return of spontaneous circulation) and 24-hour survival were then compared between the two periods using Z-test (two-tailed hypothesis) with p values below 0.05 being considered statistically significant.

RESULTS: The cardiac arrests of the first group were 201 versus 230 cardiac arrests of the second one. There was no significant change in ROSC (4.78% vs 1.99%, p=0.11) and 24-hour survival (3.04% vs 1.00%, p=0.14) of the out-of-hospital cardiac arrest victims that were transferred to our hospital between the 2 periods. An assumption about the victims overall survival rates being lower than 3.04% in our institution can be made.

CONCLUSIONS: The financial regulations that have been put in place in our institution due to the recent economic crisis led to no significant change in the immediate and 24-hour survival of out-of-hospital cardiac arrest victims treated in our ER department. These findings probably reflect healthcare personnel’s overexertion in order to adjust to the continuously worsening conditions due to crisis. On the other hand, overall survival in our institution remains low compared to bibliography.

610

PO 175Short and Long-Term Impact of an Heart Failure Multidisciplinary Management Program in Readmission and Costs of The Syndrome

Authors: Maria João Baldo, Rui Morais, Patrícia Vicente, Filipa Marques, Inês Araújo, Susana Quintão, Catarina Bastos, Ana Leitão, Luis Campos, Cândida Fonseca

Introduction: Heart failure (HF) is a syndrome with an increasing prevalence and high hospitalization rates, particularly early rehospitalization after discharge. The hospitalization costs 60-80% of the health budget for HF (2-3% of the health budget in developed countries).

Objectives: To compare the rate and causes of readmission of patients (pts) with HF before and after referral to a HF integrated multidisciplinary program (HFMP).

Methods: Retrospective observational study of HF pts referred consecutively to a HFMP during 3 months and followed-up during 1 year (Y). We compare the admissions and readmissions rates and causes one year before vs one year after referral to the HFMP.

Results: 124 pts included mean age 74 y, 61% male, % of pts having at least 1 hospitalization during 1 y before referral to HFMP (PreHFMP) vs % 1 y after referral (PostHFMP): 51 pts (62%) vs 28 (36%) (p = 0.0017). The main causes of1st hospitalization (1 y PreHFMP): acute pulmonary edema (APE) (19,60%), atrial fibrillation (AF) (19,60%), coronary heart disease (CHD) (17, 65%) and 1 y PostHFMP: CHD (28.75%), infection (Inf.) (21.43%), AF (17, 86%). Readmission rate PreHFMP: 75% (38 pts) vs 33% (17 pts) PostHFMP (p < 0.001).Readmission comparatively, 30 days, 6 months and 1 year, Pre vs PostHFMP respectively: 24% vs 6% (p = 0.01), 42% versus 20% (p = 0.008), 75% vs 33% (p <0.001). The main causes of readmissions PreHFMP: 21% Inf, APE 16%, 16% AF and PostHFMP: Inf 31%, 18.8% CHD, stroke 18.8%, 18.8% FA.

Conclusion: The inclusion of patients in HFMP is the key factor in reducing hospitalizations and readmissions in HF and consequently the costs of the syndrome. The infection remains a major cause of re-hospitalization. The readmissions without evident triggering factor decreased significantly after integration into multidisciplinary HF management program.

611

PO 176Correlation between serum concentrations of B-type natriuretic peptide and albumin in a Japanese hospital population

AUTHORS: Wong Toh Yoon, Yoshihiro Hata, Naoshi Ito, Yuichiro Otani, Sunao Takaya, Hirohiko Murata

AFFLILIATIONS: Department of Internal Medicine, Hiroshima Kyoritsu Hospital. Hiroshima City, Japan

Background/Rationale:Serum B-type natriuretic peptide (BNP) is a strong predictor of chronic heart failure (CHF), being used in guidelines as a biomarker for diagnosis and risk stratification. However, few studies regarding the correlation between BNP and serum albumin levels exists. Since CHF is also associated with low nutritional status, we examined the relationship between serum albumin levels and BNP in a general hospital population.Methods:1513 blood samples obtained in our hospital from 2012 to 2014 with serum albumin (g/dL), BNP (pg/dL), C-reactive protein (mg/dL) and blood urea nitrogen (mg/dL) measured were used in this study. Correlation tests and multivariate analysis was performed to evaluate the relationship between serum albumin levels and BNP.Results:Patients age ranged from 15 to 109 years old, with the mean being 76.0 ± 12.3 (SD). 774 (51.2%) samples were from males. Serum albumin levels were inversely correlated with BNP (r = -0.32, p<0.0001). After adjusting for age, gender, C-reactive protein levels (to reflect inflammation status) and blood urea nitrogen levels (to reflect hydration status), decrease in serum albumin levels were found to be associated with increase in BNP (β -0.10 [95%CI: -0.16 to -0.05], p<0.001).Conclusion:In a general hospital population, lower serum albumin levels is associated with higher BNP even after adjusting for age, gender, inflammation status and hydration status. This may in turn have a negative effect on patients with chronic heart failure. Nutrition support may play an integral role in the management of chronic heart failure.

612

PO 177Dagnostic Test of Platelet Lymphocyte Ratio for Screening of Complex Coronary Lesion in Different Age Group of Acute Coronary Syndrome

Irma Wahyuni1, Ika Prasetya Wijaya2, Lugyanti Sukrisman3, Sally Aman Nasu-tion2, Cleopas Martin Rumende4

Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospi-tal, Jakarta, IndonesiaCardiology Division, Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, IndonesiaHematology Division, Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, IndonesiaPulmonology Division, Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: A Complex coronary lesion is related to poor prognosis in ACS patient. The importance of early revascularization is to decrease mortality and complications related to ACS. Increasing number of patients due to health insurance policy in this country does not equal to the facilities available. Therefore, a specific tool is needed to stratify patients undergoing revascularization. Inflammatory marker such as PLR changes during ACS, has been known to be related to complex coronary lesions. The application of PLR in daily practice is not widely used. The different reference values of PLR from previous studies is caused by various demographics of each country. The diagnostic accuracy of this tool in Indonesia region needs evaluation. PLR is expected to be a tool that can assist physicians and cardiologists to stratify patients who have high probability for having a complex coronary lesion. Furthermore it may also help classify patients who need to be prioritized to get revascularization and reduce incidences of MACE.

Purpose: Evaluate the diagnostic accuracy of PLR in identifying a complex coronary lesion in ACS patient compared to Gensini score. The other aim was to identify the proportion of complex coronary lesion and cut-off point of PLR between ≤45 years old group and >45 years old group subjects.

Method: This is a cross sectional study which was conducted retrospectively in ACS patients from January 2012 until July 2015. The inclusion criterias are adult ACS patients (age ≥18 years old) diagnosed with ACS and who underwent coronary angiography during hospitalization. The diagnostic accuracy was determined by calculating the sensitivity, specificity, Positive Likelihood Ratio (LR+), and Negative Likelihood Ratio (LR-). The cut-off point was determined using ROC curve.

Results: The proportion of complex coronary lesion in this study was 47,2%. The optimal cut-off point in ≤45 years old group was 111,06 with sensitivity, specificity, LR+, and LR─ respectively 91,3%, 91,9%, 11,27 and 0,09. The optimal cut-off points in >45 years old

613

groups was 104,78 with sensitivity, specificity, LR+, and LR─ respectively 91,7%, 58,6%, 2,21 and 0,14.

Conclusion(s): The optimal cut-off point of ≤45 years old groups is 111,06 and for >45 years old group is 104,78. The diagnostic accuracy of PLR in ≤45 years old groups was very good (AUC 93,9%, p value <0,001), while in >45 years old group was moderate (AUC 77,3%, p value <0,001).

Keywords: PLR, complex coronary lesion, Gensini score, ACS

614

PO 178PROGNOSTIC VALUE OF INTERLEUKIN-10 FOR CARDIAC MORTALITY IN ACUTE CORONARY SYNDROMES

Joko Budiman Jong*, Idrus Alwi***Cardiologist, Medistra Hospital, Jakarta, **Division of Cardiology, Department of Internal Medicine,University of Indonesia, Dr. Cipto Mangunkusumo National Center General Hospital, Jakarta

Background. Inflammatory responses play an important role in the pathogenesis of atherosclerosis and acute coronary syndromes ( ACS ) and can predict the incidence and prognosis of ACS. The prognostic value for cardiac mortality of interleukin-10 in patients with ACS has not been reported in Indonesia .

Objective. Measuring the levels and determining the cut-off point of IL-10 in the ACS group who died and to be compared with the ACS group who survived, and comparing the survival patients of ACS by the cut-off point levels of IL-10 at the time of admission at ICCU Cipto Mangunkusumo Hospital.

Methods. This study is a cohort studies and retrospective survival analysis conducted by the collection of secondary data ( medical records ) ACS patients hospitalised in ICCU Cipto Mangunkusumo Hospital from May 2005 through May 2008. The survival analysis is done by using the survival curve from Kaplan Meier log rank test for survival differences.

Results. There were 81 ACS patients. Levels of IL-10 in the ACS group who died was significantly higher than the ACS group who survived. As a predictor of mortality in ACS , with a cut-off point : the levels of IL-10 ≥ 5.71 pg / mL (sensitivity of 80.8% and specificity 52.8%). The survival of ACS group with levels of IL-10 ≥ 5.71 pg / mL was significantly lower compared with ACS group with levels of IL-10 <5.71 pg / mL at the time of admission at ICCU Cipto Mangunkusumo Hospital.

Conclusions. In patients with ACS, levels of IL-10 has a prognostic value for cardiac mortality within 3 years .

Key words: Interleukin, cut-off point, survival, ACS (acute coronary syndromes).

615

PO 179Correlation Between Serum Ferritin With Severity Of Heart Failure Patients Hospitalized In Rsup Haji Adam MalikDairion Gatot, Ratna KarmilaHematology & Medical Oncology Division, Internal Medicine DepartmentFaculty of Medicine Universitas Sumatera Utara

Abstract

Background: Despite receiving adequate treatment, patients with heart failure still frequently complain of intolerance to activities and the mortality rate remains high. Anemia is a common comorbidity in patients with heart failure, in which numerous studies have reported the effects of anemia assessed by the iron status to the progression as well as the mortality of heart failure. In heart failure, disruption of iron homeostasis can occur in patients with or without anemia characterized by decreased iron status in circulation. Iron stores was reserved in the liver, bone marrow and spleen in the form of ferritin, a heap of iron in high concentration can cause oxidative stress and trigger cardiomyocyte necrosis. In a state of iron overload or inflammation, the expression of ferritin by tissue would increase. This study aims to understand the correlation of serum ferritin levels with severity of heart failure patients who were hospitalized in HAM hospital.

Methods: Research with cross sectional method performed on 43 patients with heart failure who were hospitalized in HAM hospital due to worsen condition of the heart failure as well as its comorbid.

Result: The results show the highest serum ferritin mean in NYHA IV (946.34 ng / dl) and positive correlation between serum ferritin with NYHA functional class, but failed to reach statistically significant values (p = 0.093). Whereas no correlations were showed between serum ferritin and left ventricular ejection fraction.

Conclusion: There is positive correlation between serum ferritin and NYHA functional class in patients with heart failure who were hospitalized in RSUP HAM Medan, but the correlation failed to achieve a statistically significant value. Further research is needed with larger samples to review the correlation between iron status and the severity of heart failure.

Keywords: ferritin serum, iron deficiency, anemia, heart failure

616

PO 180Thoracic Endovascular Aneurysm Repair and Debranching Surgery in Aortic Ascending Dissection with Pleural Effusion : A Case Report

Rinaldi*, Dono Antono*, Ismail Dilawar***Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia **Division of Cardiothoracic Surgery, Department of Surgery, Integrated Cardiac Care DR Cipto Mangunkusumo Hospital

Acute aortic dissection type A (AADA) remains a challenging and often fatal disease. Patients are mostly treated under emergency conditions. Depending of the extent of the injury, surgery consists of resection of the aortic tear and replacement of the ascending aorta, the hemi-arch or arch replacement using extracorporeal circulation and hypothermia with or without circulatory arrest. Thoracic endovascular aortic repair (TEVAR) has been rapidly embraced by physicians worldwide and is now a fixed part of the cardiovascular specialist’s armamentarium to treat acute and chronic thoracic aortic pathology. The replacement of the ascending aorta in patients who also had aneurysmal dilation of the same segment was developed. The scientific community summarizes all of these approaches with the term “hybrid technique”. Thus an entirely new approach to proximal thoracic aortic pathology was developed.

We report a patient with ascending aortic dissection with right pleural effusion. We treated him with a hybrid procedure, consisting of bypass grafting of the supra aortic branches off-pump, stent graft placement for thoracic endovascular aortic repair (TEVAR) and surgical debranching of the aortic arch. The current procedure avoids cardiopulmonary bypass and circulatory arrest, which may benefit early patient outcome; however, patient and device selection plays a key role for immediate success and midterm outcomes. In addition, precise procedural planning and development of customized stents may help to develop this procedure into a true alternative for conventional aortic arch replacement.

Keywords: Hybrid technique; TEVAR; arterial transposition

617

PO 181The Correlation of Amyloid A Serum Levels with the Degree of Coronary Artery Occlusion in Coronary Heart Desease at Cardiac Catheterization Laboratory RSMH Palembang

Ahmad Restu Iman (Indonesia)

Background : The main cause of death in developing and industrialized countries is coronary artery disease. Coronary artery disease is caused by luminal obstructive coronary artery called Atherosclerosis plaques. Coronary angiogrphy is invasive diagnostic to evaluate suspected myocardial ischemia or the degree of luminal obstructive coronary artery. Serum amyloid A (SAA) is a sensitive marker of an acute inflammatory state. It is early predictor of Atherosclerosis.

Objective : To asses the correlation between Serum amyloid A (SAA) and the degree of luminal obstructive coronary artery in the patients of coronary artery disease at Moehammad Hoesin General Hospital. Methods : A case series study has been conducted at Moehammad Hoesin Hospital from October – Desember 2015. Patients aged 30-60 years. Thirty eight subjects ran coronary angiography diagnostic measured Serum amyloid A (SAA). The data were analyzed with single sample and linear regression, by using SPSS version 20

Results : Thirty eight patients were referred for coronary angiography for suspected myocardial ischemia underwent plasma assays for SAA. The mean age was 52,84 ± 6,335 years (range 38 to 60 years), the mean Gensini score was 34,97 ± 3,24 (range 0 range114), The serum amyloid A was 1,436 ± 0,999 mg/L (range 0,2-)3,7 mg/L. There was positif correlation between gensini score and serum amyloid A (r = 0,978; p = 0,000; n = 38)

Conclusions : The results show a strong independent relationship between SAA and the degree of luminal obstructive coronary. SAA was independently but moderately associated with angiographic CAD,

Keywords : coronary artery disease, coronary angiography, Serum Amyloid A HUBUNGAN KADAR AMYLOID A SERUM DENGAN DERAJAT OKLUSI ARTERI KORONER PADA PASIEN PENYAKIT JANTUNG KORONER DI LABORATORIUM KATETERISASI JANTUNG RSMH PALEMBANG

ABSTRAK

618

Latar Belakang : Penyakit Jantung koroner merupakan penyebab kematian nomor satu di negara maju maupun sedang berkembang. Penyakit jantung koroner disebabkan oleh penumpukan lemak di dinding pembuluh darah yang disebut aterosklerosis. Angiografi merupakan pemeriksaan invasif untuk melihat derajat oklusi pada pembuluh darah koroner. Pemeriksaan Amyloid A Serum merupakan protein fase akut inflamasi spesifik terhadap aterosklerosis untuk memprediksi lebih awal adanya aterosklerosis.

Tujuan : Mengetahui hubungan kadar Amyloid A Serum dengan derajat oklusi arteri koroner pada pasien penyakit jantung koroner di RSMH Palembang.

Metode : Penelitian deskriptif dengan desain case series dengan teknik konsekutif sampling pada pasien penyakit jantung koroner berusia 30-60 tahun di ruang kateterisasi jantung RS Moehammad Hoesin Palembang dari bulan Oktober sampai Desember 2015. Sebelum dilakukan pemeriksaan angiografi dilakukan pengambilan darah untuk pemeriksaan amyloid A serum. Analisa data dilakukan dengan uji korelasi regresi linear. Dengan tingkat kemaknaan atau p 0,05 dan tingkat kepercayaan 90%.

Hasil : Tiga puluh delapan subjek yang terdiri dari laki-laki 31 orang (81,6%) dan perempuan 7 orang (18,4%). Rerata usia 52,84 ± 6,335 tahun (rentang usia 38-60 tahun), dilakukan pemeriksaan mendapatkan hasil rerata skor gensini penderita PJK sebesar 34,97 ± 3,24 dengan sebaran 0 sampai dengan 114, rerata kadar amyloid A serum penderita PJK sebesar 1,436 ± 0,999 mg/L dengan sebaran 0,2 sampai dengan 3,7 mg/L. Dari analisis didapatkan korelasi positif yang bermakna antara skor gensini dengan kadar amyloid A serum (r = 0,978; p = 0,000; n = 38)

Simpulan : Terdapat hubungan bermakna antara kadar amyloid A serum dengan derajat oklusi dengan menggunakan skor Gensini.

Kata kunci : Penyakit Jantung Koroner, Angiografi, Amyloid A Serum

619

PO 182IMPORTANCE OF EARLY DIAGNOSIS OF TUBERCULOUS MENINGITIS USING GENEXPERT MTB/RIF

Kughan Govinden1, GB Eow2, CF Cheah2

1 Department of Medicine, Penang General Hospital, Penang, Malaysia2 Department of Neurology, Penang General Hospital, Penang, Malaysia

INTRODUCTION: Tuberculous meningitis (TBM) is the most devastating consequence of infection with Mycobacterium tuberculosis (TB). Approximately a third of patients die soon after presenting to hospital, and many of those surviving are left with severe neurological sequelae.

CASE REPORT: A 27 year old Burmese gentleman presented to A&E Department with fever, loss of appetite and headache with diplopia for about 1 month. He had vomiting for 10 days and altered behavior(increased agitation) for 3 days. On examination, patient had neck stiffness with positive meningeal signs and 6th nerve palsy bilaterally. He was treated as meningoencephalitis and commenced on intravenous Ceftriaxone and Acyclovir on arrival. CT Brain with contrast done showed diffuse leptomeningeal enhancement with communicating hydrocephalus. We proceeded with lumbar puncture, which showed a very high opening pressure(above 50 mmHg). Cerebrospinal fluid(CSF) showed elevated protein(1.310) and significantly reduced glucose level. However, CSF cell count was nil with no acid fast bacteria detected on Ziehl-Neelsen smear. CSF GeneXpert MTB/RIF showed MTB detection at low level with no rifampicin resistance. Patient was commenced on anti-TB medications(Isoniazid, Rifampicin, Streptomycin and Pyrazinamide). Patient was referred to Neurosurgery Team for communicating hydrocephalus with high opening CSF Pressure. A ventriculo-peritoneal (VP) shunt was inserted. He completed intensive phase of anti-TB therapy for 2 months and then was discharged. He will be under maintenance phase of anti-TB treatment for next 10 months. His CSF Culture done in Mycobacterial Growth Indicator Tube(Bactec), which took about two weeks to be processed showed no growth.

DISCUSSION AND CONCLUSION: This case illustrates that early diagnosis of TB Meningitis is pivotal for early initiation of treatment and surgical interventions, if needed to prevent severe neurological sequelae. This case also reiterates the role of GeneXpert MTB/RIF as the most sensitive method in diagnosing TB Meningitis compared to other available diagnostic tests.

620

PO 183COMBINATION OF URINE LIPOARABINOMANNAN (LAM) RAPID TEST AND XPERT MTB/RIF FOR DIAGNOSING TUBERCULOSIS IN PATIENT WITH HUMAN IMMUNODEFICENCY VIRUS INFECTION: AN EVIDENCE-BASED CASE REPORT

I Made Ngurah Surya Adi1, Ana Ujainah2

1Faculty of Medicine Universitas Indonesia, Jakarta2Pulmonology Division of Departement of Internal Medicine Cipto Mangunkusumo Hospital, Jakarta

Correspondence mail: Faculty of Medicine, Universitas Indonesia, Jl. Salemba 6, Jakarta 10430, Indonesia. E-mail: [email protected]

Abstract:People with HIV infection will have 20-37 times risk of becoming infected TB because their immunity decreases. But in people with HIV infection, clinical symptoms are not typical and sputum smear examination tend to be negative due to the minimal production led to the diagnosis difficult enforced. This case report was made to assess the combination of Urine LAM rapid test with the Xpert MTB/RIF in detecting TB in patients with HIV infection. Literature searching was conducted through PubMed, EBSCO, and ProQuest with inclusion and exclusion criteria then obtained two corresponding articles. All articles showed high sensitivity (0,61 and 0,78) with high positive predictive value (0.93 and 0.73) and high posterior probability values (0.97 and 0.73) than Xpert MTB/RIF alone. These articles also showed good capability to exclude TB events refer to high specificity (99,1 and 86,2). Based on critical appraisal, combination of two diagnostic tests can be used as a screening method and also diagnostic test for TB infection in patients with HIV.

Keywords: HIV infection, TB infection, Urine LAM rapid test, Xpert MTB/RIF

621

PO 184ABO BLOOD GROUPS PROFILE WITH PHARMACOKINETIC OF DIHYDROARTEMISININ-PIPERAQUINE, PRIMAQUINE TO PATIENTS UNCOMPLICATEDFALCIPARUM MALARIA WITH ABO BLOOD GROUPS MALAY IN HALMAHERA INDONESIAN

Arend Laurence Mapanawang1, Mustofa, 2 Mahardika A Wijayanti,3 Rina Handayani, 4 Yuliani Mogy,5 Sarah Mapanawang, 6Alexander Maengkom,7Fernandes Sambode, 8Ernawati, 9Panji,10Henderina Maengkom, 11Yunice Barani, 12Frangki Mapanawang. 13Lukman Hakim14, Maikel Kiling15, Marjes Tumurang,16 Rasmin Hj Muthalib17.Doctoral Program of Medical and Health Sciences, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta Indonesia, Stikes Halmahera Indonesia, Midwafe Akademy Makarowo Tobelo.

Abstract

Malaria remains one of deadly diseases in Indonesia which mainly occurred in Tobelo, North Halmahera. Genetic factor is one of significant factors where the gene actingin protein and enzyme coding influences the drug pharmacokinetics. Aims, ABO Blood groups is corelated with severe malaria but not incidence However, no studies have been carried out on the pharmacokinetics of anti-malaria of dihydroartemisinin (DHA), piperaquine and primaquinein Indonesia.The purpose of this research is to know the kinetic profile of DHA-piperaquine and primaquine combination in the uncomplicated falciparum malaria, the relation of drug content, Cmax (peak content) and parasite clearance with DHA combination, and its pharmacological effects.Study and method, Random clinical tests were conducted with experimental method to 12 patients RSUD Tobelo, North Halmahera from September to December, 2014. Blood samples were taken sequentially starting from day 0 to day 28,and then thick blood drop, liver function, kidney function, leucocyte, erythrocyte and hemoglobin were tested, The samples were then tested to measure the kinetic concentration of ACT combination by using LCMS as well as analyzing the parameters of its pharmacokinetics.The results showed that the kinetic profile of DHA, piperaquine, and primaquine synergized well and it was mutually complementing where the patients were cured without any side effects. The kinetic profile of DHA, O groups (comprised of Ka (1.97 h), A (2.06 h), B (1.45) O groups Cmax (172.20 ng/ml), A (187,14), B (63.35). O groups Tmax (1.33), B (1.25 ng/mL), B (1.25). O groups t1/2 (1.02 h), A (0.96), B (0.48). O groups AUC (421.00 ng/h/L), A (346.21), O groups VD (641.70 L), O groups CL (1.399,21 L/h), A (301.89), The piperaquine kinetics consisted of O groups Ka (1.35 h), A (5.39), B (3.59) Cmax (1.553,99 ng/mL), A (1.226,94), B (1.25), Tmax (1.33 ng/mL), t1/2 (6.00 h), A (1.33), B (8.19) AUC (1.996.63 ng/h/L), A (1.400,39), B (982,46) VD O groups (1.024,45 L), A (1.598,95), B (2.310,02), CL O groups (392.85 L/h), A (429.39), B (610.71) The primaquine kinetics included O groups Ka (2.14 h), A (1.96), B (6.21), Cmax O (277.04), A (2.73 ng/mL), B (272.48), Tmax O (100), A (1.17 ug/

622

mL), B (1.25), t1/2 O (9.03 h), A (3.88), B (8.19), AUC O (995.25 ng/h/mL), A (1.327.66), B (372.93), VD O (95.92), A (46.28), B (190.18), CL O (27), A (17.80 L/h), B (48.27). Conclusion : Profil ABO Blood groups in malaria falciparum non complicated with Pharmacocinetic comparison group A higher `DHA ( ka, Cmax and T1/2), Piperakuin ( ka ), primakuin ( AUC), group B piperakuin ( VD, Cl), primakuin ( ka, T1/2, VD, Cl ) group O DHA ( VD), Piperakuin ( AUC, C max), Primakuin ( C Max)Keywords: Falciparum malaria, pharmacokinetic, DHA, Piperaquine, Primaquine, ABO Blood Groups.

623

PO 185DISSEMINATED CRYPTOCOCCUS GATTII WITH PULMONARY AND CEREBRAL INVOLVEMENT MIMICKING MALIGNANCY

Yeo Li Fang (Singapore)

We describe a case of an immunocompetent 59-year-old non-smoker who presented with chronic dry cough and left hemiplegia for three weeks. A chest radiograph showed a right lower lobe mass, and magnetic resonance imaging (MRI) of the brain showed a discrete enhancing lesion in the right centrum semiovale. The initial diagnosis was that of a primary lung carcinoma with metastases to the brain. Further investigations revealed gray round yeasts in the alveolar tissue, Cryptococcus Gattii in bronchoalveolar fungal cultures and a positive serum Cryptococcal antigen. Interestingly, the Cryptococcal antigen in our patient’s cerebrospinal fluid (CSF) turned out to be negative. The eventual diagnosis made was Pulmonary and Cerebral Cryptococcosis. This case nicely demonstrates that cryptococcal disease may not be confined only to immunocompromised hosts and the importance of a detailed history on risk factors such as travel and hobbies. Should neurological symptoms be present, imaging should also be done. Because Pulmonary Cryptococcus may mimic malignancy, one should have an index of suspicion and pursue a histological diagnosis.

624

PO 186Urine-Lipoarabinomanan As A Diagnostic Tool for Lung Tuberculosis in Human Immune Deficiency Patients.

Aulia Sandjaja, Susila Utama, Made Bagiada, Tuti Parwati, Raka Widiana, Ida IswariInternal Medicine Department. Faculty of Medicine Udayana University / Sanglah Teaching Hospital Denpasar

Background:Tuberculosis in HIV patients with low CD4 is difficult to diagnose, since the patients produced not adequate sputum for testing. Fortunatly there is another way to diagnose TB-HIV co infection by using Lipoarabinomannan (LAM) Urine assay. The aim of this study is to find out the sensitivity and specificity of LAM Urine assay in TB HIV co infection patients.

Methods:The cross sectional study was carried out in Sanglah Hospital from April to August 2015 to follow 66 HIV patients. A lateral flow (Alere Determine TB LAM Ag), with cut point +2 was used to identify the LAM in urine. All of the samples were examined their sputum in Lowenstein-Jensen (LJ) culture as gold standard in this study Finally, the study was analyzed using 2 by 2 tables.

Result:The average of CD4 was 36.42 cells/µL (21cells/ µL – 197 cells/ µL). Most of samples were not treated with ARV (92.4%) and Oral Anti Tuberculosis (87.9%). In addition 29 samples (43.9%) were positive in Mtb culture and 24 (36.4%) positive in LAM-urine testing. The sensitivity and specificity of LAM-urine test for samples with CD4 less than 50 cells/ µL was 78% and 93% respectively. In the other hand the sensitivity and specificity of LAM-urine test for samples with CD4 between 51-100 cells/ µL was 33% and 86% respectively.

Conclusion:The LAM-urine test is reliable enough to diagnose lung tuberculosis in HIV patients who are difficult to produce sputum and with CD4 below 100 cells/ µL.

Keywords: HIV, Lung tuberculosis, LAM-urine

625

PO 187The Effect of Primaquine Dosage on the Recurrence of Vivax MalariaJoonho AnDamyang Public Health Center, Jeollanam-do, Korea

Background: The recurrence rate of vivax malaria, the only endemic malaria species in the Republic of Korea, has been increasing recently. Thus, I investigated all patients with vivax malaria who visited Gimpo-Woori Hospital located in a high risk area of vivax malaria. In this study, I analyzed the effect of primaquine dosage on the recurrence of vivax malaria.Methods: I retrospectively reviewed 239 patients with vivax malaria infection diagnosed by Gimpo-Woori Hospital in the northwest of Gyeonggi-do from January 2005 to December 2011. I investigated factors related to the recurrence of vivax malaria such as age, sex, weight, residential area, total dosage of medications, time lag between symptom onset and first medication.Results: There was no significant difference in the recurrence rates according to sex. However, among male patients, the mean weight of the recurrent patients was significantly higher and the total dosage of primaquine per weight was significantly lower than non-recurrent patients. There was negative correlation between the recurrence of vivax malaria and the total dosage of primaquine per weight among male patients in the multivariate logistic regression analysis after adjusting for other variables such as age, time lag between symptom onset, first medication, and residential area (odds ratio, 0.173; 95% confi dence interval, 0.031 to 0.958).Conclusion: Insufficient dosage of primaquine affected the recurrence of vivax malaria, in this study. Therefore, the recurrence of vivax malaia could be prevented by appropriate admistration of primaquine according to the patient’s weight, especially in males.Keywords: Vivax Malaria; Recurrence; Weight; Primaquine

626

PO 188The Investigation and Management of Suspected Urinary Tract Infections at A General Hospital

Philip Chua – Australia

Background: Urinary tract infections (UTIs) are a common cause for hospital admission. Antibiotic therapy not consistent with local antimicrobial protocol may have long-term repercussions on patterns of resistance and treatment efficacy. The main objective of this study was to assess current practice within our institution pertaining to the diagnosis, investigation and treatment of UTIs, using the Australian Therapeutic Guidelines as the gold standard. Secondary objectives included obtaining demographic data and assessing UTI related morbidity/mortality.Methods: 83 patients admitted between 1/1/15 to 30/6/15 were included in the study. Inclusion criteria required a clinical diagnosis of UTI by a consultant/fellow, a positive urinalysis (ie. nitrite positive) or a positive urine culture. Patients below 17 years old, immunosuppressed, or presenting with concurrent infections were excluded.Results: Incidence of UTI in females peaked between 17-37yrs and 66-93yrs, whereas the majority of affected males were >70yrs old. All male patients with recurrent UTIs were further investigated through radiological imaging or cystoscopy. 17% of cases had associated delirium. 7% had associated falls. 20 patients were admitted for ≥4 days, wherein 95% were ≥65yrs old. 3 patients died during their admission, aged 91-93yrs. Positive nitrite results produced a specificity of 0.88 and sensitivity of 0.39 for the presence of UTI on culture. E. coli was the most common pathogen identified. Adherence rate to antibiotic guidelines was 73.5%. Amoxycillin with gentamicin comprised the most common intravenous regime. Cephalexin was the most common oral antibiotic. Only 47% of patients received the recommended antibiotic duration.Conclusion: Positive nitrate results are a specific but insensitive method of UTI detection. Education about correct antibiotic selection is essential in ensuring treatment efficacy and limiting antibiotic resistance. More effort is required in advocating appropriate antibiotic duration. UTI screening should be conducted in all elderly patients presenting with delirium and falls.

627

PO 189Characteristics of Multidrug-Resistant Tuberculosis in Semarang

Fathur Nur Kholis - Indonesia BackgroundMultidrug-resistant tuberculosis (MDR-TB) is a major public health problem and obstacle to global TB control. MDR-TB is much more difficult and costly to treat than drug susceptible TB. Indonesia has the second largest TB burden in the world and is one of the top ten highest MDR-TB countries globally. Epidemiological studies are expected to help identify high-risk populations for MDR-TB, which aims to prevent further transmission and spread of the disease.

Patients and methodsRetrospective cross-sectional study was conducted from October 2012 to June 2015. Secondary data was collected from the medical records of MDR-TB patients treated in MDR-TB Clinic of Kariadi General Hospital.

ResultA total of 62 culture confirmed MDR-TB patients were included in the study. Patient age ranged from 17 to 69 years old, and most are males (64.5%). Majority of patients came from low-income families (66.1%), have no history of MDR-TB contact (98,4%), and was underweight (61,3%). Diabetes mellitus is the most common comorbidity (43.6%), and chest radiography showed that 56.5% patients has cavity. Among all MDR-TB patients, 35.5% has chronic TB, 24.2% category 1 and 2 relapse cases, 19.4% failure of category 1 treatment, and 11.3% was previously lost to follow-up. Resistance pattern to first line drugs varies. Culture study found that 24 patients (38.7%) were RHES resistant, 16 (25.8%) were RH resistant, 11 (17.75%) were RHE resistant and 11 (17.75%) were RHS resistant.

ConclusionPrevalence of MDR-TB remains high in Semarang, thus the resistance pattern to all anti-TB drugs should be considered when choosing anti-TB regimens. Early diagnosis of MDR-TB, adequate clinical monitoring, identifying comorbidities, nutritional management, and choosing the optimal regimen for individual patients are important in controlling MDR-TB.

Keywords: tuberculosis, multidrug-resistant, epidemiology, resistance pattern

628

PO 190Clinical Audit: Analysis of levels of adherence to treatment guidelines and associated outcomes in the management of Cellulitis and Urinary tract infections in a Metropolitan Hospital in Western Australia

Jonathan Chia (Australia)

Clinical Audit: Analysis of levels of adherence to treatment guidelines

and associated outcomes in the management of Cellulitis and Urinary

tract infections in a Metropolitan Hospital in Western Australia

Jonathan Chia1, Rasiah Sureshkumar2 1Resident Medical Officer, Royal Perth Hospital, 2Consultant Physician, Armadale Health Service

Background:

Cellulitis and Urinary tract infections (UTIs) are 2 of the more common presentations

to the Emergency Department (ED) at a Metropolitan Hospital. The management of

these conditions is basic knowledge and many doctors, having practiced medicine for a

period of time, have a go-to antibiotic or management principle that they use. These

conditions may be managed as an outpatient or as an inpatient depending on severity.

Those managed as an inpatient are normally severe infections requiring intravenous

(IV) antibiotics.

Given the numerous antibiotic options available to medical personnel working at a

Metropolitan Hospital, the choice of a particular one in the empirical treatment of

cellulitis and UTIs is a difficult one. Therefore, there are guidelines available to staff to

guide them in their choice of an appropriate first-line antibiotic for the management of

these conditions. There is much debate about the adherence of clinicians to the

aforementioned guidelines as to its accuracy and effectiveness. With this in mind, a

retrospective analysis of antibiotic use in cellulitis and UTIs was performed to ascertain

the level of adherence as well as the treatment outcome for patients with one of these

two infections.

Aims and Objectives:

To ascertain whether or not there is good adherence to the Therapeutic guidelines

which are available on the WA Metropolitan Health Service intranet and assessing the

management outcome for patients who have had guideline-appropriate treatment

initiated. This audit will also look at the proportion of those treated for cellulitis and

UTIs who have had antibiotics changed either to or from those specified in the

guidelines and will aim to discuss whether or not there are better outcomes when

adhering to or when not adhering to the management set out in the guidelines.

Method:

Retrospective audit on patients who had been admitted to Armadale Health Service via

the ED as an inpatient for management of cellulitis and UTI between November 2014

and January 2015. Patient details were obtained through Medical Records as long as

there was an indication via clinical coding that the patient was treated for the two

infections during their stay – it may not have been their primary problem for presenting

629

Clinical Audit: Analysis of levels of adherence to treatment guidelines

and associated outcomes in the management of Cellulitis and Urinary

tract infections in a Metropolitan Hospital in Western Australia

Jonathan Chia1, Rasiah Sureshkumar2 1Resident Medical Officer, Royal Perth Hospital, 2Consultant Physician, Armadale Health Service

Background:

Cellulitis and Urinary tract infections (UTIs) are 2 of the more common presentations

to the Emergency Department (ED) at a Metropolitan Hospital. The management of

these conditions is basic knowledge and many doctors, having practiced medicine for a

period of time, have a go-to antibiotic or management principle that they use. These

conditions may be managed as an outpatient or as an inpatient depending on severity.

Those managed as an inpatient are normally severe infections requiring intravenous

(IV) antibiotics.

Given the numerous antibiotic options available to medical personnel working at a

Metropolitan Hospital, the choice of a particular one in the empirical treatment of

cellulitis and UTIs is a difficult one. Therefore, there are guidelines available to staff to

guide them in their choice of an appropriate first-line antibiotic for the management of

these conditions. There is much debate about the adherence of clinicians to the

aforementioned guidelines as to its accuracy and effectiveness. With this in mind, a

retrospective analysis of antibiotic use in cellulitis and UTIs was performed to ascertain

the level of adherence as well as the treatment outcome for patients with one of these

two infections.

Aims and Objectives:

To ascertain whether or not there is good adherence to the Therapeutic guidelines

which are available on the WA Metropolitan Health Service intranet and assessing the

management outcome for patients who have had guideline-appropriate treatment

initiated. This audit will also look at the proportion of those treated for cellulitis and

UTIs who have had antibiotics changed either to or from those specified in the

guidelines and will aim to discuss whether or not there are better outcomes when

adhering to or when not adhering to the management set out in the guidelines.

Method:

Retrospective audit on patients who had been admitted to Armadale Health Service via

the ED as an inpatient for management of cellulitis and UTI between November 2014

and January 2015. Patient details were obtained through Medical Records as long as

there was an indication via clinical coding that the patient was treated for the two

infections during their stay – it may not have been their primary problem for presenting

630

PO 191Assessment of Parents’ Awareness Level about Antibiotic Resistance

A.B.Kuzgibekova, B.A.Abeuova, K.A.Kenzhebayeva, G.M.Muldayeva, G.G.Eremicheva, A.E.Zhumabayeva

ABSTRACT

Background: Every year at about 90,000 of patients die due to the infectious resistant to antibiotics. Low level of parents’ awareness about antibiotic therapy leads to the development of antibiotic resistance. The aim of the current research is assessment of awareness of ill children’s parents about antibiotic resistance

Methods: we used a questionnaire which was developed by KarolinskaInstitut staff (Sweden).The study was held among 75 respondents in polyclinic N3, Karaganda.

Results: 96% of respondents knew names of antibiotics, and 4% could not say any antibiotic. Those who knew antibiotics mostly mentioned medications from penicillin (82%) and cephalosporin (53%) classes.According to respondents, 97% of children had received antibiotics: 94% of them had used its less than 10 courses, and 6% more than 10 courses.During the study it was revealed that 59% of respondents believe that antibiotic resistance can develop in people, whereas 25% claim that virus can be resistant to antibiotics, and 69% of respondents consider that bacteria is able to be resistant to antibiotics. In analyzing parents’ knowledge about antibiotic resistance it was found that only 17% of respondents knew that antibiotic usage among animals is able to decrease the antibiotic effects among people. In the study of antibiotic-resistant strains spreading it was revealed that respondents under-informed about it transmission from animal to human and from human to human (consequently 61% and 53% of uninformed respondents)In conclusion, it was read the statement that antibiotic resistance is a problem of Kazakhstan and the entire world, with these assertion agreed consequently 16% and 67% of respondents.

Conclusion: The above mentioned material is showed the lack of antibiotic resistance awareness and it development, which in the future may lead to further spreading of this problem.

631

PO 192Nonagenarian man with breast cancer, hypercoagulable state and diabetic nephropatyIndriyani H, MediartyHematology and Medical Oncology Division, Department of Internal MedicineSriwijaya University, Dr. Mohammad Hoesin General Hospital Palembang

Introduction: About 1 percent of all breast cancer cases in the U.S. occur in men. It may sound like a small number, but that’s still more than 2.000 new cases expected each year. In addition, more than 400 men in the U.S. are expected to die from breast cancer this year.

Case report: A 91-year old man came with chief complain of palpable mass in right breast when he visited his internist office for diabetes mellitus, hypertension and heart disease. The palpable mass was found to be 3 cm in the nipple. Fine needle aspiration was performed which evaluation of the specimen revealed malignant cells which may represent carcinoma. Total mastectomy was performed and the surgical pathology of the tumor showed invasive ductal carcinoma with grade III comedonal necrosis of no special type (ductal, NOS) with positive estrogen receptor, progesterone receptor and Ki 67. Echocardiography revealed ejection fraction of 51%, with SWMA. Laboratory tests showed fasting blood sugar was 105 mg/dL, 2 hours post prandial blood glucose was 177 mg/dL, HB1Ac was 6.8%, BUN was 39, serum creatinine 2,38. Valsartan 1x80 mg, aspilet 1x80 mg, gliquidone 2x30 mg and Letrozole 1 X 2,5 mg was initiated. Three months after starting the therapy, the clinical condition of the patient is improving. The Ca 15-3 and CEA were found to be 9.9 (normal is less than 30) and 2.63 respectively.

Discussion: At least 8 out of 10 breast cancers in men are invasive ductal carcinoma which may be alone or mixed with other types of invasive or in situ breast cancer. Because male breast is much smaller than female breast, all male breast cancers starts relatively close to the nipple. Therefore, they are more likely to spread to the nipple as seen in this case. Since most breast cancers in men are hormone-receptor-positive, hormonal therapy with tamoxifen or letrozole, depending on the stage, is often used.

Conclusion: We are reporting a case of a 91 year old man with right breast cancer which has been managed by total mastectomy and hormonal therapy. Three months after starting the treatment, the patient’s clinical condition is improving.

Key word: breast cancer, nonagenarian.

632

PO 193The Agreement Between Malnutrition Parameters In Tuberculosis with Diabetes Mellitus

Dinar Faricy Yaddin (Indonesia)

Tuberculosis (TB) and Diabetes Mellitus (DM) are both have a strong correlation with malnutrition, therefore assesment of nutritional status is important to start nutritional therapy. Body Mass Index (BMI), Subjective Global Assessment (SGA), serum albumin and total lymphocyte count are the tools that commonly used, but there is no currently gold standart on the assessment of nutritional status.The aim of this study is to evaluate the agreement between malnutrition parameters based on BMI, SGA, and total lymphocyte count with serum albumin in tuberculosis with diabetes mellitus patients.This study is a companion of TANDEM research in the faculty of medicine at Padjadjaran University. This is a cross-sectional study on Tuberculosis with DM patients using kappa formula to asses the agreement between BMI, SGA and total lymphocyte count with serum albumin.At the end of this study there were 64 TB patient wiht DM, 34 patients were male (53,1%) and 30 patients were female (46,9%). The mean age of the subject is 52±11years old. Malnutrition prevalence is 39,1% based on SGA; 31,3% based on serum albumin; 29,7% based on total lymphocyte count and 21,9% based on BMI. The agreement test shows that BMI and total lymphocyte count has slight agreement with albumin (k=0,208, p 0,087;k=0,078, p=0,531) while SGA has almost perfect agreement with albumin (k= 0,830, p< 0,001).The conclusion is there’s almost perfect aggrement between SGA with serum albumin on TB with DM patients. There is slight aggrement and not significant between BMI and total lymphocyte with albumin serum on TB with DM patientsKeywords : BMI, SGA, total lymphocyte count, serum albumin, TB with DM, agreement test

633

PO 194Association between Positivity Degree of Acid Bacilli,Cavity,Malnutrition,Dm,Smoking Status with Sputum Culture Conversion in The Two Month Treatment of MDR Tuberculosis

Dinar Faricy Yaddin (Indonesia)

Multidrug Resistant Tuberculosis (MDR TB) is substantial matter in preventing and curing tuberculosis program worldwide. The recovery number of MDR TB is low, the therapy is inconvenience, expensive and having more side effects. The conversion of M.tuberculosis in two months therapy could be used as the main indicator and first target in MDR therapy. This research is aimed to acknowledge the association between positivity degree of acid bacilli, cavity, malnutrition, diabetes mellitus (DM) and smoking status with two month sputum culture conversion.

This is a case control study gaining the secondary data from MDR TB patients in MDR TB clinic in Hasan Sadikin General Hospital from April 2012 to December 2014. The control group is TB MDR data which converted in 2 months therapy. The case group is TB MDR data which are not converted in two months.

There are 190 subjects divided in to case group and control group with 95 subjects in each group. The significant variable in univariate analysis is positivity degree of acid bacilli, cavity, DM and malnutrition. The analysis was then continued with logistic regression multivariable analysis, positivity degree of acid bacilli, cavity has the most significant association with two month sputum culture conversion. (sputum BTA +1 p = 0,000, OR = 5,46 ; IK 95% : 2,510-11,877, sputum BTA +2 p = 0,045, OR = 2.253 ; IK 95%: 1,017 - 4,989) and cavity (p = 0,000, OR = 3,22 ; IK 95%:1,61 - 6,45).

The conclusion of the research is positivity degree of acid bacilli and cavity has the most significant association with two month sputum culture conversion in the treatment of MDR TB patients.

Key words : Multidrug Resistant Tuberculosis (MDR TB), two month sputum culture conversion, cavity, diabetes mellitus, malnutrition, smoking

634

PO 195THE MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK IN THE FIRST SIX HOURS IN HASAN SADIKIN GENERAL HOSPITAL BANDUNG

Chevie Wirawan (Indonesia) Severe sepsis and septic shock still bring high mortality. Six hours Resuscitation Bundle is a guideline for severe sepsis and septic shock which has proved to decrease mortality. This study aimed to know the completeness of the management of severe sepsis and septic shock patients in the first six hours.. A descriptive observational study was conducted from September – December 2015. The subjects were patients with severe sepsis and septic shock who were admitted to Internal Medicine ward of Hasan Sadikin General Hospital Bandung. Patients’ general characteristics and 6-hours resuscitation bundle data were taken, consist of lactate measurement, blood culture sampling, broad spectrum antibiotics administration, fluid resuscitation, vasopressor use, CVP measurement, and Scvo2/Svo2 measurement. Eighty subjects were collected, 42 (52,5%) were women. The subjects consist of 59 (73,8%) severe sepsis and 21 (26,3%) septic shock patients. The proportion of severe sepsis patients who died in the first 6 hours was 6.8% and septic shock was 19.1%, respectively. In severe sepsis and septic shock patients, during the first 3 hours, lactate measurements were 1.7% and 14.3%, blood culture prior to antibiotic given were 16.9% and 9.5%, broad spectrum antibiotics administration were 32.2% and 42.9% , and fluid resuscitation for 30 mL/kg were 1.7% and 14.3%, respectively. In the first 6 hours for septic shock patients, vasopressor use were 61.9% and CVP measurement were 4,8%. No septic shock patients were measured Scvo2/Svo2. Conclusion : the completeness of the management of severe sepsis and septic shock patients in the first six hours was still low in our institution. Further study is needed to know the factors that made the completeness of the management of severe sepsis and septic shock in the first six hours still low.

635

PO 196Disseminated Tuberculosis presenting as splenic and lymphadenitis tuberculosis in an immunocompetent patient

Susilo Prihranto1, Nurul Akbar2, Nirwan Arief3, Daulat Manurung4, Togar Simanjuntak5, Budiawan Atjmadja6, S. Himawan7, Sutjahjo Endarjanto7

1Internal Medicine Dept. Cikini Hospital, 2Gastroenterohepatology Consultant of Internal Medicine Dept., 3Pulmonology Consultant of Internal Medicine Dept., 4Cardiology Consultant of Internal Medicine Dept. 5Surgical Oncology Consultant of Surgery Dept. 6Radiology Dept. 7Anatomic Pathology Dept. of Cikini Hospital

Introduction: Disseminated Tuberculosis (TB), especially splenic tuberculosis is a rare form of TB infection characterized by the lymphatic and hematogenous spread of Mycobacterium tuberculosis bacilli. Although the primary site of infection is usually the lung, other organs may be involved either in primary or post-primary infection.

Case Report: A 23-year-old male, from remote area of Papua was admitted with prolonged fever and hepatosplenomegaly, and suspected lymphoma and malaria. He had complaint of left abdominal pain because of enlargement of his abdomen, prolonged fever, anorexia, night sweaty, and loss of his weight. In past history, he had suffered from malaria and had no previous history of tuberculosis treatment.In physical examination we found high fever, conjunctival pallor, scleral icterus, palpable non painful-enlarged bilateral cervical, lymphadenopathy supraclavicular and inguinal lymph nodes. He had enlargement abdominal with hepatomegaly and splenomegaly. Chest examination were normal. Laboratory tests revealed thrombocytopenia (hemoglobin 12.2g%, WBC 4800/mm³, platelet 15000/mm³, ESR 54 mm/h). The liver function revealed elevation of conjugated bilirubin (total bilirubin 3.47 mg/dL, direct bilirubin 3.02 mg/dL, indirect bilirubin 0.45 mg/dL, albumin 2.4 mg/dL, SGOT 88 U/L, SGPT 47 U/L) and high LDH level (1,063 mg/dL). Hepatitis B, C and HIV tests were negative. The three times consecutive sputum smear of AFB test were negative. Blood smear of malaria Plasmodium vivax was positive.The chest x ray showed miliary appearance. The abdominal ultrasound showed hepatomegaly and multiple SOL in spleen with no ascites. The abdominal CT showed hepatosplenomegaly with multiple lesions in spleen.We performed biopsy of inguinal lymph node and spleen, and the pathological results both of them showed consistent with tuberculosis infection. This patient was treated with anti-tuberculosis that modified in the setting of liver dysfunction and artemisin-based anti malarials drugs. Bone marrow puncture was performed, and the result revealed hypercellular bone marrow consistent to hypersplenism. A surgical approach was proposed and then splenectomy due to hypersplenism was performed. Pathological examination of spleen specimen

636

revealed caseous necrosis and granulomatous formation including Datia-Langhans cells and epitheloid cell. His general condition was improved in a week after splenectomy. The CBC and liver function test examination revealed good improvement (hemoglobin 11.1 g%, WBC 9200/mm³, platelet 301000/mm³, bilirubin total 1.2 mg/dL, direct bilirubin 0.7 mg/dL, indirect bilirubin 0.5 mg/dL, albumin 2.9 mg/dL). He discharged from hospital after completed the intensive phase of anti-tuberculosis treatment.

Conclusion: Disseminated TB can mimic lymphoma and it must be considered in differential diagnosis of a huge spleen. Splenomegaly and hypersplenism can occur during disseminated tuberculosis. In this case splenectomy was performed due to hypersplenism and platelet level became normal after splenectomy.Antituberculosis drugs must be used as a primary treatment in disseminated tuberculosis.

637

PO 197EFFECT OF MEGESTROL ACETATE AGAINST DECREASED LEVELS OF TNF-α IN PATIENTS WITH AIDS WASTING SYNDROMEFadrian1, Armen Ahmad2, Nusirwan Acang3, Raveinal41. Internal Medicine Division, Medical Faculty Andalas University ,Padang, Indonesia2. Tropical Disease and Infection Subdivision, Medical Faculty Andalas University,

Padang, Indonesia3. Haematology and Medical Oncology Subdivision, Medical Faculty Andalas University,

Padang, Indonesia4. Allergy Immunology Subdivision, Medical Faculty Andalas University, Padang,

IndonesiaBackground: The presence of wasting syndrome in AIDS patients may increase morbidity and mortality. TNF-α plays an important role in the degradation process and wasting of muscle mass. Megestrol acetate, an appetite stimulant, have been used routinely in cancer patient with anorexia cachexia, but not in AIDS wasting syndrome patients. Megestrol acetate act directly in the peripheral blood mononuclear cells to inhibit the synthesis and release of TNF-α, in order to improve wasting syndrome.

Method: This study is randomized double blind controlled trial in AIDS wasting syndrome patients at M Djamil hospital, Padang, Indonesia. 16 patients were divided into 2 groups, group 1 (8 patients) were intervention group who received megestrol acetate suspension 800mg/day and standard therapy, group 2 (8 patients) were control group who only received standard therapy. TNF-α were measured at baseline then followed after 1,2,3, and 4 weeks, while body weight measured at baseline and after 4 weeks of treatment. Comparison of megestrol acetate pre and post treatment, the intervention and control group, were analyzed by General Linear Model Repeated Measured statistical analysis using SPSS program.

Result:Megestrol acetate has an effect on reduced levels of TNF-α after a week and continues until 4 weeks of usage. On this study, changes of serum TNF-α level at baseline and 1st, 2nd, 3rd, and 4th week in intervention group compared to control were (23.21;16.51;15.98;13.88;10.93) : (13.01;12.3;13.61;15.03;17.08)pg/ml (p<0.05) respectively. We also found increasing in body weight after 4 weeks administration. Change of body weight in intervention group compared to control were (39.66;44.7) : (45.62;43.9)kg (p<0.05) respectively.

Conclusion:Megestrol acetate has an effect to reduce levels of TNF-α and increase of body weight in AIDS patients in order to lower the risk of wasting syndrome. Administration of megestrol acetate can be considered for giving routinely to AIDS wasting syndrome patients.

Keywords: AIDS, Wasting syndrome, TNF-α, Megestrol acetate

638

PO 198Co-morbidity profile and Mortality among HospitalizedTuberculosis Patients : a retrospective cohort study

Agus Jati Sunggoro*, Zulkifli Amin**, Cleopas M Rumende**

* Department of Internal Medicine, Faculty of Medicine, Sebelas Maret University, Surakarta, Indonesia** Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, University of Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia

ABSTRACTBackground: Indonesia is the world’s fourth highest tuberculosis burden in the world. Tuberculosis is the second leading cause of death for all age in the country, according to the Health Ministry. Mortality remains high among tuberculosis hospitalized patients compare to the non-TB patients. The high death rate likely reflects an increase dying not only from TB, but also from co-morbid condition.Objective: To describe comorbidity profile characteristic and determine mortality rate among hospitalized tuberculosis patients in Cipto Mangunkusumo Hospital, Jakarta, Indonesia.Methods: We performed a retrospective cohort study among hospitalized TB patients in Cipto Mangunkusumo Hospital between January 2008 – September 2013. Data were collected at initiation of inpatients period and the main outcome was all-cause mortality during hospitalization. We assessed comorbidity in this study by using Charlson Comorbidity Index (CCI), a method that is used to estimate risk of death from comorbid disease. Results: A total of 470 TB patients were evaluated in this study. There were 339 (72.1%) male and 131 (27.9%) female patients. Median age of the population was 34 (range 18 to 86) years old. In-hospital mortality rate was 25.1%. Septic shock was found as the most common cause of death in this study (49.2%). The most common comorbidity faund were chronic liver disease 111 (23.6%) patients and diabetes 49 (10.4%) patients. The median CCI score was 2 (range 0-11). The percentage who died with a CCI score of 0 was 20,3%, contrast with 51.7% who died with a CCI score greater than 5.Conclusion: In-hospital mortality rate was 25.1%. Septic shock was found as the most common cause of death in this study. The most common comorbidity faund was chronic liver disease. Comorbid illness had substantial influence on patients outcome. Presence comorbid increase case fatality rate tuberculosis case.

Key words: in-hospital mortality, tuberculosis, Comorbidity, Chalson comorbidity index

639

PO 199THE DIFFICULTIES OF DIAGNOSING CYTOMEGALOVIRUS PNEUMONIA IN HIV PATIENTS : CASE REPORTS

Joyce Bratanata1, Lie Kie Chen1, Gurmeet Singh2

1. Division of Tropical and Infectious Disease, Department of Internal Medicine, Faculty of Medicine University of Indonesia

2. Division of Respirology and Critical Illness, Department of Internal Medicine, Faculty of Medicine University of Indonesia

Abstract

Opportunistic pneumonias are major causes of morbidity and mortality among HIV patients especially with advanced immunosuppression. Cytomegalovirus (CMV) pneumonia is extremely uncommon, but the diagnosis is difficult.In the first case of 63 years-old male, with three weeks of fever, cough and loss of body weight. In the second day of admission the patient become unconscious and shortness of breath. The laboratory examination revealed elevated transaminase enzymes, elevated procalcitonin serum level, reactive anti-HIV, low absolute CD4 (70 cells/uL), reactive of antitoxoplasma IgG . Head CT scan showed a space-occupaying lesion and herniation. Despite of the therapy for cerebral toxoplamosis, bacterial pneumonia, pneumocystitis pneumonia, tuberculosis and antifungal for the pneumonia, the symptoms were getting worse. The patient got intubated on the 12th day of admission. After 11 days on ventilator, the patient was deceased. Subsequently, CMV PCR was detected from the bronchoalveolar lavage.The second case of 46 years-old male, with two weeks of fever and shortness of breath. The laboratory examination revealed elevated procalcitonin serum level, reactive anti-HIV, low absolute CD4 (12 cells/uL) and bilateral opacities from chest X-ray. Although the patient already got therapy for bacterial pneumonia, pneumocystitis pneumonia and tuberculosis but the dyspnea become worse. On the fifth day of admission the patient have chest CT scan and revealed ground-glass opacities. The patient receiving parenteral ganciclovir for the CMV pneumonia and discharged from the hospital after 14 days of treatment.

Conclusion : Developing countries are facing difficulties in diagnosis of CMV pneumonia in HIV patients. This case also highlights the need for faster diagnosis of CMV in this particularly population. In worsening cases, with positive serology or CMV-PCR test result, should be treated empirically.

Keywords : Cytomegalovirus, Pneumonia, HIV

640

PO 200NEWER VIRAL INFECTION.. BANGLADESH SCENARIO

Prof. Md. Enamul KarimProfessor and Head, Department of Medicine, Dhaka Medical College, Dhaka, Bangladesh

Despite an elaborate planning and measures to tackle microbes, emerging infectious diseases remain a crucial global challenge. Emerging infections can be defined as ‘‘infections that have newly appeared in a population or have existed previously but are rapidly increasing in incidence or geographic range’’ . Infectious diseases account for 20% of global mortality, with viral diseases causing about one third of these deaths. In addition to the rapidly changing societal, environmental and behavioral patterns observed among the population of Bangladesh in the face of rapid urbanization and ever- increasing global travel and trade, there is also a dramatic rise in the spectrum of infectious diseases. Emergence/ re-emergence of several viral infections has been reported from Bangladesh in the past few decades. They include infection due to Nipah, Severe acute respiratory syndrome (SARS), Influenza H5N1, Influenza H1N1,Influenza H7N9 , Chikungunya, Human Enterovirus-71, Dengue, Japanese Encephalitis, Severe fever with thrombocytopenia syndrome (SFTS), Middle East Respiratory Syndrome Corona Virus (MERS CoV ) and Zika virus infection . This increase is a result of both the increase in the rate of emerging zoonotic infections across the globe and our enhanced ability to detect and identify agents. When considering the threat posed by emerging viruses, it is useful to divide them into three categories: newly emerging viruses, reemerging viruses , and viruses deliberately spread by bioterrorists . Recognizing this urgent need to respond to the rising threats of highly infectious viral diseases and to comply with the International Health Regulations (2005) by WHO, Bangladesh has already taken several steps to address a number of issues for maintaining a sustainable animal, human and eco-health, including proper waste disposal in laboratories and industries, hygienic animal slaughtering practices in wet markets, and monitoring of antibacterial resistance and residual effect. New technologies have expanded the sensitivity and scope of our detection and diagnostic capability. However, a pathogen may still go undetected if it does not cause a significant disease outbreak. Creating increased awareness and training of clinical microbiologists/virologists for identification of new/emerging pathogens, and prompt reporting and management of outbreaks is essential to tackle the threat posed by emerging/re-emerging infection.

641

PO 201Characteristics of Patient with Decubitus Ulcer, Bacteria and Resistence of Anti-Bacteria at Arifin Achmad General Hospital Riau Province

Ligat Pribadi S1, Rita Endriani2, Yoppy Agung3, Syahadel K3

1 Department of Internal Medicine Faculty of Medicine Riau University – Arifin Achmad General Hospital Pekanbaru2 Department of Microbiology Faculty of Medicine Riau University3 Faculty of Medicine Riau University

Background: Decubitus ulcer is a localized tissue damage caused by ischemia of the skin due to excessive external pressure in patients treated with limited activity. Decubitus ulcer infection can be caused by various types of bacteria and treated by various choices of antibacterial.

Aim of this study: The aim of this study is to determine the characteristics, bacteria that cause infection and resistance of anti-bacterial of patients with decubitus ulcer at Arifin Achmad General Hospital.

Methods: The design of this study was a descriptive study with cross sectional method in Arifin Achmad General Hospital. The object of this study was all patients with grade II, III and IV decubitus ulcers who were willing to participate in this study. The sample was taken from the ulcer’s swab. The sample was cultured, identified the type of bacteria and tested anti-bacterial sensitivity at Laboratory of Microbiology Faculty of Medicine Riau University. The results were presented in frequency tabular form and expressed as a percentage.

Results: The results showed 30 samples overall. Boys were the most dominant gender (53.33%), 46-65 age (51,85%), neurology disorders (46,67%). The highest results showed from laboratory findings are leukocyte >104 (72,73%), . The most dominant bacteria were Gram-negative bacteria (96,66%) that was Klebsiella sp (43,33%), Enterobacter sp and E. coli 13.33% each. The highest resistance of anti-bacteria was cepazolin (96,55%), tetrasiklin (93,10%) and ampicillin (89,65%), cefotaxim and ceftriaxone 86,21% each.

Conclusion: The most dominant bacteria found on swabs of decubitus ulcers were gram negative bacteria mainly Klebsiella sp and the lowest antibiotic resistance was fosfomycin.

Key words: Decubitus Ulcer, Gram-negative Bacteria, anti-Bacterial Resistance

642

PO 202A CASE OF POSSIBLE ARTEMISININ-BASED COMBINATION THERAPY—RESISTANT MALARIA WITH LOEFFLER’S SYNDROME

Faisal Parlindungan (Indonesia)Department of Internal MedicineAnuntaloko General District Hospital, Parigi-Moutong Regency, Central Sulawesi

BackgroundIndonesia is home to various tropical infection and diseases. Often there are co-infection of different organisms that complicate each other. We encountered a case of possible artemisinin-based combination therapy-resistant malaria complicated with Loeffler’s syndrome.Case presentationA 62 year old female was admitted with high grade fever with chills, headache, nausea, vomiting and dyspnea. She had a temperature of 39oC and respiratory rate of 32 breaths/min. Auscultation revealed coarse crackles in the right lower lung zone. A blood smear revealed (+) Plasmodium falciparum infection. The working diagnosis was malaria and pneumonia. The patient was given oral artemisinin-based combination therapy (ACT) and broad spectrum antibiotic. Three days later, she remained in high fever and dyspnea. A repeat blood film for malaria still showed (+) Plasmodium falciparum. The diagnosis of ACT-resistant malaria was considered and the patient was given oral quinine. The fever gradually resolved, but the patient remained dyspneic and having excessive nausea and vomiting. At the fifth day, an adult Ascaris lumbricoides was expelled from her nose. Her respiratory and gastrointestinal condition was dramatically improved. The patient was given albendazole therapy. After the oral quinine and albendazole course was finished, repeat blood film of malaria showed no parasitemia dan stool test showed no ascariasis. ConclusionThis case highlights the various tropical disease that can be encountered in Indonesia. Clinicians should be aware of the endemic status of the region. Particularly for malaria infection, close monitoring and surveillance for ACT-resistant malaria is needed. There is also a need to reassess the quality and efficacy of ACT in Indonesia.

643

PO 203ANTI-RABIES VACCINE COMPLIANCE AFTER ANIMAL BITE: LESSONS LEARNT FROM RABIES CENTER IN MAUMERE, EAST NUSA TENGGARA, INDONESIA

Lutfie*, Asep Purnama**, Candida Isabel Lopes Sam****Former General Doctor at Tjark Corneile Hillers Maumere Hospital; East Nusa Tenggara; Indonesia.** Department of Internal Medicine; Tjark Corneile Hillers Maumere Hospital; East Nusa Tenggara; Indonesia.*** Department of Neurology; Tjark Corneile Hillers Maumere Hospital; East Nusa Tenggara; Indonesia.

Corresponding author:Lutfie. Dharma Nugraha Hospital. Jalan Balai Pustaka Baru no 19 Rawamangun. Phone: +6285213508203; e-mail: [email protected].

Background: Rabies, the lethal infectious disease with 99% death rate, is still troubling Indonesia. In our workplace in Maumere, there were around 12.232 cases of animal bite and 20 deaths due to rabies confirmed for the last 15 years. As a way of post-exposure prophylaxis to prevent rabies, we have no anti-rabies immunoglobulin so it’s very obligatory that the anti-rabies vaccine be taken completely, or there will still be risk of developing rabies. In this study, we aimed to evaluate anti rabies vaccine compliance as well as factors related following animal bite cases in Maumere.

Methods: We performed a cross sectional study to analyze whether patients who took the first schedule of rabies vaccine after animal bite completed their second or third one (on day 7 or 21) according to national rabies program guideline. The study was performed in TC Hillers hospital, a rabies center in Maumere, from January 2013 to December 2015. Records of all animal bite victims were studied and data regarding their compliance for completion of vaccination schedule, sociodemographic, wound characteristic, and animal related factors were analyzed.

Results: A total of 738 patients were included in our study. The subjects were predominantly male (59,8%) aged less than 18 years old (70,9%). Almost all patients (98,5%) were bitten by dog. Only 307 patients (41,6%) completed the anti-rabies vaccine schedule. Higher proportion of compliance was found in patients with dead or killed animal during observation period (p = 0,041). The same significant result was also revealed as the compliance tended to be higher in multiple bite cases (p = 0,041). However, no significant association found between the compliance with estimated distance to rabies center, time of first vaccination, location of bite(s), wound category, and wound irrigation.

644

Conclusions: The present study showed that the compliance to anti-rabies vaccination for post-exposure prophylaxis is poor, therefore must be a cause of serious concern.

Keywords: anti rabies vaccine, animal bite, compliance.

645

PO 204Long-Term Steroid Abusers as Predictive Factor for Frailty and Subsequent Clinical Deterioration in Geriatric Population

Ricardo Adrian Nugraha1, Radityo Bagus Wicaksono1, Devianty Octavia1, Devy Putri Zennita1, Wilbert Sudihardjo1, Ira Yunita1, Gurid Anggiridiaksha1, Haykal Hekmatyar1, Nurdini Salsabilla1, Vidya Wati1, Indri Wahyuni2, Novira Widajanti3, Lilik Djuari4, Subur Prayitno4

1Faculty of Medicine, Airlangga University, Surabaya – Indonesia2Ophtalmology Department, Dr. Soetomo Hospital – Airlangga University3Geriatric Division, Internal Medicine Department, Dr. Soetomo Hospital – Airlangga University4Public Health Department, Faculty of Medicine, Airlangga University, Surabaya – Indo-nesia

Correspondence email: [email protected]

Background. Problem of long-term steroid abusers has surfaced widespread in Indonesia since a long year ago. Larger but less visible population of steroid abuse began to emerge along with the spread of uncertified traditional herbal drink. A lot of long-term steroid abusers are now entering pre-elderly and elderly age; they represent the leading wave of a new type of aging former substance abusers, with specific medical and psychiatric risks. Accumulating case reports have described functional deterioration and frailty in elderly who are long-term steroid users. However, no controlled study has assessed the history of long-term steroid abusers and comparison with non-abusers.

Objective. Analyze the relationship between frailty and subsequent clinical deterioration in long-term steroid users on pre-elderly and elderly population at Mojoagung District.

Methods. Cross-sectional study was conducted in Mojoagung District, with multi-stage cluster random sampling, collecting 63 samples. Data were collected by questionnaire to access frailty phenotype (weight loss, fatigue, slowness, weakness and low physical activity) and geriatric assessment (Activity Daily Living [Bathel Index], nutritional status [MNA], and cognitive function [MMSE]). Statistical analysis applied Pearson’s correlation, Independent Sample t-test, Chi-square test with Coefficient Contigency. 63 subjects were composed of 19 pre-elderly (55-64 years old) and 44 elderly subjects (>65 years old), 28.6% men and 71.4% women, with a mean age of 69.65 (±10.07) years.

Results. 18 of 63 subjects(28.6%) were steroid abusers for more than 30 years. Of the 18 abusers, diabetes mellitus were found in 55% subjects(n=10), whereas in non-steroid abusers, diabetes mellitus were only found in 22% subjects (p=0.010, r=+0.323, PR 2.5 [1.26-4.96; 95%CI]). Cataract were found in 12 steroid abusers(66.67%) and 17 non-

646

steroid abusers(37.78%) (p=0.038, r=+0.253, PR 1.76 [1.07-2.90; 95%CI]). Osteoporosis were found in 6 steroid abusers (33.33%) and 4 non-steroid abusers(8.89%) (p=0.016, r=+0.289, PR 3.75 [1.20-11.74; 95%CI]). Gastritis were found in 14 steroid abusers (77.78%) and 10 non-steroid abusers(22.22%) (p<0.001, r=+0.517, PR 3.50 [1.92-6.38; 95%CI]). Long-term steroid abusers were associated with higher risk of frailty and falls (PR 3.25 (95%CI 1.75-6.02); p<0.001), declining functional independency (PR 1.71 (95%CI 1.09-2.67); p=0.031), worsening nutritional status (PR 1.83 (95%CI 1.05-3.19); p=0.043), and declining cognitive function test (PR 2.50 (95%CI 1.19-5.27); p=0.017).

Conclusion. Long-term steroid abuse often manifest greater adverse effect in elderly, such as diabetes mellitus, cataract, osteoporosis, and gastritis. Steroid abuse were associated with poor results in geriatric assessment. These findings suggest necessity for limiting and monitoring distribution of steroid among uncertified traditional herbal drink and OTC drugs at market. As this wave of aging users approaches, it is important to initiate larger and more systematic studies of the long-term effects of steroid, thus we can better inform both the present and future generations.

Keywords: Elderly, Frailty, Geriatric Assessment, Nutritional Status, Steroid Abusers

647

PO 205Introduction Of Comprehensive Geriatric Assessment In A Community-Based, Primary Care Setting: Experience From Rorotan, North Jakarta

Irma Savitri Madjid (Indonesia)IEPusat Kesehatan Masyarakat Kelurahan Rorotan / Rorotan Community Health Center, Jakarta, Indonesia

Background: Increased life expectancy results in a larger proportion of the elderly, both worldwide and in Indonesia. Management of elderly patients requires a more comprehensive approach compared to adults in general. Comprehensive geriatric assessment (CGA) has shown various benefits in improving patient outcome. Nevertheless, application of CGA in primary care, especially in community-based setting, is still limited.

Methods: We introduced CGA in a nationwide community-based elderly program called “Pos Pelayanan Terpadu Lanjut Usia (Posyandu Lansia)”. We chose two Posyandu Lansia in our area and included all participants of 60 years or older. Aspects of CGA that were evaluated are functional status using Activities of Daily Living and Independent Activities of Daily Living, nutritional status using Mini Nutritional Assessment, susceptibility of depresison using Geriatric Depression Scale, cognitive status using Mini Mental State Examination, and susceptibility of elder mistreatment using the American Medical Association’s Diagnostic and Treatment Guidelines on Elder Abuse and Neglect.

Results: Out of 60 people who came during our period of data collection, only 26 people were 60 years or older and agreed to participate in our study with a gender distribution of 12 male and 14 female. We found 1 male with mild dependency based on ADL, 1 male and 3 females with partial dependency based on IADL, 6 females with increased risk of cognitive impairment, 1 female with increased risk of depression, and 1 female with both depression and elder mistreatment. Nearly half (12 out of 26) of the participants are overweight or obese.

Conclusion: Introduction of CGA in our Posyandu Lansia has revealed that elderly population in our area has several elderly-related problem that may not be seen using a general approach during day-to-day examination. Future studies may be conducted using a more sophisticated research design to explore a wider variety of CGA aspects.

648

PO 206MARFAN SYNDROME AS GENETIC DISORDER IN ADULTS AND CHILDREN BAJRAKTAREVIC ADNAN 1*, TOKIĆ URFETA 1*, BEGIĆ ZIJO 2*, ČENGIĆ ADISA 2*, ABDUZAIMOVIĆ ALISA 3* , SULJEVIĆ ISMET 4*, SOKOLOVIĆ ŠEKIB 5*, BUKSA MARKO 5*, KULIC MEHMED 5*, KACILA MIRSAD 6*, VRANIC HARIS 7*.

Public Health Institution of Health Center Sarajevo 1*, Pediatrics Clinic Sarajevo-Cardiology-Rheumatology Department 2*, Biochemical Allerology Laboratory Tešanj 3*, Clinical Medical Center Sarajevo 4*, Internal Clinic Kosevo- Cardiology Clinic 5*, Cardio Surgery Clinic Sarajevo 6*, Vascular Clinic Sarajevo 7*.

INTRODUCTION: Marfan syndrome is a genetic disorder of connective tissue. It has a variable clinical presentation, ranging from mild to severe systemic disease. The most serious manifestations involve defects of the heart valves and aorta, which may lead to early death if not properly managed. The syndrome also may affect the lungs, eyes, dural sac surrounding the spinal cord, the skeleton, and the hard palate. People and children with Marfan syndrome tend to be unusually tall, due to the disorder causing people or children with the condition to have long limbs and long, thin fingers and toes. AIMS: Marfan syndrome is inherited as an autosomal dominant condition. Approximately 25-30 percent of Marfan syndrome cases, this mutation occurs as the result of a new mutation. The risk of passing the abnormal gene from affected parent to offspring is 50 percent for each pregnancy.

METHODS: The Ghent criteria consists of major and minor criteria. The major criteria are features or symptoms common in people and children with Marfan syndrome that are rare in people or children who don’t have it. Minor criteria are features or symptoms present in people and children with Marfan syndrome, but are also present in people or children who don’t have it.

RESULTS: The heart and blood vessels or cardiovascular (97,3%), skeletal (98,9%), and eye or ocular systems (70,0%) are most often affected. To control the flow of blood through child or adult patient heart’s chambers, heart had four valves inovolved in this Marfan syndrome: mitral valve 48,4%, aortic valve 19.4%, tricuspid valve 29.3% and pulmonary valve 2,9% of our findings. Defects or disruptions or mutations of the fibrillin-1 (FBN1) gene have been linked to Marfan syndrome and related disorders.

CONCLUSIONS: Advances in the management of the cardiovascular manifestations of Marfan syndrome have led to a significant decrease in the morbidity and mortality that are associated with this condition.KEY WORDS: Marfan syndrome, Adults, Children.

649

PO 207The Effect of Therapy Spiritual Emotional Freedom Thecnique (SEFT) Changes on Blood Pressure in Elderly Hypertension Experience in Rejosari Karangan Trenggalek 2015

Dwi Septian Wijaya1, Siswanto2, Hery Wibowo3

Master Progam In Biomedical Sciences, Brawijaya University, Malang, Indonesia1

Lecture in Faculty of Medicine, Brawijaya University, Malang, Indonesia2

Emergency Departement, Balangan Hospital, South Kalimantan, Indonesia3

Email : [email protected]

Period elderly is the last period of human development. Where a person has decreased physical function and social in nature. One method to treat hypertension that is the method of Spiritual Emotional Freedom Technique (SEFT) is by tapping on the 18 key points along the body’s 12 energy pathways. This study aims to determine the effect on blood pressure SEFT method especially in the elderly with hypertension in the Rejosari Karangan Trenggalek Year 2015. The method used is pre experiment with one group pretest posttest design. The level of blood pressure before and after the therapy is given in the measure for 6 sessions in 2 weeks. That each session takes 20 minutes and blood pressure measured again. Sampling is done by simple random sampling with a sample of 16 people. Analysis of data using Shapiro Wilk test Paired T Test and analyzed using computer software obtained results ρ value (0,000) < (α = 0.05). These results indicate that SEFT therapy effective in lowering blood pressure. The analysis results showed that the therapy SEFT effectively to changes in blood pressure with values (ρ value = 0.000). Therefore SEFT therapy can be used as alternative therapy to lower blood pressure in elderly hypertensive patients. By doing non-pharmacological therapy is expected to reduce the patient’s physical complaints and can enrich the knowledge and skills.

Keywords: Hypertension, SEFT, Elderly

650

PO 208Case Report : Frailty Syndromes of Elderly with Fungal Pneumonia as One of It’s Debilitating Complications

Edwardus Setiawan - Indonesia

ABSTRACT

This case report presented about frailty syndrome in elderly who presented mainly with chronic fatigue and loss of appetite which was on its hospital course then compounded with typical fungal pneumonia due to opportunistic infection. Frailty syndrome itself is described as a distinctive health state related to ageing process in which multiple body systems gradually lose their in built reserves. Fungal pneumonia is described as infection of the lung which come from fungal origin. The highlighted part from these 2 problem would be immunocompromised state. This case report describe the clinical pathway in an elderly patient with typical presentation of frailty syndrome and an opportunistic infection that happen in immunocompromised patient as the risk factor. These data were all collected on December 2015 – January 2016 while patient was hospitalized in BIMC Hospital Kuta and data was then taken into reports afterwards.

Keynote : Frailty syndrome, elderly, fungal pneumonia, immunocompromised.

651

PO 209Transition between Frailty States and Its Prognostic Factors Among Indonesian Elderly

Siti setiati, Purwita Wijaya Laksmi, Rahmi Istanti, Tirza S Tamin, Euphemia SetoDivision of Geriatrics Department of Internal Medicine Faculty of MedicineUniversitas Indonesia

Background : The prevalence of frailty is increasing in older adults. It is a syndrome which characterized by multisystem dysfunction and associated with medical comorbidities, increased risk of disability, and mortality. Frailty is a dynamic process that can change over time, but less is known about transition between frailty states in Indonesian elderly. The aim of this study is to find transition between frailty states and its prognostic factors among Idnonesian elderly.

Methods : A prospectives cohort study (follow-up 2 years) that included 96 elderly subjects was carried out in Geriatric Clinic Cipto Mangunkusumo Hospital Jakarta. Frailty assessed every 12 months for 24 months, was defined based on Frailty Index-40 item questionaire. Transition between frailty states was defined as (1) changed of frailty status from robust/pre-frail become frailty (transition to greater frailty) or (2) from frail become pre-frail/robust or from pre-frail become robust (transition to lesser frailty) or (3) no changed in frailty states (constant frailty status). Data on age, functional status (Barthel ADL index), cognitive status (GDS score), health related quality of life (SF-12), polypharmacy, handgrip strength, gait speed (fifteen feet walking test), and commorbidities (CIRS score) were collected at baseline. Statistical analyses were performed using logistic regression to obtain prognostic factors of transition between frailty states.

Results : During a follow up of 2 years (2013-2015), proportion of elderly who had transition to lesser frailty, greater frailty, and constant frailty status were 22.0%, 29.0%, and 49.0%. In order to obtain prognostic factors of transition between frailty states, we divided transition become 2 categories that is (1) transition to lesser frailty or constant frailty status and (2) transition to greater frailty. Prognostic factors for transition between frailty states were handgrip strength (RR 0.93; 95% CI 0.86-1.03) and commorbidities (RR 1.2; 95% CI 1.05 – 1.4).

Conclusion : Frailty among elderly is a dynamic process, most of subjects in this study had constant frailty status during follow-up. Prognostic factors for transition between frailty states were handgrip strength and comorbidities.

Keywords : Transition of frailty states, elderly, handgrip strength

652

PO 210Cut- Off Point of Handgrip Strength as A Diagnostic Test for Frailty Syndrome Among Elderly People in Indonesia

Siti setiati, Purwita Wijaya Laksmi, Tirza S Tamin, Rahmi Istanti, Euphemia Seto

Division of Geriatrics Department of Internal Medicine Faculty of MedicineUniversitas Indonesia

Abstract

Background : Frailty is an important problem in elderly people and related to adverse health outcome, therefore it has to be screened and evaluated. Frailty commonly diagnosed by questionaire of Frailty Index-40 item score (FI-40) or CHS index, but asssessment using those questionaire is impractical in the clinical setting, time-consuming nature and need of trained health personnels. The role of muscle strength in frailty condition influence physical disability and mortality. Handgrip strength (HGS) is one of component for diagnostic related to loss of muscle strength. Measurement of HGS is faster and easier. The aim of this study was to determine the cut-off point and diagnostic accuracy of handgrip strength (HGS) as a frailty indicator for elderly people in Indonesia.

Method: This cross-sectional study was conducted at Geriatric Clinic Cipto Mangunkusumo Hospital Jakarta among 269 elderly patients aged 60 years old and above (106 men and 163 women). Frailty was diagnosed based on FI-40 and handgrip strength was measured using Jamar Hydraulic Hand Dynamometer Model J00105. Cut-off point and area under curve of HGS were analyzed using ROC curve and diagnostic accuracy of HGS was analyzed to generate sensitivity, specificity, PPV, and NPV.

Result: The proportion of fit/robust, pre-frail, and frailty elderly according to FI-40 were 3.7%, 71.0%, and 25.3% respectively. The optimal HGS cut-off point for elderly man was < 23.5 kgf (sensitivity 71%; specificity 58%; PPV 38%; NPV 85%) and for elderly women was < 14.5 kgf (sensitivity 82%; specificity 56%; PPV 37%; NPV 91%).

Conclusion: The optimal cut-off point of HGS as a frailty indicator for elderly people in Indonesia were < 23.5 kgf for man and < 14.5 kgf for woman. Diagnostic accuracy of HGS was good in elderly man and woman.

Keywords: handgrip strength, cut-off, frailty, elderly people

653

PO 211Validation Questionnaire Frailty Syndrome

Priyo P. Utomo1, Muhamad Apandi2, Lazuardhi Dwipa2

1Internal Medicine Departement Medical Faculty Padjadjaran University/Dr Hasan Sadikin Hospital Bandung, 2 Geriatric Division Internal Medicine Departement Medical Faculty Padjadjaran University/Dr Hasan Sadikin Hospital Bandung

ABSTRACT

Life expectancy of older adult population in the world including Indonesia hasincreased along with the incidence of Frailty Syndrome. Frailty syndrome increasesthe risk of falls, decreasing quality of life, hospitalization and mortality in olderadults. The effort to detect Frailty Syndrome is important for every healthpractitioner, but there are still difficulties in performing the avalaible tools since itrequires specific requirements, skills also relatively longer time. Therefore TheInternational Association of Nutrition and Aging has developed a questionnairenamed FRAIL Score which has been validated and much easier to perform. FRAILScore has not been validated up until now in Indonesian Language. The purpose ofthis study was to validate the FRAIL Score.This was a validation study which first underwent through an adaptation processfrom English to Indonesian language by a forward-backward translation method. Thisstudy was conducted in Geriatric Clinic of Internal Medicine Department of HasanSadikin General Hospital. The inclusion criteria were patients above 60 years old, andthere was no cognitif dysfunction. A diagnostic test was used to validate FRAILScore compare of Indonesian adapted FRAIL score with Cardiovascular Health Studyscore. Inter-reliability test was performed by Cohen’s Kappa test.Out of total 116 subjects there were 110 subjects who met the inclusion criteria.Indonesian adapted FRAIL Score questionnaire (RAPUH) had a sensitivity of 58.6%,specificity of 83.3% and the Receiving Operator Curve of 70.9% (95% CI 60.88% to91.1%) with the Likelihood Ratio of +3.52 and -0.49. Inter-reliability test resultsshowed that each item of the RAPUH questionnaire showed a good ‘perfectagreement’ with score more than 0.81.RAPUH questionnaire is a valid tool to detect Frailty Syndrome.

Keyword : FRAIL Score, eldery, Frailty Syndrome, Validation

Korespondensi : Priyo Panji Utomo, dr., Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Padjadjaran/Rumah Sakit Dr. Hasan Sadikin Bandung, Jalan Pasteur No. 38 Bandung, mobile 0811220364, e-mail [email protected]

654

PO 212Association Between Diabetes and Dementia in Geriatric Patients

Nadhira Anindita Ralena - Indonesia

Background: Number of geriatrics in the world grew rapidly in 2015, including in Indonesia. Its number is predicted to rise until 3.2 billion in 2100. The risk of dementia may increase until 24% in geriatric patients. This is one of the crucial public health concerns, since various fatal diseases, including diabetes, might cause dementia itself. Diabetes has been found in 5.6% of people in Indonesia, resulting it as one of public health concerns in Indonesia. The objective is knowing the characteristics of patients with diabetes and dementia, also showing the association between diabetes and dementia.

Methods: Obtained data is from medical records of geriatric patients in Cipto Mangunkusumo Hospital, Jakarta. Design of research is case-control. 106 samples are taken for 5 independent variables. Each population size from each variable is taken from literature reading. Then, the numbers are calculated through a formula. Total of numbers from each calculation is 53. Sample size is twice than 53 for a more valid result. Patients included in this research are all ≥60 years old and outpatients in the hospital from year 2010-2015. Data is divided into 35 case subjects (dementia patients) and 71 control subjects (non dementia patients). After that, patients history is observed, whether patients have had diabetes. Other possible risk factors, such as age, sex, hypertension, and dyslipidemia, are written as confounding variables.

Results: Logistic regression analysis shows association between diabetes and dementia with OR 2,278 (0,938;5,532). Age also acts as a contributing factor in the occurrence of dementia, pointing out OR 3,604 (1,355;9,591). Sex does not show any correlation to the occurrence of dementia with OR=1. Meanwhile, hypertension and dyslipidemia may act as inhibiting factor of dementia, showing OR<1.Findings or Conclusion: Diabetes and age are associated with dementia in geriatric patients.

655

PO 213Non-Physical Factors Associated with Malnutrition in Elderly PatientsIndra Kurniawan, Edward Jim, Ventje Kawengian

Department of Internal Medicine, Faculty of Medicine Universitas Sam Ratulangi – Prof. Dr. R.D. Kandou Hospital, Manado, Indonesia

Introduction: malnutrition still remains an important health problem in elderly patients, particularly in developing countries. The causes of malnutrition are physical and non-physical. Much of malnutrition is preventable. Several studies have suggested effective and cost-effective interventions, which are not only clinical. This study was aimed to determine non-physical factors associated with malnutrition in elderly patients. Methods: a cross-sectional study was conducted using survey to elderly patients who received health service in Prof. Dr. R. D. Kandou Hospital between October 2015 and April 2016. Their caregivers were also interviewed. Clinical, dietary, anthropometric, and laboratory data as well as comprehensive geriatric assessment were evaluated. Exclusion criteria are severe chronic illness, severe physical limitation, and severe neuropsychological problem. Non-physical factors investigated were low income, inability to obtain food appropriately, lack of social support, mild depression, mild anxiety, multiple drug use, dietary restriction, and lack of nutritional knowledge. Logistic regression analyses were performed, and odds ratios were used to determine factors associated with malnutrition.

Results: Fifty subjects were participated in this study. Factors significantly associated with malnutrition are lack of social support (p=0.04, OR=3.69, 95%CI 1.05-12.96) and lack of nutritional knowledge (p=0.02, OR=4.03, 95%CI 1.20-13.52). Conclusion: Lack of social support and lack of nutritional knowledge are non-physical factors associated with malnutrition in elderly patients.

Key words: malnutrition, elderly, non-physical factors.

656

PO 214The Beneficial Effect of Javanese Traditional Massage in Improving Dementia, Quality

of Sleep, and Quality of Life, in Geriatric Patients

Lisa Kurnia Sari*, Nyoman Kertia**, Dewa Putu Pramantara***, Setyo Purwono****, Eko Rusmiati*****, Djati Santoso******, Tia Yulviantari*******

*Internal Medicine Department, Bethesda Lempuyangwangi Hospital – Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia, **Rheumatology Division, Internal Medicine

Department, Sardjito Hospital – Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia, ***Geriatric Division, Internal Medicine Department, Sardjito Hospital – Faculty of

Medicine, Gadjah Mada University, Yogyakarta, Indonesia , ****Pharmacology Deparment, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia , *****Bethesda Community

Development Center, Yogyakarta, Indonesia, ******Nursing Department, Bethesda Hospital, Yogyakarta, Indonesia, *******Center of Traditional Medicine Development and Application

Yogyakarta Special Region, Indonesia

ABSTRACT Background Dementia is one geriatric problem in Yogyakarta. Previous study showed that Javanese Traditional Massage, combined with extract of Curcuma xanthorrhiza radix, Centella asiatica leaf, and Clarias batrachus, could improve Mini Mental State Examination (MMSE) score in geriatric patients. This study aim to know the effect of Javanese Traditional Massage alone, in improving dementia, quality of sleep, and quality of life. Methods This was an observational study conducted in Yogyakarta. Thirty-three subjects with mild to moderate dementia were treat with Javanese Traditional Massage twice weekly, for 4 weeks. Dementia, quality of sleep, and quality of life were assessed using Mini Mental State Examination (MMSE), Pittsburg Sleep Quality Index (PSQI), and Indonesian adapted-Short Form-36 (SF-36) questionnaires every two weeks (before, during, and after treatment). Eritrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Creatinine Kinase (CK), Aspartate Transaminase (AST), were also measured before and after massage to know the parameter for muscle damage. Total Antioxidant Status was measured before and after massage to know effect of Javanese Traditional Massage in antioxidant activity. Results There was improvement in MMSE score (p=0,000), before (22,06 ± 2,65), after 2 weeks (24,67 ± 3,18), and after 4 weeks massage treatment (26,58 ± 2,85). Sleep quality was also improved (p=0,024), with PSQI score 8,33 ± 3,15 before treatment, 7,15 ± 2,55 after 2 weeks treatment, and 6,79 ± 2,55 in the end of treatment. Quality of life which was measured by SF-36 score showed improvement in physical health limitation (p=0.003), energy (p=0.043), pain (p=0.014), and general health (p=0.001). There was no significant difference in physical function, emotional limitation, emotional wellness, and social function. There was significant increase in AST before (22,94 ± 16,87 mg/dL) and after (24,73 ± 17,56 mg/dL) treatment (p=0,002), and decrease in Total antioxidant Status (TAS), before (1,67 ± 0,18) and after (1,57 ± 0,09) treatment (p=0,001). Conclusions Javanese Traditional Massage could reduce dementia, improve quality of sleep, and improve quality of life, in geriatric patients. There were significant increase in AST and significant decrease of TAS in these subjects, which need further investigation.

657

The Beneficial Effect of Javanese Traditional Massage in Improving Dementia, Quality of Sleep, and Quality of Life, in Geriatric Patients

Lisa Kurnia Sari*, Nyoman Kertia**, Dewa Putu Pramantara***, Setyo Purwono****, Eko Rusmiati*****, Djati Santoso******, Tia Yulviantari*******

*Internal Medicine Department, Bethesda Lempuyangwangi Hospital – Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia, **Rheumatology Division, Internal Medicine

Department, Sardjito Hospital – Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia, ***Geriatric Division, Internal Medicine Department, Sardjito Hospital – Faculty of

Medicine, Gadjah Mada University, Yogyakarta, Indonesia , ****Pharmacology Deparment, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia , *****Bethesda Community

Development Center, Yogyakarta, Indonesia, ******Nursing Department, Bethesda Hospital, Yogyakarta, Indonesia, *******Center of Traditional Medicine Development and Application

Yogyakarta Special Region, Indonesia

ABSTRACT Background Dementia is one geriatric problem in Yogyakarta. Previous study showed that Javanese Traditional Massage, combined with extract of Curcuma xanthorrhiza radix, Centella asiatica leaf, and Clarias batrachus, could improve Mini Mental State Examination (MMSE) score in geriatric patients. This study aim to know the effect of Javanese Traditional Massage alone, in improving dementia, quality of sleep, and quality of life. Methods This was an observational study conducted in Yogyakarta. Thirty-three subjects with mild to moderate dementia were treat with Javanese Traditional Massage twice weekly, for 4 weeks. Dementia, quality of sleep, and quality of life were assessed using Mini Mental State Examination (MMSE), Pittsburg Sleep Quality Index (PSQI), and Indonesian adapted-Short Form-36 (SF-36) questionnaires every two weeks (before, during, and after treatment). Eritrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Creatinine Kinase (CK), Aspartate Transaminase (AST), were also measured before and after massage to know the parameter for muscle damage. Total Antioxidant Status was measured before and after massage to know effect of Javanese Traditional Massage in antioxidant activity. Results There was improvement in MMSE score (p=0,000), before (22,06 ± 2,65), after 2 weeks (24,67 ± 3,18), and after 4 weeks massage treatment (26,58 ± 2,85). Sleep quality was also improved (p=0,024), with PSQI score 8,33 ± 3,15 before treatment, 7,15 ± 2,55 after 2 weeks treatment, and 6,79 ± 2,55 in the end of treatment. Quality of life which was measured by SF-36 score showed improvement in physical health limitation (p=0.003), energy (p=0.043), pain (p=0.014), and general health (p=0.001). There was no significant difference in physical function, emotional limitation, emotional wellness, and social function. There was significant increase in AST before (22,94 ± 16,87 mg/dL) and after (24,73 ± 17,56 mg/dL) treatment (p=0,002), and decrease in Total antioxidant Status (TAS), before (1,67 ± 0,18) and after (1,57 ± 0,09) treatment (p=0,001). Conclusions Javanese Traditional Massage could reduce dementia, improve quality of sleep, and improve quality of life, in geriatric patients. There were significant increase in AST and significant decrease of TAS in these subjects, which need further investigation.

658

PO 215Factors Associated with Hand Grip Strength in IndonesianElderly Patients

Nur Riviati, Siti Setiati, Purwita Wijaya Laksmi

Division of Geriatric Departement of Internal MedicineFaculty of Medicine Universitas Indonesia

Background:Serious affect of the ageing process is occured in skeletal muscle. There is a decreasing of mass and muscle strength, called sarcopenia. Muscle strength is more instrumental than muscle mass as predictors of mortality and frailty status, so assessment of muscle strength becomes important. Handgrip strength can represent the overall muscle strength. The examination of handgrip strength is simple, inexpensive, and easy to do. There are many determinant factors that can influence handgrip strength. Body mass index and waist circumference still on controversy. Chronic diseases is still not observed yet. This aim of this research is to obtain determinant factors that can influence handgrip strength in elderly.

Objective : To obtain determinant factors that can influence handgrip strength in elderly and how the relationship among age, gender, waist circumference, nutritional status, and chronic diseases with handgrip strength in elderly Methods: This cross sectional study was conducted to elderly outpatient age 60 years or above who visited Geriatric Clinic Cipto Mangunkusumo Hospital Jakarta and Mohammad Hoesin Hospital Palembang in August 2015. Data of age, gender, nutritional status, chronic diseases, waist circumference, arm circumference, calf circumference, and handgrip strength were collected. Cochran Mantel Haenzel was used to obtain determinant factors of handgrip strength

Results: 269 subjects were recruited in this study. women which the most subject were 212 (60,2%), average of age was 69,7 years old (SB 6,3), average of waist circumference was 90,6 (SB 10,7), the most nutritional status was normal 304 (86,4%), the highest comorbidity was hyptertension 227 (44,3%), and average of handgrip strength were 19,8 (SB 5,1) in women and 29,1 (SB 6,9) in men. Determinant factors of handgrip strength were age (p=<0,001, PR=3,6) and nutritional status (p<0,001, PR=2,8).Conclusions: Determinand factors of handgrip strength were comorbidity (hypertension, diabetes mellitus, stroke, coronary heart disase, chronic obstructive pulmonary disease), nutritional status, and increasing of age

Key words: elderly,chronic disease ,handgrip strength

659

PO 216Association between Muscle Mass with Hands Grip Strength and Time Up Go (Tug) in Elderly Population at Banjarmasin City, A Preliminary StudyWiwit Agung Sri Nur Cahyawati (Indonesia)

Abstract Association Between Muscle Mass with Hands Grip Strength and Time Up Go

(TUG) in Elderly Population at Banjarmasin City, A Preliminary Study Wiwit Agung, I Dewa Putu Pramantara, Probosuseno

Study Program Specialistic II, Geriatric Division/Internal Medicine RSUP Dr. Sardjito, Jogjakarta

Background: Aging is connected with loss of muscle mass. This condition causes main consequences that are loss of muscle strength and limited physical performance, which impact the quality of life and functional status in elderly.The objective of this study is to find the relationship of muscle mass with hands grip strength and TUG in community-dwelling elderly subjects. Materials and methods : This was a cross-sectional study in 91 elderly subjects, which conducted on January until March 2016 at Posyandu Lansia, Banjarmasin City. Hands grip strength was measured using handsgrip dynamometer, and muscle mass was measured using BIA type Omron Karada Scan HBF-371. Data analyzed by descriptive statistic and correlation with Mommen Pearson. Result : The demografic data consisted elderly men (n=33) 36.26% and women (n=58) 63.73%. Men’s age average were 67.61±6.01 years old, and women’s were 68.12±6.79 years old. The mean of muscle mass in men was 12.83±2.75 kg, and in women was 10.27±3.47 kg. This study result the increased of age followed by decreassed of muscle mass. The mean of men’s muscle mass at age 60-79 years was 13.76±2.26 kg, 70-79 years was 11.53±3.17 kg, 80-90 years was 11.78±0.72 kg. The average hands grip strength was 20.36±6.72 kg in men and 12.77±4.38 kg in women. In statistical analysis we found positive correlation between muscle mass with hands grip strength r=0.266 (p=0.011), muscle mass with TUG r=-0.076 (p=0.473). Conclusion : Muscle mass decreased by aging. Among individuals aged 60 and older, muscle mass and hands grip strength are positively correlated. Key : muscle mass, hands grip strength, TUG

660

PO 217 POSTER PRESENTATIONPROFILE OF ADIPONECTIN SERUM AND FRAILTY IN ELDERLY PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Erika Marfiani, Jusri Ichwani, Novira Widajanti, Daniel Maranatha Division of Geriatric, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Frailty being an important geriatric syndrome, its prevalence and associated mortality risk in older patients with Chronic Obstructive Pulmonary Disease (COPD) are unknown. People with COPD experience marked deficits in muscle strength and mass, impaired functional status and underweight which places them at risk for frailty. Based on literature showed that plasma adiponectin levels in normal-weight and underweight patients with COPD were remarkably elevated. This study described profile of adiponectin serum in elderly COPD patients with frailty.

Methods: This observational descriptive cross-sectional study was carried out on 40 geriatric COPD patients. Patients underwent spirometry degree of frailty defined by the Fried criteria. Venous blood sample was obtained to measure the adiponectin serum level.

Results: Of the 40 male patients, the mean age was 70,35 ± 7,29 years. 14 patients robust, 13 patients prefrail and 13 patients frailty. The mean BMI was 21,33 ± 3,72. The mean serum level of adiponectin in 3 group of frailty elderly COPD patients are 7.35 ± 3,18, 8.41 ± 5,47, 9.76 ± 4,88 ug/ml (normal serum of adiponectin is 2.54 - 6.06 ug /ml). Serum adiponectin level different in the three group and in highest level is in frailty patients. The level of adiponectin in all three group higher than normal, its mean that in COPD patients reveal hyperadiponectinemia.

Conclusions: The higher level of adiponectin the more severe frailty condition in patients with COPD.

Key Word : Adiponectin, COPD, Frailty

661

PO 218POSTER PRESENTATIONTHE INFLAMMATORY CYTOKINE (INTERLEUKIN-6 SERUM) AND FRAILTY IN OLDER MEN RECRUITED FROM VETERAN COMMUNITY IN SURABAYA-INDONESIA

Novira Widajanti, Ari Christi Muliono, Jusri IchwaniDivision of Geriatric, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Frailty, increasingly recognized as an important and common geriatric syndrome, is identifiable by a validated set of criteria consisting of three or more of the following five measurable characteristics: slowed motor performance (by walking speed), poor endurance and energy (self-report of exhaustion), weakness (by grip strength), unintentional weight loss and low physical activity (by PASE). The chronic elevation of IL-6 encountered in many older people is much less understood. IL-6 has been implicated in the pathology of a number of chronic inflammatory conditions. This study investigated the relationship between hs IL-6 serum and frailty in older men from Veteran Community who are active in doing physical exercise regularly.

Method: This was a cross-sectional study in community-dwelling older men recruited from Veteran community in Surabaya-Indonesia. Frailty was determined using CHS criteria. hs IL-6 serum levels were measured using standard ELISA. Non parametric analysis was performed to assess the relationship between hs lL-6 serum and Frailty. Spearman Correlations performed to assess the relationship between hs IL-6 serum and measurable Frailty components. Results: Forty-three men with a median age of 67 years (range 60-76) completed the study. IMT 24,670,45 kg/m2, MNA score 27 (19-30), B-ADL were independent, MMSE score 25,91 0,344, median of grip strength 31kg (20-48), walking speed 0,81m/s (0,43-1,87), PASE scale 142 kkal/week (25-575). The prevalence of frailty was 7%. Median hs IL-6 serum 2,636 pg/ml (1,03-13,37). Hs IL-6 serum levels were significantly higher in frail older adults than those in robust and pre-frail (median 12,17 pg/ml; 2,51 pg/ml; 2,46 pg/ml, p<0,05 respectively). Sub analysis of measurable frailty component revealed positive corelation between hs IL-6 serum and age (r=0,379, p<0,05), negative correlation between hs-IL 6 serum and MNA score, grip strength, low physical activity (r= -0,399; -0,324; -0,369, p<0,05 respectively).

Conclusion: Elevated hs IL-6 serum is associated with prevalent frailty in Older Men recruited from Veteran Community in Surabaya-Indonesia.

Keyword: Interleukin-6, Frailty, Veteran Community, Older Adults

662

PO 219Endoscopy procedure related factors for sedation satisfaction in gastrointestinal endoscopy.Eun Hyo Jin1

1Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center

Introduction: Conscious sedative endoscopy is commonly performed in clinical practice. Sedative satisfaction with endoscopy is important for quality control in endoscopy center. It may be affected by various factors such as patients characteristics, procedure related factors. The aim of this study is to evaluate patient satisfaction with conscious sedative endoscopy and to determine the procedure relating factors affecting sedation satisfaction during examination.

Methods: A total of 456 outpatients who underwent endoscopy under midazolam sedation were enrolled prospectively between March 2014 and August 2014. All patients completed pre-endoscopy and post-endoscopy questionnaires about sedative satisfaction. Nurse recorded the procedure related data including midazolam dose, frequency and procedure time. The main outcome was sedative satisfaction. Univariate and multivariate proportional odds logistic models were performed to identifying the factors which were most relevant for tendency to increase satisfaction in each group.

Results: The study cohort included 167 (36.6%) esophagogastroduodenoscopy, 167 (36.6%) colonoscopy, and 122 (26.8%) combined group (esophagogastroduodenoscopy and colonoscopy together). EGD group showed most satisfied with conscious sedation, followed by combined group and colonoscopy group. In multivariate analysis, total procedure time (p=0.041) in EGD and young age (p=0.005), longer colonoscopy withdrawal time (p=0.036) in colonoscopy group were procedure related factors with decreasing satisfaction. Young age (p=0.022), longer inter-procedure time (p=0.027) and colonoscopy withdrawal time (p=0.002) were related with decreasing satisfaction in combined EGD and colonoscopy group.

Conclusions: In conclusion, sedative satisfaction appears to depend on total procedure time in EGD, age (≤50), colonoscopy withdrawal time in colonoscopy and age (≤50), colonoscopy withdrawal time and inter procedure time gap in combined group. For increasing sedative satisfaction, we pay attention to sedative status of patients who need long procedure time and consider additional dose of hypnotics.

663

PO 220CLINICAL OUTCOMES OF NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING IN PATIENTS WITH WARFARIN

Yun Duk Jung, Woo Chul Chung, Dae Bum Kim, Ji Min Lee, Yeon-Ji Kim Department of Internal Medicine,The Catholic University of Korea College of Medicine, Seoul, Korea

ABSTRACT

Background: To reduce the risk of thromboembolism, warfarin is prescribed and it is monitored by the international normalized ratio (INR). During warfarin therapy, non-variceal upper gastrointestinal bleeding (NVUGIB) is the main complication, and we aim to explore differences in clinical characteristics and outcomes of patients who were hospitalized due to NVUGIB associated with warfarin therapy.

Methods: A consecutive series of patients who had NVUGIB associated with warfarin therapy (n=63) between 2005 and 2014 was retrospectively analyzed. We evaluated the clinical characteristics and outcomes, when they were compared with the patients who were hospitalized due to NVUGIB caused by other drugs (anti-platelet agent or non-steroidal anti-inflammatory drugs, n=92).

Results: In patients with warfarin, the rate of endoscopic ulcers was 79.4%, whereas non-ulcer bleeding was 20.6%. Despite the adequate range of INR, 30.2% of patients had NVUGIB. Endoscopic hemostasis was performed in 33.3%. There were vitamin K reversal or fresh frozen plasma infusion in 57.1% and there were no thromboembolic events during bleeding episode. When they were compared with the other drug-induced NVUGIB, the frequency of endoscopic hemostasis and prevalence of ulcer bleeding were significantly low in warfarin associated bleeding (P=0.03, P<0.01, respectively). Re-admission rate was significantly high in warfarin associated bleeding (P<0.01). The age, sex, Rockall score, and re-admission rate were not different between two groups.

Conclusions: In NVUGIB with warfarin, re-admission rate was significantly high. It suggested that new drug would be substituted for warfarin.

Key Words: Gastrointestinal bleeding; Warfarin; Peptic ulcer

664

PO 221Endoscopic Biliary Stent Insertion through Duodenal Stent in Patients with Combined Malignant Biliary and Duodenal Obstruction under Stent or PTBD Guidance

Jong Jin Hyun, Jung Wan Choe, Dong-won Lee, Seung Young Kim, Sung Woo Jung, Young Kul Jung, Ja Seol Koo, Hyung Joon Yim, Hong Sik Lee, Sang Woo Lee, Chang Duck Kim

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine

Background/Rationale: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated by guidance from previously inserted stent or percutaneous transhepatic biliary drainage(PTBD) tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent(SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.

Methods: A total of 6 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of duodenal SEMS from July 2012 to December 2015 at Korea University Ansan Hospital. All patients either had previously inserted biliary SEMS, plastic stent or PTBD for guiding insertion of biliary SEMS. M-duodenal (Bonastent, Korea) SEMS, a specialized SEMS with expandable lattices in the mid portion, were used for duodenal SEMS. Technical and clinical success rate, adverse events, overall survival were evaluated.

Results: The mean age of the patients was 56.3 years(range:38-82 years). Duodenal strictures were located in the first portion of the duodenum in 1 patient (type I), in the second portion in 3 patients (type II), and in the third portion in 2 patients (type III). Technical success rate of combined metallic stenting was 100%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in 4 patients, plastic stent in 1 patient, and PTBD in 1 patient. Clinical success rate was 83.3%(5/6). There were no early adverse events. Mean survival period after combined metallic stenting was 118.6 days(range:56-245 days).

Conclusion: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance from previously inserted biliary SEMS, plastic stent or PTBD. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.

665

Key Words: Malignant biliary obstruction, Malignant duodenal obstruction, Metal stent, Guidance

666

PO 222Early vs late bedside endoscopy for gastrointestinal bleeding in critically ill patients

Joo Sung Kim, Jee Hyun Kim, Yoo Min Han, Jung Won Lee, Jaeyoung Chun, Changhyun Lee, and Jong Pil Im

Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea

Background/Aim: Gastrointestinal (GI) bleeding is an important complication in critically ill patients. The aim of this study was to compare the outcomes of early endoscopy (within 24 h of GI bleeding) with late endoscopy (after 24 h of GI bleeding) in the intensive care unit (ICU) setting.

Methods: We retrospectively reviewed the medical records of patients who underwent bedside endoscopy for non-variceal GI bleeding following ICU admission at Seoul National University Hospital from January 2010 and May 2015.

Results: 253 patients underwent bedside esophagogastroduodenoscopy (EGD) for upper GI bleeding (early, 187; late, 66) and 69 bedside colonoscopy (CS) for lower GI bleeding (early, 36; late, 33). Common endoscopic findings were peptic ulcer (34%), and acute gastric mucosal lesion (17%) in EGD group, and ischemic colitis (24%) and acute hemorrhagic rectal ulcers (20%) in CS group. Early EGD significantly increased the rate of finding bleeding focus (82% vs. 73%, p = 0.003) and endoscopic hemostasis (60% vs. 8%, p = 0.002) as compared with late EGD. However, early CS significantly decreased the rate of identifying bleeding focus (58% vs. 82%, p = 0.008) and hemostasis (7% vs. 16%, p = 0.011) because of its higher rate of poor bowel preparation and blood interference as compared with late CS. Risk factors of upper GI rebleeding were antiplatelets or anticoagulants therapy, coagulopathy, high level of BUN, and high blood transfusion requirements. In case of lower GI bleeding, coagulopathy was only significant factor associated with rebleeding.

Conclusions: Early bedside EGD is effective for diagnosis and endoscopic treatment in the ICU patients with GI bleeding. CS should be carefully performed after adequate bowel preparation.

667

PO 223The Role of Gastric Microbiota other than Helicobacter pylori in Next Generation Medicine Perspective

Michael Jonatan, Ricardo Adrian Nugraha, Firas Farisi Alkaff, Tan Nicko OctoraFaculty of Medicine, Universitas Airlangga – Surabaya, INDONESIA

Background. Human stomach holds a core microbiome. Little is known about the compositions of gastric microbiota except Helicobacter pylori in human health and disease. In this study, we aimed to explain human gastric microbiota in both gastric mucosa and gastric juice from barcoded from RT-PCR in 16S rRNA gene.

Methods. An integrated literature search identified 14 studies; after screening for relevance and quality, we identified eight peer-reviewed articles. The data were analysed with qualitative content analysis.

Results. A shift of abundance microbiota had been identified from culture-independent methods. Ten microbiota have been detected in the stomach juice and stomach mucosa: Actinobacteria, Bacteroidites, Firmicutes, Fusobacteria, Haemophilus, Prevotella, Proteobacteria, Streptococcus, Rothia, and Veillonella; nevertheless, the composition of human gastric microbiota is dynamic and have wide range variation in individualized person, affected by genetic, diet, drugs, diseases, and immunity.

Finding. Homeostasis in gastric microbiota could be essential for the maintaining human’s health by enhancing humoral immune system. Future studies concerning microbial and metabolomic profiles on gastric microbiota are needed to improve balance in gut.

Keywords: gastric microbiota, gastritis, Helicobacter pylori, peptic ulcers, stomach bacteria

668

PO 224Structural Alteration of Gut Microbiota in Colorectal Cancer Patients

Fauzi Yusuf (Indonesia)Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Medicine University of Syiah Kuala/ Dr. Zainoel Abidin General Teaching Hospital,Banda Aceh- Indonesia

Background : Colorectal cancer (CRC) is a leading cause of cancer-related mortality worldwide. The human colon is also an anatomical location with the largest number of microbes. It is natural, therefore, to anticipate a role for microbes, particularly bacteria, in colorectal carcinogenesis. Here in we reported the relation between the microbiota structures and severity of patients with colorectal cancer compared to healthy patients.

Methods : We conducted sixteen colorectal cancer and 16 healthy patients in Indonesia’s Aceh province. An exploration of the diversity and temporal stability of the dominant bacteria and several bacterial subgroups was undertaken using 16S rRNA gene denaturing gradient gel electrophoresis.

Results : Analysis of PCR-DGGE from patients and healthy patient with characteristics similar to colorectal patient was showed a different appearance. The different appearance was found on PCR product using primer for Bifidobacterium groups. Patients with colorectal cancer were not showed any band appearance. In contrast, healthy patients were showed one clear band with size + 500bp.

Conclusion : We have identified a structural imbalance of the gut microbiota, represented by the decreasing of Bifidobacterium, which may be a significant feature of human CRC.

.

669

PO 225INTERACTION BETWEEN CHRONIC NEUROINFLAMMATION AND PAROXYSMAL SYMPHATETIC HYPERACTIVITY IN HYPERTENSION

Yogi Agung Prima Wardhana[1], Ricardo Adrian Nugraha[1], Michael Jonatan[1], Radityo Bagus Wicaksono[1], Rina Judiwati[2]

[1] Faculty of Medicine, Universitas Airlangga – Surabaya[2] Department of Biomedics, Faculty of Medicine, Universitas Airlangga – SurabayaEmail: [email protected]

Introduction. There is a strong relationship between autonomic nervous system and immune systems playing a prominent role in the initiation and maintenance of hypertension and significantly contributes to cardiovascular mortality. Hypertension is associated with neuroinflammation and increased sympathetic tone. Studies have shown consistent association between hypertension, proinflammatory cytokines and the cells of the innate and adaptive immune systems. Overactivity of the renin-angiotensin system, oxidative stress, and cyclooxygenases (COX) in the brain are implicated in the pathogenesis of hypertension.

Methods. We appraised several trials from Pubmed and Cochrane database to examine sources of heterogeneity, including difference in clinical outcomes and exposure measurements. For studies that used similar sources of data over concurrent periods and similar age range, only the study with the largest data set was included in the meta-analysis.

Results. Hypertensive stimuli, such as angiotensin II, DOCA-salt, and norepinephrine, cause T cells and monocytes/macrophages to accumulate in the brain and their vascularization. These cells release inflammatory cytokines, such as IL-6, interferon-γ, and IL-17, that promote vascular hypertrophy. In rat models, hypertension exhibited significantly higher levels of TLR4 in the hypothalamus, especially in Paraventricular Nuclei (PVN). TLR4 inhibition within the PVN attenuated MAP, improved cardiac hypertrophy, reduced TNF-α, IL-1β, iNOS levels, and NFκB activity in SHR but not in WKY rats. These results were associated with a reduction in plasma NE and HMGB1 levels and an increase in IL-10 levels in SHR. We also found that hypertension, induced by either angiotensin II or l-NG-nitro-l-arginine methyl ester, is accompanied by microglial activation as manifested by microgliosis and proinflammatory cytokine upregulation.

Discussion. Inflammation of forebrain and hindbrain nuclei controlling the sympathetic nervous system (SNS) outflow from the brain to the periphery represents an emerging concept of the pathogenesis of neurogenic hypertension. Angiotensin II (Ang-II) and prorenin were shown to increase production of reactive oxygen species and pro-inflammatory cytokines (interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α)) while simultaneously decreasing production of interleukin-10 (IL-

670

10) in the paraventricular nucleus of the hypothalamus and the rostral ventral lateral medulla. Peripheral chronic inflammation and Ang-II activity seem to share a common central mechanism contributing to an increase in sympathetic neurogenic vasomotor tone and entailing neurogenic hypertension. Both hypertension and obesity facilitate the penetration of peripheral immune cells in the brain parenchyma. We suggest that renin-angiotensin-driven hypertension encompasses feedback and feedforward mechanisms in the development of neurogenic hypertension while low-intensity, chronic peripheral inflammation of any origin may serve as a model of a feedforward mechanism in this condition.

Conclusion. Hypertension alone can facilitate the penetration of peripheral immune cells in the brain parenchym. We suggest that renin-angiotensin-driven hypertension encompasses feedback and feedforward mechanisms in the development of neurogenic hypertension while low-intensity, chronic peripheral inflammation of any origin may serve as a model of a feedforward mechanism in this condition.

Keywords: Angiotensinogen, Hypertension, Neuroinflammation, Hypothalamus

671

PO 226RAPID IMMUNOCHROMATOGRAPHY STOOL ANTIGEN TEST IS INSUFFICIENT FOR DETECTING HELICOBACTER PYLORI INFECTION IN SURABAYA INDONESIA

Alida Avisiena, Ummi Maimunah, Iswan A. Nusi, Muhammad Miftahussurur, Anny Setijo Rahaju

Division of Gastro-Enterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Although histopathology is a standard method to diagnose Helicobacter pylori, it has disadvantages, such as expensive cost, requires infrastructures and trained staffs. On the other hand, rapid immunochromatography of H. pylori stool antigen is a reliable method to diagnose an active infection, which is inexpensive and easy to perform. Nevertheless it has not been adequately validated in Indonesia. The objective of this study is to determining diagnostic value of H.pylori stool antigen test by rapid immunochromatography compared with histopathology as gold standard for diagnosing H. pylori infection.

Method: Helicobacter pylori stool antigen test was determined by monoclonal based-rapid immunochromatography. The histopathological examination as gold standard was based on Updated Sydney System.

Result: Sixteen of 93 dyspeptic patients (17.2%) in Department of Internal Medicine Dr. Soetomo Hospital Surabaya Indonesia had H. pylori infection by histopathology. The sensitivity, spesificity, positive predictive value, negative predictive value and accuracy of H.pylori stool antigen test by rapid immunochromatography were 38.0%, 94.0%, 55.0%, 88.0% and 83.9 % respectively. The positive likelihood ratio was 5.8 and it would increase pre-test probability as much as 37.8%. The negative likelihood ratio was 0.68 and it would increase pre-test probability of negative H. pylori infection only as much as 5.4%.

Conclusion: Helicobacter pylori stool antigen test by monoclonal based - rapid immunochromatography was insufficient to rule out nor to rule in diagnosis of H. pylori infection in Surabaya Indonesia.

Keywords: Helicobacter pylori, H. pylori stool antigen, monoclonal antibody, rapid immunochromatography, dyspepsia

672

PO 227CORRELATION BETWEEN HELICOBACTER PYLORI DENSITY AND INTERLEUKIN-8 EXPRESSION OF GASTRIC MUCOSA IN DYPESPSIA PATIENTS

Hesti Ismarini, Iswan Abbas Nusi, Ummi Maimunah

Division of Gastro-enterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Density of Helicobacter pylori colony has been associated with worse clinical manifestation, chronic infection, uneffective therapeutic response and malignancy. Interleukin-8 (IL-8) is one of cytokine play role in inflammatory response, may induce gastric mucosal injury. Adhesin and outer membrane protein of Helicobacter pylori directly may induce IL-8 secretion. This study determined correlation between Helicobacter pylori density and IL-8 expression of gastric mucosal in dyspepsia patients in Endoscopy Unit Gastroentero-Hepatology Division of Internal Medicine Departement in Dr. Soetomo Hospital Surabaya.

Method: Cross sectional, participated by dyspepsia patients which infected by Hp in Endoscopy Unit Dr. Soetomo Hospital Surabaya. Helicobacter pylori density determined as histopathology based on Updated Sydney System. We use immunohistochemistry technique to know the expression of IL-8 from gastric biopsy specimen. The percentage of area in gastric mucosa show the expression of IL-8.

Result: We found best IL-8 expression in gland epithelial gastric mucosa (p=0.028). We also found correlation between Helicobacter pylori density and gastric mucosa IL-8 expression in gland epithelial (rs=0.622, p=0.004), surface epithelial (rs=0.510, p=0.026), and infiltration cell in lamina propria (rs=0.054, p=0.028).

Conclusion: There is significant correlation between Helicobacter pylori density and IL-8 expression of gastric mucosa in dyspepsia patients.

Keywords: Density Helicobacter pylori, Interleukin-8 expression

673

PO 228Semi-Solidified Elemental Diet to Prevent Recurrent Aspiration Pneumonia During Percutaneous Endoscopic Gastrostomy (PEG) FeedingHaruna Nakamura (Japan)Additional authors: Wong Toh Yoon, Youhei Kubota, Kazuki NishiharaCorresponding authors: Haruna NakamuraAffiliations: Hiroshima Kyoritsu Hospital, Japan

Background/Rationale: Elemental diet can be used in patients with percutaneous endoscopic gastrostomy (PEG) to reduce the risk of aspiration. It has been reported that elemental diet has more rapid gastric emptying properties and results in fewer episodes of aspiration compared to standard liquid feed in bedridden PEG patients. Semi-solid feed has also been shown to inhibit gastroesophageal reflux in PEG patients. Therefore, semi-solidified elemental diet may be the ultimate gastric feeding method for PEG patients to prevent aspiration pneumonia.

Methods: Here we report a case of a PEG patient with aspiration pneumonia who achieved stable gastric feeding using semi-solidified elemental diets. Semi-solidified elemental diet is thickened liquid elemental diet and can be infused though PEG within 15 minutes.

Results: An 86-year old man was admitted with aspiration pneumonia. He has been bedridden for 10 years and was receiving enteral nutrition through PEG using semi-solid feed. After two weeks, he recovered with the use of empirical antibiotic therapy. Because he developed aspiration pneumonia despite using semi-solid feed, we decided to switch the feed to elemental diet. However, this patient fell into a critical condition with aspiration pneumonia again. Finally we decided to change from standard liquid elemental diet to semi-solid elemental diet by adding thickening agent to the liquid elemental diet. The patient eventually achieved stable enteral feeding and was transferred to the rehabilitation ward without further complications.

Conclusion: This case report supports the use of semi-solidified elemental diet to reduce the risk of aspiration pneumonia when semi-solid feed or elemental diet does not work. Both elemental diet and semi-solid feed have their advantages in terms of preventing aspiration. Therefore, we should receive much benefit by combining both properties into our PEG feeding regimen.

674

PO 229The Association of ABO Blood Group and Helicobacter pylori Infection In Batak Toba Tribe patients, Samosir Island, North Sumatra, Indonesia

Zulkhairi, Marthin Pasaribu, Triana Silalahi, TaufikSungkar, Muhammad Miftahussurur, Ari FahrialSyam, Lukman Hakim Zain, Yoshio Yamaoka

Background: It iswell known that blood group antigens are related to the development of peptic ulcers and gastric carcinoma. Batak Toba, a predominantly ethnic in Samosir Island of Sumatra, is one of the groups with the highest prevalence of H. pylori infection in Indonesia. In addition, they had specific genotype of H. pylori than other ethnics in Indonesia. It will be interesting to know the association between H. pylori infection and ABO blood groups in Batak Toba Tribe.

Methods: A total of 50 patients of Batak Tribe with dyspeptic symptoms (25 female and 25 male; mean age of 47.64 ± 11.3 years; range, 22–73 years) were included in a cross sectional study at outpatient clinic of Hadrianus Sinaga General Hospital, Samosir Island, North Sumatra, Indonesia. H. pylori infection was diagnosed based on rapid urease test (CLO test, Kimberly-Clark, USA) results. ABO blood group phenotypes were determined by a standard hemagglutination test. The association between H. pylori infection and ABO blood group were tested using Kruskal-Wallis test.

Results: The thirty-eight of the fifty (76.0%) patients were positive for H. pylori. There was significance association between salary income and H. pylori infection (p=0.049). Among H. pylori-positive patients, the blood type O (52.7%) had tended significantly higher frequency than blood type B, A and AB (23.7%, 21.0%, 2.6%, respectively, p= 0.09). In contrast, blood type B was the predominant among H. pylori-negative patients (50.0% vs. 33.3%, 16.7% and 0.0% for blood type O, A and AB, respectively). There was no significance association between H. pylori infection and ABO blood group (p=0.37).

Conclusion: There was association between H. pylori infection with salary income. Blood group O was the predominant among H. pylori-positive patients. However, there was no significance association between ABO blood groups with H. pylori infection.

675

PO 230Use of D-dimer Assay as an Initial Investigation for Diagnosis of Pulmonary Embolism in a Metropolitan General Hospital in Perth, Western Australia

Thaminda Liyanage (Australia)

Introduction/Aim: Accurate diagnosis of pulmonary embolism (PE) remains a challenge for physicians. High index of clinical suspicion and appropriate use of investigations are keys to success.

National institute for clinical excellence (NICE) in the United Kingdom guidelines suggests performing D-dimer assay on low risk patients while high risk patients undergo imaging directly. We sought to audit the current practice in diagnosis of PE at Armadale Health Service against NICE guidelines.

Methods: We retrospectively surveyed medical records of all patients received a D-dimer test from 1st to 31st of September 2014. We extracted data on D-dimer results, evaluation of pre-test probability based on Wells criteria, subsequent imaging, final diagnosis and associated conditions potentially leading to false positive D-dimer results. Wells score was recalculated for each patient based on admission documentation. Patients received a D-dimer assay for reasons other than suspected PE were excluded from analysis. D-dimer value of >0.50mg/L was considered positive.

Results: 92 patients received a D-dimer assay in specified period. We retrieved medical records for 85 patients - 73 received a D-dimer test for suspected PE and 12 for DVT. Seven records were either in use or off-site hence unavailable to audit.

Of 73 patients, 30 had positive D-dimer results, 24 underwent imaging (21-CTPA, 3-V/Q) and five were confirmed to have PE. One patient with negative D-dimer also underwent CTPA which was negative for PE. 11 patients had acute infection at the time of D-dimer assay, 7 were positive, 4 had CTPA but none revealed PE. Wells score was documented in only three patients prior to D-dimer assay. However, based on calculated Wells score 64 had low (<4) and 9 had high (>4) probability.

Conclusion:

We identified substantial deviations from NICE guidelines in the current practice at Armadale Health Service. Introducing a local management protocol and re-audit is recommended.

Grant Support: No specific funding received for this project.

676

PO 231SERUM URIC ACID IS POSITIVELY ASSOCIATED WITH PULMONARY FUNCTION IN KOREAN HEALTH SCREENING EXAMINEES: A CROSS-SECTIONAL STUDY

1Jiwon Hwang, 2Jae-Uk Song, 2Joong Kyong Ahn1Department of Internal Medicine, National Police Hospital, 2Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

Background: Serum uric acid (SUA) has double-edged characteristics. Recent studies suggest that hyperuricemia may be an independent risk factor for impaired pulmonary function in the general population while in view of its antioxidant properties, uric acid potentially has important beneficial effects within the respiratory system. The aim of this study was to determine whether level of SUA, a potent antioxidant, is linked to pulmonary function in health screening examinees without overt clinical disease.

Methods: We performed a cross-sectional study on 69,928 Koreans without overt medical conditions who underwent a health examination in 2010.

Results: A total of 30,572 male and 39,356 female subjects enrolled (median age 40 (range 35-46). The overall prevalence of hyperuricemia was 25.5% in males and 8.5% in females. Increasing age was positively associated with SUA level. In sex-stratified analyses of SUA level, mean SUA level was positively associated with a quartile increase in FVC% and FEV1% in both genders (P < 0.001). There were also a significant positive correlation between SUA level and spirometric measures (FEV1% or FVC%) in both genders (FVC%, r = 0.361; FEV1% r = 0.314 in men and FVC%, r = 0.413; FEV1%, r = 0.382 in women). Multiple regression analysis was performed to assess whether FEV1% and FVC% were independently associated with the prevalence of hyperuricemia. The adjusted ORs for hyperuricemia comparing quartiles 2, 3, and 4 to quartile 1 (the reference group, highest quartile) of FVC% in men were 0.876 (95% CI, 0.809-0.949), 0.631 (0.574-0.695), and 0.311 (0.278-0.349), respectively. The adjusted ORs for hyperuricemia comparing quartiles 2, 3, and 4 to quartile 1 of FEV1% in men were 0.791 (95% CI, 0.729-0.859), 0.565 (0.513-0.623), and 0.302 (0.270-0.337), respectively (p for trend <0.001). Similarly, the adjusted ORs of hyperuricemia in women decreased significantly across quartiles 2 to 4 of FEV1% and FVC % compared with the highest quartile as the reference group (P for trend <0.001).

Conclusions: SUA was positively associated with FVC% and FEV1% in a healthy Korean population. This finding has important implications for the hypothesis that hyperuricemia might have a favorable effect on lung function. Longitudinal follow-up studies and prospective interventional studies are required to confirm this positive association between SUA and lung function.

677

PO 232DIFFERENCES IN LUNG FUNCTION IN VARIOUS DEGREES OF PULMONARY TUBERCULOSIS SEQUELAE

Eko Budiono, Ika Trisnawati, Sumardi, Iwandheny Sepmeitutu

Pulmonology Departement of Internal Medicine Dr. Sardjito Hospital, Faculty of MedicineGadjah Mada University.YogyakartaIndonesia

Tuberculosis remains a global health problem for developing countries, especially in Indonesia which is the fifth highest in the world. Tuberculosis sequelae can occur on most patients who experienced healing after treatment. Tuberculosis sequelae changes cause changes in the lungs so that the decline in lungThis study aims to determine differences in lungfunction, forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) at various degrees of sequelae tuberkulosis.Desain this is a cross-sectional study in an outpatient BP4 Yogyakarta from September 2013 until the sample met. Differences were analyzed by t- test and analysis of normality with Shapiro-Wilk test. Significant difference when P<0.05 with 95% confidence intervals.

Results: the study subjects were 44 patients consisted of 29 (65,8%) males and 15 (34,1%) women. Subjects who met the criteria examined thoracic images posteroanterior (PA). The degree of severity of thoracic images assessed by Willcox index. Spirometry tests performed to get an overview of lung function such as FEV1 and FVC. Basic characteristics of the study subjects according to pulmonary function abnormalities restriction showed at most that 28(63,6%). Significant differences in FEV1 lung function in mild degree with severe degree (p = 0,024) and FVC significantly in lung function in mild degree with severe degree (p = 0,031).

Conclusion: There are significant differences in lung function, FEV1 and FVC at mild degree by severe degree.

Keywords: Tuberculosis sequelae, pulmonary function, Willcox index

678

PO 233Pulmonary Embolism in Young Adult : A Case Report

Sri Shujuan1, Hanafi B. Trisnohadi21Department of Internal Medicine, Medistra Hospital, Jakarta, Indonesia2Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta

Background :Pulmonary embolism (PE) presents with a wide spectrum of illness ranging from mild to severe. The differential diagnosis of PE covers a spectrum from life threatening disease such as acute myocardial infarction (AMI) to innocuous anxiety states.

Case Presentation :A 31 years old Caucasian male was admitted with dyspnea since two weeks before. No history of cough and fever. He had dyslipidemia, no family history of coronary disease. His hemodynamic was stable, chest Xray showed upper normal limit heart size and lungs were normal. The ECG revealed negative T wave in lead V1-V3. The CK and CKMB were normal, but the hs-troponin I was slighty increased. We performed cor angiography and since the result was normal, he was discharged with atypical chest pain as the last diagnosis. One month later, he came with worsening dyspnea and leg discomfort. He told us that his father and siblings had a hypercoagulable condition. His hemodynamic was stable but his oxygen saturation was 90-91%. The ECG and chest Xray were similar to the previous one. D dimer level, hs-troponin I, and BNP were raised, so considering these findings, we could not exlude the possibility of PE. There was no right ventricle enlargement from the echocardiography. The doppler examination of the venous vessels of the lower extremities was normal. The CT angiography revealed positive sign of bilateral PE in the main pulmonary arteries, especially in the right one. So an intravenous unfractionated heparin under control of aPTT was administered. After 20 days of hospitalization the patient was discharged from the hospital in good general condition with the recommendation of LMWH therapy.

Conclusion :PE should be considered in the differential diagnosis of dyspneu and it is very important to identify risk factors associated with the development of PE, especially in young adults.

679

PO 234The Longitudinal Association between Changes in Lung Function and Changes of Abdominal Visceral Obesity in Korean NonsmokersHae Yeon Kang1, Eun Kyung Choe2, Seung Ho Choi11Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea2Department of Surgery, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea

Corresponding authorHae Yeon Kang, M.D., Ph.D.E-mail: [email protected]

Background: Obesity, especially abdominal obesity, is suggested to be associated with decreased pulmonary function. We planned to investigate whether obesity index including abdominal visceral obesity was associated with forced expiratory volume in first second (FEV1) and forced viral capacity (FVC) in an asymptomatic non-smokers through the longitudinal study.

Method: The clinical records of consecutive subjects were retrospectively reviewed who underwent a comprehensive health evaluation including spirometry and abdominal fat CT more than twice between 2007 and 2014. We included only never-smokers based on a self-administered questionnaire. Longitudinal changes in body mass index (BMI), waist circumference (WC) and abdominal adipose tissue were analyzed with respect to changes of FEV1 and FVC.

Results: Among a total of 1145 subjects, 428 (37.4 %) were male and mean age was 52.3 years (25-81 years). Mean follow-up period was 1105 days (over 3.0 year). The mean BMI and WC among males and females in baseline were 24.3 kg/m2 and 87.0 cm, 22.3 kg/m2 and 80.1 cm, respectively. Although total adipose tissue (TAT) of the abdomen in males (266.4 cm2) was similar to that in females (261.7 cm2), the ratio of visceral adipose tissue (VAT)/subcutaneous adipose tissue (SAT) was different; 0.95 in males and 0.48 in females. Increasing abdominal obesity (WC, TAT and VAT) was associated with decreasing lung function (FEV1), whereas decreasing abdominal obesity was related with increasing lung function in males. However, there was no significant relationship between changes of SAT and changes in lung function in males. These effects were not observed in females.

Conclusions: In Korean non-smokers, changes of abdominal visceral fat was inversely related with changes of lung function in males over a mean three year period. This result suggest that decreasing abdominal visceral obesity could increase lung function in males despite aging.

680

PO 235Influences of Gamma-Amınobutyrıc Acıd on The Respıratory Responses to HypoxıaNermin Yelmen., Ibrahim Guner., Gülderen Sahin.

Department of Physiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.

Background: Acute hypoxia produces an increase in ventilation. When the hypoxia is sustained, the initial increase in ventilation is followed by a decrease in ventilation. Hypoxia causes changes in brain neurotransmitters depending on its severity and durations. The purpose of this study was to investigate the role of gamma-aminobutyric acid (GABA) and glutamate for hypoxic ventilatory response in rabbits.

Methods: The experiments were performed in rabbits anesthetized with Na-pentobarbitone (25 mg/kg i.v ). Tidal volume (VT), respiratory frequency (f/min), ventilation minute volume (VE), mean systemic arterial pressure (BP) and integrated phrenic nerve activity ( IPA) were recorded during the breathing of the normoxic and hypoxic (8% O2 - 92% N2) gas mixtures. For intracerebroventricular (ICV) injections of reagents in each animal, cannula was placed in left lateral cerebral ventricle by stereotaxic method. Analysis of statistical significance of differences in respiratory parameters during experimental phases was performed with the Wilcoxon-Matched Pairs test. In all phases, p<0.05 was considered significant.

Results: After ICV injection of GABA (0.48 mg/kg), air breathing in rabbits caused a depression of respiratory activity (p<0.05). On the other hand, after ICV injection of GABA, breathing of hypoxic gas mixture (8% O2 - 92% N2) in rabbits produced the hypoxic hyperventilation (p<0.05). After ICV injection of GABA, blockade of GABA (A) receptors with bicuculline (0. 2 mg/kg) did not prevent the hypoxic hyperventilation. In contrast, after ICV GABA injection, blockade of glutamate NMDA receptors with MK-801 (0.09 mg/kg) completely abolished the hypoxic hyperventilation observed while the animals were breathing hypoxic gas mixture.

Conclusions: Our findings suggest that ICV injection of GABA causes respiratory depression in normoxic conditions, and that it increases ventilation in hypoxic conditions by increasing,glutamate which may be synthesized or released by the effect of GABA via a mechanism not clearly understood.

681

PO 236KORELASI ANTARA KADAR LEPTIN SERUMDAN TINGKAT KEPARAHAN TUBERKULOSIS PARU DI RUMAH SAKIT MOHAMMAD HOESIN, PALEMBANG

Adi Kurniawan, Zen AhmadSubbagian PulmonologiDepartemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Sriwijaya Rumah Sakit Mohammad Hoesin Palembang

Latar Belakang: Tuberkulosis paru adalah penyakit menular yang disebabkan oleh Mycobacterium tuberculosis. Sistem imun seluler berperan dalam mekanisme pertahanan terhadap infeksi Mycobacterium tuberculosis. Leptin merupakan hormon yang disekresikan jaringan adiposa, berperan pada pengaturan sistem imun seluler. Pada beberapa penelitian kadar serum leptin dilaporkan menurun pada penderita Tuberkulosis paru karena inflamasi kronik dan penurunan kadar leptin berhubungan dengan meningkatnya derajat keparahan tuberkulosis paru. Namun, beberapa riset menunjukkan hasil yang bertolak belakang. Pemeriksaan rontgen toraks merupakan cara yang praktis dan tidak invasif untuk menentukan derajat keparahan tuberkulosis paru.

Tujuan: Mengetahui korelasi antara kadar leptin serum dan tingkat keparahan Tuberkulosis paru di RSMH Palembang.

Metode: Penelitian observasional prospektif analitik dengan desain potong lintang. Penelitian ini dilakukan di poliklinik pulmonologi dan ruang rawat inap penyakit dalam Rumah Sakit Mohammad Hoesin Palembang sejak Februari 2016 sampai dengan Juni 2016. Jumlah sampel ditentukan sebanyak 42 subjek. Setiap subjek penelitian dilakukan anamnesis, pemeriksaan fisik, pemeriksaan darah rutin, kimia klinik, sputum serial BTA 3 kali, rontgen toraks dan kadar leptin serum. Analisis Spearman digunakan untuk menilai korelasi antara kadar leptin serum dan derajat keparahan tuberkulosis paru.

Hasil: Kadar leptin serum pada kelompok Tuberkulosis paru pada median 700,8 (123,4-22300,6) pg/mL. Didapatkan korelasi negatif sedang yang bermakna antara kadar leptin serum dan derajat keparahan tuberkulosis paru (r = -0,422, p=0,005).

Simpulan: Terdapat korelasi negatif sedang yang bermakna antara kadar leptin serum dan derajat keparahan tuberkulosis paru

Kata kunci: Tuberkulosis paru, leptin serum, rontgen toraks, derajat keparahan tuberkulosis paru

682

CORRELATION BETWEEN SERUM LEPTIN LEVEL AND THE SEVERITY OF PULMONARY TUBERCULOSIS IN MOHAMMAD HOESIN HOSPITAL, PALEMBANG

Adi Kurniawan, Zen AhmadDivision of PulmonologyDepartment of Internal Medicine Faculty of Medicine Sriwijaya UniversityMohammad Hoesin Hospital Palembang

Background: Pulmonary tuberculosis is a lung disease caused by Mycobacterium tuberculosis. Celluler immune system has role in immunity to Mycobacterium tuberculosis infection. Leptin is a hormone that is secreted by fat tissue. It has role in immune celluler modulation. Leptin level has been reported in a few literatures to be low in tuberculosis patients because of chronic inflamation and this is associated with the severity of pulmonary tuberculosis. However, some studies contradicted the findings. Chest X-ray is the most practical and non-invasive test to detect the severity of pulmonary tuberculosis.

Objectives: To find correlation between leptin serum levels and the severity of pulmonary tuberculosis in Mohammad Hoesin Hospital Palembang

Methods: This was an analytic prospective observational study with cross-sectional design. This study was conducted at the pulmonary ambulatory clinic and internal medicine inpatient wards of Mohammad Hoesin Hospital in Palembang from February 2016 until June 2016. Sample size was determined to be 42 subjects. Besides history taking and physical examinations, routine complete blood count, serum electrolytes levels, liver enzymes levels, liver function tests, serial 3 collections of sputum smear tests, a posterior anterior view of chest X-ray and serum leptin level were measured in all subjects. Spearman analysis was used to find the correlation between serum leptin level and the severity of pulmonary tuberculosis.

Results: Median value of serum leptin levels was 700,8 pg/mL (range: 123,4-22300,6) pg/mL. Statistical analysis showed significant negative correlation between serum leptin level and the severity of pulmonary tuberculosis (r = -0,422, p=0,005).

Conclusions: There was a significant moderate correlation between serum leptin level and the severity of pulmonary tuberculosis.

Keyword: Pulmonary tuberculosis, serum leptin level, chest X-ray, the severity of pulmonary tuberculosis.

683

PO 237HUBUNGAN KADAR LEPTIN SERUM DAN KEJADIAN TUBERKULOSIS MULTIDRUG RESISTANT DI RUMAH SAKIT MOHAMMAD HOESIN PALEMBANG

Ari Sisworo, Zen Ahmad

Latar Belakang: Tuberkulosis multidrug resistant (Tb MDR) terjadi bila Mycobacterium tuberculosis resisten terhadap rifampisin dan isoniazid, dengan atau tanpa OAT lainnya. Strain Tb MDR lebih virulen dibanding kasus lama Tb yang masih sensitif OAT. Leptin merupakan hormon yang disekresikan jaringan adiposa berperan pada pengaturan sistem imun, alamiah maupun adaptif. Kadar leptin menurun pada penderita Tb karena inflamasi kronik dan penurunan kadar leptin berhubungan dengan kerentanan untuk terjadinya infeksi.

Tujuan: Mengukur kadar leptin serum penderita Tb MDR dan kasus lama sensitif OAT serta menganalis apakah terdapat hubungan kadar leptin serum dan kejadian Tb MDR.

Metode: Desain penelitian ini adalah case control. Subjek penelitian terdiri dari 51 orang, 26 kelompok kasus, Tb MDR dan 25 kelompok kontrol, kasus lama sensitif OAT. Kedua kelompok dilakukan matching berdasarkan jenis kelamin dan IMT. Setiap subjek penelitian dilakukan anamnesis, pemeriksaan fisik dan pemeriksaan

penunjang: darah rutin, kimia klinik, pemeriksaan sputum BTA, dan pemeriksaan geneXpert. Pemeriksaan kadar leptin dilakukan setelah subjek penelitian dinyatakan positif Tb pada pemeriksaan geneXpert.

Hasil: Kadar leptin serum pada kelompok Tb MDR berada pada median 755,49(107,95-4673,76) pg/ml sedangkan kelompok kasus lama sensitif OAT berada pada median 990,82(205,20-12777,85) pg/ml. Secara statistik tidak terdapat hubungan antara kadar leptin serum dan kejadian Tb MDR di RS Mohammad Hoesin Palembang (p=0,124). Pada penelitian ini kadar leptin berhubungan dengan jenis kelamin dan tidak berhubungan dengan usia, IMT, BTA sputum dan luas lesi.

Simpulan: kadar leptin serum penderita Tb MDR lebih rendah dibandingkan penderita Tb kasus lama masih sensitif OAT namun secara statistik tidak bermakna.

Kata kunci: Tb MDR, kadar leptin serum, pemeriksaan geneXpert

684

ASSOCIATION BETWEEN SERUM LEPTIN LEVEL AND MULTIDRUG RESISTANT TUBERCULOSIS IN MOHAMMAD HOESIN HOSPITAL PALEMBANG

Ari Sisworo, Zen Ahmad, Linda Andriani

Background: Multidrug resistant tuberculosis (MDR Tb) is defined as M. tuberculosis that has resistance at least to both isoniazid and rifampicin. MDR Tb strain is more virulence compared with drug-sensitive strain. Leptin, a hormone secreted by adipose tissue, has been shown to regulate the immune response, innate and adaptive response. Leptin level is low in tuberculosis patients because of chronic inflamation and this is associated with increased infection susceptibility.

Objectives: To measure leptin level in MDR Tb patient and drug-sensitive tuberculosis patients and also explore the association between leptin level and MDR Tb in Mohammad Hoesin Palembang Hospital.

Methods: The study design was case control. The subjects consisted of 51 patients, 26 patients were MDR Tb as case group and 25 patients were drug sensitive tuberculosis patients as control group. Both of group was matched according sex and body mass index (BMI). Blood routine, biochemichal parameters, sputum smear test, chest radiograph, and geneXpert examination were measured in all subjects. Leptin level were measured in patients with positif tuberculosis result in geneXpert examination.

Results: Serum leptin level MDR tb patients was 755,49(107,95-4673,76) pg/ml while drug-sensitive tuberculosis is 990,82(205,20-12777,85) pg/ml. There was no association between leptin level and MDR Tb statistically (p=0,124). In this study leptin level was associated with sex but not associated with age, BMI, sputum smear and Tb severity according chest radiograph.

Conclusions: Leptin level in MDR Tb patients was lower compared drug sensitive Tb patients but not association statistically.

Keyword: MDR tb, leptin level, geneXpert examination

685

PO 238Procalcitonin as A Biomarker of Severity Degree in Sepsis Due to PneumoniaWachyoe Hadi Saputra

Wachyoe Hadi Saputra (Indonesia)

Objective: Measuring PCT level can be as the examination having the role to differ the systemic inflammatory response syndrome (SIRS) and sepsis. This study aims to know the PCT level in accessing the sepsis degree at pneumonia patients.

Methods: This study was an analytical study with cross-sectional design. There were 30 samples obtained since February 2013 until March 2014 at the Emergency Room and Inpatient Room of Internal Medicine Local Public Hospital dr. Zainoel Abidin Banda Aceh. The sample collection was conducted with quota sampling technique. The data was analyzed with Anova and followed with LDS. The data was considered to be significant if the p value is < 0,05.

Results: The study results were obtained the minimum limit value of PCT level at pneumonia of 0,091 ng/dl, sepsis of 0,686 ng/dl, severe sepsis of 3,593 ng/dl and shock sepsis of 21,703 ng/dl.

Conclusions: The analysis results showed that the higher PCT level makes the higher disease severity.

Keywords: Procalcitonin (PCT), Sepsis Degree, Pneumonia.

686

PO 239Diagnostic Test Using Interferron Gamma for Anti Tuberculosis Drug Intensive Phase Treatment Evaluation in Patient with Pulmonary Tuberculosis

I Dewa Putu Gede Wedha Asmara (Indonesia)Internal Medicine Society of Bali

Background. Evaluation of ATD intensive phase treatment in pulmonary TB is still using sputum smear as the main parameter but in some cases it couldn’t be done. This can make a problem in assessing the treatment outcome. TB patients express elevation in IFNγ levels, which is related to the activity of cellular immune response mediated by Th1 lymphocytes. ATD therapy will reduce levels of IFNγ so that IFNγ has a potential role to be used as a parameter to evaluate the therapy.

Objectives. To determine the role of IFNγ as an alternative diagnostic test to evaluate the intensive phase ATD therapy in pulmonary TB patients.

Methods. A diagnostic test of smear-positive pulmonary TB post ATD intensive phase treatment by examining serum levels of IFNγ compared with the results of sputum smear examination as a gold standard at Sanglah and Sanjiwani hospital. IFNγ levels were measured by ELISA technique. Diagnostic test is done by using a 2x2 table calculation.

Results. Obtained 59 smear positive pulmonary TB, mostly men (55.9%), age 18-53 years (34.5 ± 7.7), 81.4% were new cases pulmonary TB and 18.6% were relapse. The sensitivity of IFNγ test was 88%, specificity 76.5%, positive predictive value 73.3%, and negative predictive value 89.7%.

Conclusions. IFNγ examination could be used as an alternative diagnostic test to evaluate intensive phase ATD therapy in pulmonary TB especially in patients who could not perform sputum smear examination.

Keywords: ATD intensive phase, sputum smear, serum IFNγ

687

PO 240ADIPONUTRIN AND PHOSPHOLIPASE A2 LEVELS IN PATİENTS WITH PULMONARY TUBERCULOSIS BEFORE AND AFTER TREATMENTKorkmaz GG1, OğurIu O2, Gelisgen R3, Yurt S4, Gezginc Poyraz RG4, Koşar F4, Uzun H3 1. Kırklareli University, School of Health, Kırklareli, Turkey.2. Bagcilar Research and Education Hospital, Department of Pulmonary Disease,

Istanbul, Turkey.3. Istanbul University, Cerrahpasa Faculty of Medicine, Department of Biochemistry,

Istanbul, Turkey. 4. Clinic of Chest Diseases, Yedikule Chest Diseases and Chest Surgery Training and

Research Hospital, İstanbul, Turkey. Tuberculosis remains a major public health concern worldwide. Adiponutrin (PNPLA3, patatin-like phospholipase domain-containing protein 3), is a transmembrane protein which is predominantly expressed in adipose tissue and liver. Its activity is regulated by fasting and feeding. Increasing energy uptake causes up-regulation of adiponutrin. Moreover, it was reported that adiponutrin may have a role lipid metabolism and regulation of energy balance. The aim of this study was to investigate whether serum adiponutrin and lipoprotein-associated phospholipase A2 (Lp-PLA2) levels differ between pulmonary tuberculosis patients and healthy controls. And also the importance of adiponutrin as a marker of alteration on energy balance during tuberculosis treatment and the possible role of these parameters for the assessment of treatment efficiency were evaluated. Also, the relationship between serum adiponutrin, Lp-PLA2, glucose, insulin, HOMA-IR and lipid parameters were investigated. 30 active pulmonary tuberculosis patients (F/M: 10/20, aged:34,9±15,7 years) and 24 healthy persons (F/M: 12/12; aged:35,5±10,1 years) for the control group were enrolled the study. Serum adiponutrin and Lp-PLA2 levels were evaluated by ELISA in tuberculosis patients before the treatment and 2 months after antituberculosis treatment. Adiponutrin, phospholipase A2, insulin and HOMA-IR values were not significantly different between in healthy controls, before and after treatment. In before treatment group, serum glucose, total cholesterol, HDL-cholesterol levels were found to be significantly lower than control group. Compared with before treatment group, serum tryglyceride, total cholesterol, and HDL-cholesterol levels were found to be significantly elevated in treatment group. Our findings show that adiponutrin and Lp-PLA2 may not be useful for assesment of treatment efficiency, due to there were no significant difference between control group, before and after treatment group. This is the first study to investigate the importance of adiponutrin levels in tuberculosis patients. Further studies are necessary to investigate genetic alterations of adiponutrin gene in tuberculosis patients.

Key word: Adiponutrin, lipoprotein-associated phospholipase A2, pulmonary tuberculosis.

688

PO 241Association between Hepatitis G and Unknown Chronic HepatitisSaeed Soleiman-Meigooni1, Ali Asgari2, Seyyed Javad Hoseini-Shokouh2, Jalil Rajabi2, Mohammad Hassan Kazemi-Galougahi31. Infectious Disease Research Center, AJA University of Medical Sciences, Tehran,

Iran, corresponding author. Email: [email protected]. Infectious Disease Research Center, AJA University of Medical Sciences, Tehran,

Iran.3. Ph.D. Candidate of Epidemiology, Department of Epidemiology & Biostatistics, School

of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background: Hepatitis G virus (HGV) is a hepatotrope virus with unknown importance. The genome of the virus has been detected in patients with acute or chronic non-A-E hepatitis, cirrhosis, and hepatocellular carcinoma. The aim of this study was to determine the association between hepatitis G and unknown chronic hepatitis.

Methods: This case-control study was performed in Ebne-Sina military hospital in Hamadan, Iran. The cases were 35 military staff with unknown chronic hepatitis. The control group consisted of 59 healthy subjects who had normal levels of serum alanine aminoteransferase (ALT). The data were analyzed by SPSS, version18, using Fisher’s exact test, the Student’s t-test, and multivariate logistic regression analysis.

Results: Only one patient in the case group (2.9%) tested positive for HGV antibodies, and no one was infected in the control group. There was no association between HGV infection and unknown chronic hepatitis in our study (P=0.37). A significant association was found between the male gender and unknown chronic hepatitis (OR=14.9, P=0.01).

Conclusion: No association between HGV infection and unknown chronic hepatitis was found in our study, so it was not necessary to evaluate these patients for HGV infection.

Keywords: hepatitis G, chronic hepatitis

689

PO 242Characterization of Nucleos(T)Ide Analogue Resistance Mutations Among Treatment-Naïve Chronic Hepatitis B Minangkabau Ethnic Patients

Suryadi Syam,* Nasrul Zubir,** Arnelis,** Saptino Miro,** Julius,** * Department of Internal Medicine Pariaman Hospital** Department of Internal Medicine dr. M. Djamil Hospital / Medical Faculty Andalas University

Background. Minangkabau ethnic is unique because differences in genotypes and subtypes of hepatitis B virus (HBV) compared to other ethnic groups in Sumatra. Resistance of nucleos(t)ide analogue (NA) treatment in patients with chronic hepatitis B (CHB) caused by mutations in the reverse transcriptase region VHB associating to the determination of HBV genotypes and subtypes.

Aim of the study. To understand the characterization of mutation and the relationship between nucleos(t)ide analogue resistance mutations against its genotypes in treatment-naïve chronic hepatitis b Minangkabau ethnic patients

Methods. This study was an observational study with cross sectional study design. Sequencing of DNA fragments with ABI Prism 310 genetic analyzer. Nucleos(t)ide analogue mutations, genotypes, subgenotype, and subtypes then analyzed.

Results. There are 33 subjects (28 men and 5 women), with a mean age 46.1±10:39 years, genotype C 25 (75.8%) and genotype B 8 (24.2%) subjects. Nucleos(t)ide analogue mutations found in 31 (93.9%) subjects, namely the putative mutation 65.9% and 34.1% pretreatment mutations. Putative mutation analysis demonstrated lamivudine resistance occurs 21 (77.8%), adefovir 3 (11.1%), the combination of lamivudine and adefovir resistance 2 (7.4%) and a combination of lamivudine resistance, adefovir and entecavir 1 (3.7% ) subjects. There was no relationship between the incidence of mutations with the type of genotype (p = 0.568). But there was significant differences statistically between lamivudine resistance compared with the genotype C and genotype B (p = 0.002), as well as adefovir resistance (p = 0.02).

Conclusion. Among treatment-naïve chronic hepatitis b Minangkabau ethnic patients was found putative mutation and pretreatment mutation. Further research is needed to know the clinical response and virologic response of treatment with nucleos(t)ide analogue.

Keywords: nucleos(t)ide analogue resistance mutations, hepatitis B virus, chronic hepatitis B, treatment-naïve patients, ethnic Minangkabau

690

PO 243Portal Vein Tumor Thrombosis in Hepatocellular Carcinoma Patients in Secondary Referral General Hospital at Karawaci, Tangerang, Banten, Indonesia

Andree Kurniawan, Nata Pratama Hardjo Lugito, Margaret Merlyn Tjiang,Theo Audi YantoInternal Medicine, Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang, Banten, Indonesia

Background: Hepatocellular carcinoma (HCC) is a major cause of cancer death worldwide accounting for over half a million deaths per year. The natural history of HCC with portal vein thrombosis (PVTT) is dismal, approximately 2-4 months. PVTT is reportedly found in 10%-40% of HCC patients at diagnosis. There is still limited study exploring PVTT in HCC in Asian population especially in Indonesia. The aim of this study is to describe the incidence and clinical characteristic of PVTT in HCC in secondary care hospital at Karawaci, Tangerang, Banten, Indonesia.

Methods: A cross-sectional study was conducted in adult patients admitted to General hospital at period of January 1, 2013 to December 31, 2015. Data were collected using structured questionnaire on basic demographic factors, behavior risks, laboratory profiles and imaging reports. Descriptive analysis was performed on the data collected. Diagnosis of PVTT was using abdominal Multi-slice helical CT scan

Results: Fifty five patients fulfilled the criteria for liver cirrhosis in the study period. Thirty five patients (63.6%) were male. Thirty seven (67.3%) patients were fulfilled Child Pugh B criteria, 10 patients (18.2%) were fulfilled Child Pugh A criteria and others were Child Pugh C criteria. Twenty nine patients (52.7%) had positive hepatitis B infection and 4 patients (7.3%) had hepatitis C infection. Fourteen patients (25.4%) fulfilled criteria of HCC. Five patients with HCC were positive PVTT. Four patients with PVTT died in hospital. The mean of D-dimer level using ELISA technique was 5.6 + 0.9 g/L

Conclusions: The incidence of PVTT in HCC in secondary care hospital at Karawaci, Tangerang, Banten, Indonesia was 35.7%. Four of five patients with PVTT in HCC died in hospital during diagnosis.

Keywords: Cancer, Cirrhosis, Venous thromboembolism

691

PO 244Protective Effect of Zinc on Hyperglycemia-Mediated Oxidative Damage in The Hepatic Tissues of Experimental Diabetic Rats

Ozlem Sacan1, Bertan Boran Bayrak1, Ismet Burcu Turkyilmaz1, Ozgur Mutlu1, Nuriye Akev2, Refiye Yanardag1,1. Department of Chemistry, Faculty of Engineering, Istanbul University, Avcilar-Istanbul,

TURKEY2. Department of Biochemistry, Faculty of Pharmacy, Istanbul University, Beyazit-Istanbul,

TURKEY

Diabetes mellitus is a complex multifactorial disease that involves severe insulin dysfunction, conjunction with gross abnormalities in glucose homeostasis and lipid-protein metabolism. This metabolic disease affects all systems in the body, including the liver. Hyperglycaemia, mainly caused by insulin resistance, affects the metabolism of lipids, carbohydrates and proteins and can lead to non-alcoholic fatty liver disease, which can further progress to non-alcoholic steatohepatitis, cirrhosis and finally, hepatocellular carcinomas. Zinc (Zn) is one of the most important essential trace elements playing indispensable role in human health and disease. The liver plays a central and crucial role in the regulation of carbohydrate metabolism. This central role for the liver in glucose homeostasis offers a clue to the pathogenesis of glucose intolerance in liver diseases but little insight into the mechanisms of liver disease in diabetes mellitus. This study was designed to determine the possible protective effects of Zn on the biochemical changes in the liver tissues of streptozotocin (STZ) induced diabetic rats. Female Swiss albino rats were divided into 4 groups. Group I, control; Group II, control + zinc sulfate; Group III, STZ-diabetic; Group IV, diabetic + zinc sulfate. Diabetes was induced by intraperitoneal injection of STZ (65 mg/kg body weight). Zinc sulfate was given daily by gavage at a dose of 100 mg/kg body weight every day for 60 days to groups II and IV. At the last day of the experiment, rats were sacrificed liver tissues were taken. Protein carbonyl levels and adenosine deaminase activity increased whereas catalase, superoxide dismutase, glutathione-S-transferase and sodium potassium ATPase activities significantly decreased in liver tissues of diabetic rats. Administration of zinc reversed significantly these effects. In this study, the ameliorative effects of Zn on STZ-induced liver injury, was demonstrated through biochemical parameters of oxidative damage.

692

PO 245Hepatoprotective Activity of Vitamin U Against D-galactosamine Induced Hepatic Injury in Rats

Ismet Burcu Turkyilmaz, Refiye Yanardag

Department of Chemistry, Faculty of Engineering, Istanbul University, 34320, Avcilar-Istanbul, TURKEY

Liver injury induced by chemicals, drugs and viruses has been recognized as a toxicological problem. Galactosamine (GalN) is a well known toxin and has been found to possess various adverse effects in liver. Vitamin U (Vit U), S-methyl methionine sulphonium chloride is a methionine derivative and has beneficial power on gastric and intestinal functions and also hepatoprotective , cytoprotective, antiinflammatory effects. In this study, we aimed to investigate the protective effects of Vit U on GalN induced liver injury. Female rats were randomly divided into four groups as follows: Control group: rats received saline (0.9 g % NaCl); Vit U given group (50 mg/kg/day, by gavage); D-GalN given group (500 mg/kg, ip) and D-GalN +Vit U given group (in the same dose). Vit U was given orally for 3 days. Vit U was given 1 h prior to the administration of D-GaIN. 8 hours after D-GaIN injection, rats were decapitated and liver tissue samples were taken. Tissues were homogenized in saline to make 10% (w/v) homogenate and were centifuged. In supernatant, glutathione (GSH) and protein carbonyl (PC) levels and aspartate transaminase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP) activity were determined. PC level and AST, ALT, activities were increased significantly in D-GalN given group when compared with control group. There was also an increase in GSH levels and ALP activity, however it was not significant. Administration of Vit U reversed these effects. We can conclude that D-GalN administration might have increased oxidative stress and that Vit U can be effective in decreasing oxidative stress in liver.

693

PO 246ACUTE PHASE PROTEINS FOR THE DIAGNOSIS OF BACTERIAL INFECTIONS IN CIRRHOSIS

Hendra Koncoro*, I Ketut Mariadi**, I Dewa Nyoman Wibawa***Department of Internal Medicine Sint Carolus Hospital, Jakarta, Indonesia**Division of Gastroentero-hepatology, Department of Internal Medicine,Medical Faculty University of Udayana/ Sanglah General Hospital, Denpasar, Indonesia

ABSTRACT

Background: Bacterial infection is related with poor outcome, but often full of diagnostic difficulties in cirrhotic patients. The role of clinical parameters such as systemic inflammatory response syndrome, leukocyte count, neutrophil count, and other protein markers remains unclear in liver cirrhosis patients.Aim: The aim of this study was to evaluate the usefulness of inflammatory protein markers and determined which markers were best for the diagnosis of infection in decompensated cirrhotic patients.

Methods: This was a diagnostic study consisted of 80 cirrhotic patients admitted to Sanglah general hospital, Denpasar from August 2014 until July 2015. The presence of infection were evaluated. Markers of infection consist of leukocyte count, neutrophil count, neutrophil to lymphocyte ratio (NLR), and acute phase proteins such as C-reactive protein (CRP) and resistin were measured. Accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined.

Results: Twenty patients (25%) had bacterial infections and spontaneous bacterial peritonitis (SBP) was the most common infections occurred. NLR, CRP, and resistin were higher in bacterial infections group (p < 0.05). Multiple logistic regression analyses showed that CRP and resistin were predictive factor for occurrence of bacterial infections (p < 0.05). For the diagnosis of infection, baseline CRP – using a 11.65 mg/L cut-off value - and resistin – using a 13 ng/mL cut-off value - generated area under the receiver operating characteristic (ROC) curve of 0.796 and 0.787, respectively. The sensitivity, specificity, PPV, and NPV for CRP were 90%, 73%, 52.9%, and 95.7%, respectively. For resistin, the sensitivity, specificity, PPV, and NPV were 90%, 59%, 41.9%, and 94.6% respectively.

Conclusions: The present study suggests moderate to high accuracy for CRP and resistin as a diagnostic aid for bacterial infections in liver cirrhosis.

Keywords: C-reactive protein, Resistin, Bacterial infection, Liver cirrhosis

694

PO 247The Role of traditional Alcohol ( Tuak) within Amoebic Liver Absces (ALA) in North Sumatera, IndonesiaEndang, Yosia Ginting, Armon Rahimi, Tambar Kembaren, Franciscus Ginting, Restuti Saragih

Division of Tropical Medicine and Infectious Diseases, Department of Internal Medicine,University of Sumatera Utara (H.Adam Malik General Hospital and Pirngadi Hospital) Medan-Indonesia

Background: The aim of this study to describe the role of traditional alcohol (tuak) in Amoebic liver abscess patients.Material and Method: The present study was undertaken on patients who diagnosed with ALA from January 2014 to December 2015 at department of Internal Medicine in the Regional Referral Center H.Adam Malik General Hospital and Pirngadi Hospital. The diagnosis were based on :1.Anamnesis, 2.Clinical findings 3.Laboratory investigation, 4.Ultrasound or CT scan evidence of an abscess, 4.History of alcohol consumption

Result : All 56 patients were diagnosed with ALA were male, the mean age of the patiens was 43 yo (range 24-65 yo) , all of patient had been consuming traditional alcohol (tuak) for 5–15 years. Traditional alcoholic (tuak) plays a vital role, but the underlying mechanism is still been unclear. The most common complication was pleural effusion 10 patients, (17,75%), followed by pleuropulmonary 1patient, (1.78%). Intravenous metronidazole and oral paromomycin were administered to all patients. Percutaneous abscess aspiration was performed to all patients.

Conclusion: This study was revealed that heavy traditional alcohol (tuak) consumption is a major predisposing factor for ALA Perhaps alcoholism could make the liver more susceptible to infection ALA. Cellular and humoral immunologic response may also be impaired by alcohol. All patients discharged from the Hospital with clinical improvement

KeywordsLiver abscess, traditional alcohol

695

PO 248Review of Sarcoidosis in in a Province of Korea from 1996 to 2014

Young-Chul Kim, Min-Seok Kim, Cheol-Kyu Park, Jung-Hwan Lim, Taeok Kim, In-Jae Oh

Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Hwasun, Jeonnam, Republic of Korea

Introduction. As introduction of endobronchial ultrasound (EBUS) facilitated transbronchial needle aspiration (TBNA) biopsy of mediastinal lymph nodes, incidence of histopathologically confirmed sarcoidosis is increasing. We investigated clinical features of sarcoidosis diagnosed from 1996 to 2014 in two university affiliated hospitals in a province of south Korea.

Materials and methods. Cases with confirmed disease codes of sarcoidosis were searched from electronic medical records of Chonnam national university (CNU) hospital and CNU Hwasun hospital (CNUHH) from year 1996 to 2014. Demographic data including smoking history and methods of diagnosis, results of tuberculin skin test, highest value of serum level of angiotensin converting enzyme (ACE) and serum calcium, extrapulmonary involvement, natural course of diseases and use of corticosteroid were collected and analyzed.

Result. We could find 99 cases of confirmed sarcoidosis. There were only 8 patients diagnosed as sarcoidosis before the year 2007, while the rest were diagnosed from the year 2008, when EBUS was introduced. The annual number of newly diagnosed sarcoidosis cases had been increased. Average age of diagnosis was 48.7 years (standard deviation, SD 14.1). There were 51 males and 49 female patients, and 64% of patients were never-smokers. EUBS was used in 75.8%, open surgical biopsy in 13.2% and mediastinoscopic biopsy in 5.1% of patients. Skin and ocular involvement were noted in 11.1% and 15.2% of patients, respectively. Among 31 patients who had skin tuberculin test, 28 case showed negative result. The mean level of ACE was 68.1 U/L (SD 31.7) and the serum calcium was 9.3 mg/dL (SD 0.5). At the time of diagnosis, disease stages of sarcoidosis were stage I (42.4%), stage II (55.6%) and stage III (2%). Spontaneous remission of sarcoidosis was observed in 31.3%, stable disease in 37.3%, and systemic steroid treatment was initiated in 24.2% of cases. Among the patients treated with systemic steroids, 66.7% showed improvement of disease. The median duration of steroid treatment was 5 months.

Conclusion. With the use of EBUS technique, the number of newly diagnosed patients with sarcoidosis is increasing. About one third of cases showed spontaneous remission, while one fourth of cases required systemic steroid treatment.

696

PO 249STEVENS-JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN) IN Dr SOETOMO GENERAL HOSPITAL SURABAYA, INDONESIA : A FOUR YEARS’ REVIEW

Wita Kartika Nurani, Gatot Soegiarto, Ari Baskoro, Chairul Effendi, Deasy Fetarayani

Division of Allergy and Immunology, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo Hospital Surabaya, Indonesia

Background : Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) has become a major concern because of high morbidity and mortality rate. This study was conducted to determine the characteristic of the patients, causes and management outcome.

Method : A retrospective study in internal medicine ward dr Soetomo General Hospital Surabaya, Indonesia during 2011-2014.

Result : We identified 29 patients hospitalized due to SJS, SJS-TEN overlap and TEN, 15 patients were female and 14 patients were male, 9 patients (31 %) were survive while 20 patients (69 %) were passed away. The average of age was 38.9 years old. The infection of HIV/AIDS was confirmed in 10 patients. Drug information was available for 25 patients (86, 2%). Drugs that were associated with SJS/TEN were: cotrimoxazole, amoxicillin, antituberculoid drugs, ciprofloxacin, clindamycin, cefadroxil, ceftriaxone, metronidazole, nevirapin, carbamazepine, metampiron, mefenamic acid, clobazam, and allopurinol. Blood gas analysis were available in 22 patients, thus the SCORTEN were measured : SCORTEN 0 (4 patients), SCORTEN 1(10 patients), SCORTEN 2 (4 patients), SCORTEN 3 (2 patients), SCORTEN 4 (2 patients). All of the patients received supportive treatment.

Conclusion: It was concluded that SJS, SJS-TEN overlap, and TEN were predominantly medication-induced and associated with substantial morbidity and mortality. Early recognition and supportive treatment is very important.

697

PO 250A SUCCESSFUL HYDROXYCHLOROQUINE TREATMENT FOR URTICARIA AND CHRONIC ANGIOEDEMA PATIENT: A CASE REPORT

Suriani Alimuddin, *Iris Rengganis, *Nanang Sukmana

*Division of Allergy-Immunology, Department of Internal MedicineUniversity of Indonesia

Background : Chronic urticaria affects 2-3% people in the world and significantly reduce patient’s quality of life. Many physicians think little of this disease and gave long treatment of steroid without considering the side effects. Hydroxychloroquine is one promising treatment for chronic urticaria with better tolerance than steroid alone.

Case report: A 22-year old female with chief complaints were itching of the body with positive skin lesions, eyes swelling, and sometimes felt shortness of breath since 6 years ago. The symptoms were more often since 15 months ago without significant causes. Symptoms only disappeared with antihistamine and steroid.From physical examination, we found normal vital signs and other examinations. Dermatology status was shown swelling erythema lesion with pale-lenticular center. The laboratory results showed total IgE 123 ng/mL, negative serum IgE atopic, total level of vitamin D 25-OH was 14.5 ng/mL, positive ANA test (titer >1/1000), and negative profile ANA test.From all findings, we diagnosed the patient with chronic urticaria caused by autoimmunity of the patient. At first, the patient was given methylprednisolone 16 mg, loratadine 10 mg, and vitamin D3 1000 mg once daily but the symptoms were disappeared after 200 mg hydroxychloroquine was added.

Conclusion : Chronic urticaria with autoimmune-based can be treated with the combination of steroid and hydroxychloroquine. Considering the side effects of the treatments is very important to improve the quality of life of the patient.

Keywords : chronic urticaria, angioedema, hydroxychloroquine, steroid

698

PO 251CORRELATION DEPRESSION AND TUMOR NECROSIS FACTOR-ALPHA (TNF-α) LEVEL IN UNCONTROLLED BRONCHIAL ASTHMA PATIENTS

M. Ali Apriansyah*, Rudi Putranto**, Hamzah Shatri,** Eddy Mart Salim**** Division of Psychosomatic, Department of Internal Medicine Medical Faculty - University of Sriwijaya / Dr. Moh. Hoesin Hospital, Palembang Indonesia** Division of Psychosomatic, Department of Internal Medicine Medical Faculty - University of Indonesia / Dr. Cipto Mangunkusumo Hospital, Jakarta Indonesia*** Division of Allergy-Immunology, Department of Internal Medicine Medical Faculty – University of Sriwijaya / Dr. Moh Hoesin Hospital, Palembang Indonesia

Background : Depression occurs at high rates in people with chronic diseases, including bronchial asthma, with the prevalence of depression approaching 50% in patients treated in tertiary care asthma clinic. Tumor necrosis factor alpha (TNF-α) is known to play a critical role in the pathogenic mechanism of a number of chronic inflammatory disease, including bronchial asthma and depression. There has not been any research data on the subject in Indonesia.

Aim : The objective of this study was to investigate the correlation between depression and TNF-α level in uncontrolled bronchial asthma.

Method : This study was a cross sectional study conducted in 40 patients with uncontrolled bronchial asthma at the allergy immunology clinic outpatient of Dr Moh Hoesin Hospital Palembang, during June 2014 until August 2014. Uncontrolled bronchial asthma assessed using the Asthma Control Test (ACT) questionnaire, whereas depressive symptoms assessed by Beck Depression Inventory (BDI) questionnaire, and confirmed the diagnose of depression by the criteria of the Diagnostic and Statistical Manual for Psychiatry-IV Text Revision (DSM-IV TR) / International Code Diagnose 10 (ICD-10). Serum levels of TNF-α was measured by the method of quantitative enzyme-linked immunosorbent assay ( ELISA ).

Result : The median value of the score of depression and serum TNF- α level in this study were 16 (10 - 45) and 4.09 (1.29 - 19.57) pg/mL. There was no significant correlation between depression and TNF-α level (r = -0.265, p = 0.098)

Conclusion : There was no significant correlation between depression and TNF-α level in uncontrolled bronchial asthma

Key Words : depression, TNF-α level, uncontrolled asthma bronchial

699

PO 252The Comprehensive General Physicians in Chronic Phase of Disaster is very important. Beyond the Great East Japan Earthquake

Toshihiko Hata (Japan)

Background: In super acute phase after the Great East Japan Earthquake (11 March 2011), Disaster medical association team (DMAT) consisted of emergency physiciansacted in disaster areas in the East Coast of Japan. On the other hand, these areas needed chronic care support by general physicians because of the enormous destructions of the medical facilities by the tsunami. The Japanese Red Cross Society had sent disaster emergency outpatient assistance doctors to Isinomaki Red Cross IRCH) Hospital, was intact because of moving away from the Pacific Ocean three years ago.　Methods: Determination of specialism by direct hearing and information from home page of each Red Cross Hospitals. Results: Cumulative 81 medical doctors were 38 internal medicine physicians, trainees 15, emergency physicians 12, surgeon 6, pediatrician 3, orthopedic surgeon 3, anesthesiologist 2, obstetrician 2, from April to August 2011. At first 6 dispatched doctors were resident and did emergency outpatient work in IRCH for 6 days and dispatched. A lot of Cases of pneumonia and bronchial asthma due to debris and rubble by Tsunami were seen. All dispatch doctors corresponded to primary surgery including fractures and trauma, pediatric diseases, and posttraumatic stress disorder due to earthquake itself, tsunami damage, and radiation problem of Fukushima. Conclusions: The comprehensive role of general physicians is very important in chronic phase of disaster medical assistance. Medical Facilities in the area with many earthquakes should be moved apart from the sea in order to avoid the damage of tsunami.

700

PO 253Diminishing Average Hospital Stay in Orthopedic Surgery Area. A 6 Years Follow Up.Authors: AM Garrido Castro 1, P Losada Mora 2, JL Carrillo Linares 1, R Gómez Huelgas 1. Hospital Virgen de la Victoria, Málaga, Spain. 1 Internal Medicine, 2 Cardiology.

Introduction:The prevalence of chronic diseases is very high among the elderly population. Such conditions may lengthen the time of hospital stay in surgical units. These include a history of high blood pressure is one of the most frequent.

Objetives: Analyze if the average stay of known hypertensive patients admitted to Orthopaedic Surgery area differs from the average stay of non-hypertensive patients. We analyzed those with any kind of medical decompensation.

Material and methods: Descriptive analysis of patients admitted to the Trauma and Orthopaedic Surgery Area who suffered some type of medical decompensation and needed the intervention of Internal Medicine, Cardiology and/or Nephrology. The average stay of two groups, patients with known and documented hypertension, and patients with no history of hypertension, were calculated.

Results: From June 2008 to March 2015 1573 consultations were made from the Orthopedic Surgery Area to an assigned team of professionals of Internal Medicine, Cardiology and Nephrology. The average stay was 14.01 days.Of these 1573 patients evaluated, 1034 (65.7%) had a documented history of hypertension. The average stay of the first subgroup was 14.15 days. The average stay of the group of non-decompensated hypertensive patients was 13.75 days.The Clinical Documentation Department provide the average stay data of the patients in Orthopedic Surgery during that period of time (including our 1573 patients). The result was an average stay of 8.03 days. Besides, compared to the standard of SAS (Andalusian Healthcare Service), in 2009 the average stay in Orthopedic Surgery was 28% over the standard. From 2009 the stay diminish progressively till in 2015 is 3% below the standard.

Conclusions: Although we need to consider some more circumstances, there is a progressive diminish of average stay in Orthopedic Surgery Area since the Team assigned to medical control in surgical areas started working. Two out of three patients consulted had a history of hypertension. Their average stay is slightly higher than that of non-hypertensive. Although accurate and more comprehensive studies to determine other variables are needed, the data seem to suggest a relationship between the presence of a history of hypertension and an increase in the average stay. The early evaluation of these patients by Internal Medicine, Cardiology or Nephrology may be beneficial in terms of reduced hospital stay.

701

PO 254TITLE: FATHERS’ PERCEPTIONS OF COUPLE-BASED COGNITIVE-BEHAVIORAL INTERVENTION

Fei-Wan Ngai (Hong Kong)

Background: Having a first child is a key marker of the transition into parenthood that requires substantial adjustment of couples’ life. Cognitive behavioral therapy has been shown to be effective in improving parental psychosocial health. However, there is limited qualitative evaluation of the impacts of delivering couple-based cognitive behavioral therapy during the transition to parenthood. The objective of this study was to explore Chinese fathers’ perceptions of a couple-based cognitive-behavioral intervention at early postpartum.

Methods: An exploratory qualitative design was used. A purposive sample of 30 first-time Chinese fathers who had participated in a couple-based cognitive-behavioral intervention was interviewed at 6 weeks postpartum. Data were collected using a semi-structured interview protocol, about the father’s involvement, their perceived benefits of participating in the couple-based cognitive-behavioral intervention, and factors influencing the effectiveness of the intervention. Data were analyzed using content analysis.

Results: The results revealed that Chinese fathers perceived the couple-based cognitive-behavioral intervention to be helpful in increasing confidence in the paternal role, increasing sense of support, and enhancing emotional control in themselves and their partners during the perinatal period. Suggestions for improvement included extending the intervention with sharing sessions to facilitate paternal role taking and involving other family members in the intervention, such as their parents and parents-in-law.

Conclusion: The findings highlight the importance of couple-based cognitive-behavioral intervention in facilitating paternal adaptation during the transition to early fatherhood in Hong Kong. The results of this study provide direction for the development of cultural relevant care to promote perinatal health.

702

PO 255Haplotypes analysis of Adiponectin SNPs among PCOS Saudi Arabian women

Nabil MTIRAOUIǂ, Intissar EZZIDIǂ and Faisel ABU DUHIERǂǂPrince Fahd Bin Sultan Research Chair, Using Advance Technology for Disease detection and Treatment, Faculty of Applied Medical Sciences, University of Tabuk

Background: Polycystic ovary syndrome (PCOS) is a common endocrine disorder in females and is associated with altered metabolic processes, in particular insulin resistance. Several studies have shown that polymorphisms in the adiponectin gene might be associated with the risk of PCOS.In the present study, we assessed the relationship of haplotypes tagging nine common single nucleotide polymorphisms (SNPs) in the adiponectin gene(- 11391 G/A, - 11377 C/G, - 4041 A/C, - 3964 A/G, 45 T/G, 276 G/T, 349 A/G, 712 A/G, 1233 T/C) with the risk of PCOS. A case control study was conducted in total of 162 PCOS cases and 162 control subjects of Saudi Arabian women (Tabuk region) using high throughput genotyping methods.

Results: Overall, we didn’t observe significant differences in genotype or allele frequencies for the nine SNPs.The analysis of different blocks haplotype based on the Linkage Disequilibrium (LD) given by haploview software coded major alleles as «1», while minor alleles were coded as «2». This analysis demonstrated that the frequency of the haplotype 21211 (rs2241766/ rs1501299/rs2241767/rs3774261/ rs17366743) is significantly high (P corrected= 0.009). This haplotype of susceptibility had been shown to increase the risk of PCOS (OR (IC 95%)=2.16 (1.22 - 3.82))Moreover, our results reveal significant differences between the controls and cases on the frequency of (1 1 2 1 1) haplotype (P corrected= 0.001) as protective haplotype against PCOS risk (OR (IC 95%)=0.24 (0.09 - 0.59)).

Conclusion : We can conclude that PCOS patients with the haplotype 21211 of adiponectin gene have higher susceptibility to the disease and those with haplotype1 1 2 1 1 have higher protection against the disease. However, there are not significant differences in the distribution of genotypes and alleles among PCOS patients and controls in Saudi Arabian women.

703

PO 256Association of TCF7L2 gene polymorphisms with an elevated risk of PCOS In Saudi Arabian womenIntissar EZZIDI, Nabil MTIRAOUI and Faisel ABU DUHIER

Background: Polycystic ovary syndrome (PCOS) is a common and heterogeneous endocrine disorder in females at reproductive age with well-established metabolic and hormonal abnormalities such as glucose homoeostasis and insulin resistance. Several reports have presented TCF7L2 (Transcription factor 7-like 2)as plausible gene associated with the risk of PCOSIn the present study, we assessed the relationship of haplotypes tagging nine common single nucleotide polymorphisms (SNPs) in the TCF7L2 gene (rs7901695, rs4506565, rs7903146, rs12243326, rs7895340, rs11196205, rs12255372, rs11196229, rs11196236) with the risk of PCOS. A case control study was conducted in total of 162 PCOS cases and 162 control subjects of Saudi Arabian women (Tabuk region)

Results: Overall, although the minor allele frequency of the rs11196229 was in borderline of significance (P=0.06) we didn’t observe significant differences in genotype or allele frequencies for the nine SNPs.A statistically correlation clearly revealed that the homozygous genotype TT of rs4506565 was higher in PCOS case when analyzed under recessive genetic model compared to control subjects (P=0.022) with an increased risk to the disease which remain high even after adjustment for age and BMI (aOR= 2.28 (1.10-4.72)). The analysis of different haplotype blocks based on the Linkage Disequilibrium (LD) given by haploview software demonstrated respectively that the frequency of the haplotypes T-G-C-G-G-T and T-A-G-G-A-T (rs12243326/ rs7895340/rs11196205/rs12255372/ rs11196229/rs11196236) were significantly high in PCOS women compared to control subjects (P corrected= 0.009 and 0.045). These haplotypes of susceptibility have been shown to increase the risk of PCOS as follow (OR=2.16 (1.22 - 3.82( and OR=4.68 (1.04-21.06).

Conclusion : We can conclude that genetic polymorphisms of TCF7L2 are associated with increased risk of PCOS in Saudi Arabian women. PCOS patients with the haplotype T-G-C-G-G-T and T-A-G-G-A-T of TCF7L2 gene have higher susceptibility to the disease.

704

PO 257Daily Vitamin D Intake and Serum Vitamin D Concentrations of Male Professional Baseball Players in Japan

Masafumi Nagano - Japan

Background & Purpose: Vitamin D is one of the substances involved in bone metabolism, besides, vitamin D receptor expresses on several organs and it has been shown that vitamin D play many positive roles in human body (Cannell, 2009). It is reported thatserum vitamin D concentration respond to vitamin D supplementation in a dose-dependent manner(Heaney, 2003). International Society of Sports Nutrition recommends 400 IU of vitamin D intake daily. The aim of this study is to investigate and assess relationships between Vitamin D intake, and serum Vitamin D concentrations of professional baseball players in Japan.

Methods: The subjects were fifty seven male professional baseball plyers in Japan. We used Food Frequency Questionnaire designed for vitamin D intake (Uenishi, 2008) for measuring daily vitamin D intake, and blood test of serum 25(OH) D, which is a marker of vitamin D status in human body, was performed. Regression analysis was done for the assessment of correlations between dietary Vitamin D intake and serum 25(OH)D.

Results: Subjects had enough intake of vitamin D(mean 461.8 ± 114.9 IU), however, a large part of them had low concentrations of serum 25(OH) D (mean 28.0 ± 7.9 ng/ml). Regression analysis revealed no significant correlations between dietary Vitamin D intake and serum 25(OH)D.

Discussion: Male professional baseball plyers in Japan had enough vitamin D intake, but they had lower vitamin D concentrations than we expected. This results were strange because baseball is outdoor sports, and they ate enough daily vitamin D. There is a possibility that the recommended amount of daily vitamin D is not good enough for maintain serum 25(OH)D. Further studies to investigate the optimal amount of vitamin D intake are needed.

705

PO 259Performance of Rapid Emergency Medicine Score in Predicting Mortality of Internal Medicine Emergency Patients at Moh Hoesin Hospital Palembang

Zen Ahmad, Nelda Aprilia SalimInternal medicine departementMoh Hoesin hospital /Sriwijaya University Faculty of Medicine Palembang, Indonesia

Background: Rapid emergency medicine score (REMS) is superior to stratify patients based on severity of illnesses in emergency because of its simplicity but lack of performance for certain diseases which need supportive examinations to evaluate progression. The researchers wanted to evaluate performance of REMS in predicting mortality of internal medicine emergency patients at Moh Hoesin hospital Palembang. To identify significant mortality predictors and adding them to REMS creating REMS-modified, then evaluate performance of REMS-modified.

Methods: Prospective cohort study of internal medicine patients attended to ED during October 2014 – March 2015. Age, temperature, MAP, heart rate, respiratory rate, SpO2, and GCS were measured at ED, then REMS were calculated. Hb, WBC, blood glucose, serum creatinine and potassium and ECG were examined. Patients admitted to the wards were followed until outcome happened, i.e. discharge from hospital dead or alive. Calibration of REMS were analyzed with calibration plot and Hosmer-Lemeshow, discrimination with AUC of ROC curve. Multivariate analysis using logistic regression were used to identify significant mortality predictors. They were added to REMS creating REMS-modified then analyzed the performance.

Results: Total of 700 patients were obtained, 655 (93,6%) were followed through outcome and analyzed. Only 579 with complete laboratory and ECG were analyzed for significant predictors and REMS-modified performance. Mortality happened in 129 (19,7%) patients. Calibration of REMS was good, r = 0,851 and p = 1,000. The discrimination was poor with AUC 0,603+0,028 (p<0,001; CI 95% 0,55-0,66). Significant mortality predictors were respiratory rate and Hb. The calibration of REMS-modified (REMS + hemoglobin) was good with r = 0,754 and p = 0,174, and discrimination showed AUC 0,618+0,030 (p< 0,001; CI 95% 0,560-0,676).

Conclusion: REMS showed good calibration but poor discrimination in predicting mortality of internal medicine emergency patients at Moh Hoesin hospital Palembang. Significant mortality predictors were respiratory rate and Hb. REMS-modified showed good calibration but still poor discrimination.

Key words: Emergency, internal medicine, mortality, Rapid Emergency Medicine Score (REMS), validation, REMS-modified

706

PO 260Impact of acetylsalicylic acid on sperm chromatin dispersion test, testosterone and LH levels in adult mouse

Authors: Fahimeh Mohammadghasemi1 , Farzaneh Mahmudi1 Address: Anatomical Sciences Department, Guilan University Of Medical Sciences, Rasht-Iran 1

Introduction: Acetylsalicylic acid (ASA) is a non-steroidal anti-inflammatory drug, causes reproductive failure in human males or animals. The aim of this study was to assess the effect of acetylsalicylic acid on sperm chromatin dispersion( SCD) test, testosterone and LH in adult mouseMaterials and Methods: In this experimental study 49 adult male mice were equally divided into seven groups. Group 1 (control) received no drug. Group 2 (sham) received vehicle. Groups 3,4,5,6 and 7 received 0.05,0.1, 0.5,1 and 5 mg ASA daily. All animals were treated orally for 14 days. On the day of 15 epididymis were removed and evaluations were made by radioimmunoassay (RIA) and SCD test for study of serum testosterone or LH level and sperm’s DNA fragmentation respectively. Data were analyzed with statistical tests of ANOVA, Tuckey or correlation test.

Results: Serum LH level were not changed in all groups however in groups 5,6 and significantly reduced serum testosterone levels(p<0.05). ASA in groups 5,6 and 7 reduced large halo-sperms. DNA fragmentation were significantly increased just in 5mg/kg group. There was not statistical correlation between LH levels and SCD test findings . A Negative correlation were found between small hallo fragmented sperms and testosterone( p<0.02 r= -0.347).

Conclusion: The results showed that ASA has deleterious effects on sperm’s DNA especially in dose of 5mg/kg. There is a significant correlation between testosterone and sperm’s DNA fragmentation in higher doses of ASA. These effects may be due to testosterone hormone alterations.

Key words: Acetylsalicylic acid, chromatin dispersion test, sex hormones, DNA fragmentation

707

PO 261Plasma Level of SCUBE-1 is elevated in Patients with Stroke-like Episodes due to Mitochondrial DisordersPeterus Thajeb, MD, DMedSci(Hon), 1,2,3 Dao-Fu Dai, MD, PhD, 4 ,5 Teguh Thajeb, MD, 6 and Ruey-Bing Yang, PhD 3,5

1 Lily Evergreen Neurology, and 2 Tjioe-Tjuan Neuroscience Technologies, Taoyuan, Taiwan ROC; 3 Faculty of Medicine, National Yang Ming University, Taipei, Taiwan, ROC;4 Department of Pathology, University of Washington, School of Medicine, Seattle, WA, USA, and 5 Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, ROC; 6 Department of Internal Medicine and Nephrology, Landseed Hospital, Ping-Jen District, Taoyuan City, Taiwan, ROC

Signal peptide-CUB (Complement proteins C1r/C1s, Uegf, Bmp1)-EGF-like domain containing protein-1 (SCUBE-1) is a novel, evolutionarily conserved, cell surface protein expressed in abundance in the alpha-granules of platelets, in the intravascular platelet-rich thrombus, in human umbilical vein endothelial cells (HUVECs), in the sub-endothelial matrix of atheromatous plaques, and in the plasma of patients with acute coronary artery syndrome and acute ischemic stroke [Grimmon et al 2000; Yang et al 2002; Tu et al 2006; Dai et al 2008]. We report herein for the first time that SCUBE-1 is also elevated in the plasma of patients with mitochondrial disorders (mtD) and acute phase of stroke-like episodes (SLEs). Four probands from 4 unrelated families with young-onset of stroke-like episodes (SLEs), mitochondrial myopathy, encephalopathy/epilepsy, with plasma lactic acidosis (MELAS) or without lactic acidosis (non-syndromic mtD) were investigated. Mutations of the mitochondrial DNA were A3243G in 2 patients with MELAS and large scale 5kb deletion in another 2 patients without lactic acidosis. The plasma levels of SCUBE-1 during the acute phase of the SLEs were markedly elevated in all patients. The mean + S.D in patients with mtD was 471.6mg/dL + , hundred-folds higher than the age-matched normal controls and subjects with acute lacunar brain infarctions. The plasma SCUBE-1 levels decline over time. Magnetic resonance spectroscopy of the patients without plasma lactic acidosis (non-syndromic mtD) showed mild elevation of the concentration of lactic acid at the brain regions of stroke-like episodes. We therefore conclude that SCUBE-1 is a novel biomarker for clinical follow-up of the course of patients with stroke-like episodes due to mutations of the mtDNA .Keywords: Biomarker, Lactic acidosis, Mitochondrial disorder, Mutation, SCUBE-1, Stroke-like episode

708

PO 262RORγt-specific transcriptional interactomic inhibition suppresses inflammatory diseases associated with TH17 cells

Tae-Yoon Park (South Korea)

Background/Rationale: RORγt is the major transcriptional factor that orchestrates the differentiation of TH17 and production of interleukin-17(IL-17). IL-17 plays critical roles in the pathogenesis of inflammatory diseases and host defense against bacterial and fungal infections. Therefore, the present issues focus on current knowledge of the regulation, functional mechanisms and targeting strategies of RORγt in the context of inflammatory diseases. However, recent studies from multiple groups have demonstrated the activities of small-molecular inhibitors against RORγt, we developed protein drug which can overcome the severe toxic side-effects of small-molecules.

Methods: We developed a novel therapeutic strategy to modulate the functions of RORγt using cell-transducible form of transcription modulation domain of RORγt (tRORγt-TMD). To confirm whether the tRORγt-TMD-mediated inhibition of TH17 differentiation is responsible for its protective/therapeutic effectiveness on rheumatoid arthritis(RA), the level of TH17 cells in the spleen were examined on day 8 and those in inflamed joints on day 5, 8, 11, 16, and 21 after immunization, respectively

Results: tRORγt-TMD specifically inhibited TH17-related cytokines induced by ROR-γt, thereby suppressing the differentiation of naïve T cells into TH17, but not into TH1, TH2, or Treg cells. tRORγt-TMD injected into RA model can be delivered effectively in the splenic CD4+ T cells and joint-infiltrating CD4+ T cells, and suppress the functions of TH17. The clinical severity and incidence of RA were ameliorated by tRORγt-TMD in preventive as well as therapeutic manner and significant reduction of both infiltrating CD4+ IL-17+ T cells and inflammatory cells into the joint was observed.

Conclusion: Therefore, tRORγt-TMD can be novel therapeutic reagent with the natural specificity for the treatment of inflammatory diseases associated with TH17. This strategy can be applied to treat various diseases where a specific transcription factor has a key role in pathogenesis.

709

PO 263PHYSICIANS’ PERSPECTIVES ON DO-NOT-RESUSCITATE (DNR) ORDERS – A SINGLE CENTRE SURVEY IN SINGAPORE

Moy Wai Lun (Singapore)

Background: Do-Not-Resuscitate (DNR) orders have been in use in hospitals worldwide for many years. However, very few studies explore the attitudes of physicians towards making such decision. The purpose of this study is to investigate the physicians’ perspectives on DNR orders in Singapore.

Methods: 57 physicians from the General Medicine department in Khoo Teck Puat Hospital, Singapore participated in a questionnaire survey.

Results: The participants comprised of senior doctors (42%) and junior doctors (58%). Approximately 70% of them underwent medical training overseas. Despite coming from culturally diverse backgrounds, none of them thought that DNR order contradicted with their religions or beliefs. Although junior doctors conducted DNR discussions more frequently than senior doctors (59% versus 41%), only 34% of the junior doctors felt comfortable doing so as compared to 75% of senior doctors (P = 0.003). Only 39% of the participants had received training on DNR discussion. More than 90% of the participants opined that patients with advanced organ failure (poor candidate for transplant or replacement therapy) and metastatic cancer should not be resuscitated in the event of cardiopulmonary arrest. Most participants (88%) believed that CPR and escalation of therapy beyond ward-based care were not appropriate for patients who were put on DNR order. Some would withhold enteral nutrition, oxygen supplementation and antibiotics as well (5%, 2% and 5% respectively).

Conclusion: The determination of resuscitation status is complex and practices vary among physicians. While a formal guideline may help in the standardisation of the delivery of patient care, it is important to recognise exceptions do occur and each case should be judged on its own merits. When there is a doubt, it is appropriate to seek guidance from the more senior and experienced doctors.

710

PO 264ANALGESIC EFFECTIVENESS TOWARD PATIENTS WITH CERVICAL CANCER IN X HOSPITAL SAMARINDA

Adji Prayitno Setiadi1, Hernanda Saputri21Centre for Medicines Information and Pharmaceutical Care (CMIPC), Faculty of Pharmacy, Universitas Surabaya, Indonesia2 Faculty of Pharmacy, Universitas Surabaya, Indonesia

Background: Cervical cancer is one of the women’s health problems in Indonesia, with 41 new cases and deaths found every day, and with an estimation of 40,000 new cases found every year (Rasjidi, 2007) and belongs to the second highest level in East Kalimantan. WHO states that two of three people with cancer will die because of their illness and along the way, 45.0-100.0% of them would experience light until severe pain intensity. The use of analgesic in overcoming pain intensity of cancer is the most important thing in the therapy of cervical cancer patients. The research aims to analyse the appropriateness of analgesic selection and effectiveness toward patients of cervical cancer undergoing inpatient care facility in X Hospital Samarinda.

Methods: The data collection is conducted through using the retrospective method from the patients’ medical records from January 2011 until December 2014 which will be descriptively analysed. The accuracy of analgesic selection is compared with WHO’s 3 stage analgesic ladders. The degree of the pain is measured with the method of Verbal Rating Scale (VRS) and analgesic effectiveness is measured through the reduction degree of pain with the Visual Analogue Scale (VAS).

Results: Among 47 data of medical records, there are 30 patients who received analgesic therapy. 36.7% experienced Pain Intensity grade I and the rest were grade II, 60% of patients received single analgesic therapy and the rest were combination. 71.2% received NSAID while the rest Opioid.

Conclusions:The analgesic appropriateness was 20.0% and the effectiveness was 53.3% of complete remission. Therefore it needs to be enhanced in order to increase quality of life, improve the functions, adherence and give patients the means to focus on something worthwhile in their lives. Un thorough treated pain leads to request for physician-assisted frustration also leads to unnecessary hospital admission to emergency departments.

711

PO 265CASE REPORT : Ebstein Anomaly in PregnancyLusiani, MD, SyahrirAzizi MD, Christopher Suwita MD, Astrid Karina MDCardiology Division, Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: Ebstein’s anomaly (EA) is a rare but fascinating congenital cardiac abnormality with various associated intra-cardiac anomalies. The common associated anomalies are PFO or ASD that leads to pulmonary hypertension. There are multifarious genetic factors. Maternal lithium therapy and other environmental factors such as viral infections are may in rare cases lead to EA. The physiological changes of pregnancy may worsen the hemodynamic consequences and can be complicated with tachyarrhythmia or cardiac failure.

Case description: A 27-year-old primiparous woman with 28 weeks gestational age admitted to our hospital with worsening shortness of breath. She was diagnosed with EA three years ago, but left untreated because of her preference. The patient was not cyanotic and her vital signs were stable. Her ECG showed incomplete RBBB and prolonged PR-interval. Blood tests revealed mild anemia. Observation of two-dimensional echo with color flow Doppler study showed EA with PFO as additional defects, EF of 57%, LV and LA dilatation, RV atrialization, severe TR, and moderate PH with RVSP of 44.3 mmHg. The patient then underwent elective section caesaria at 30 weeks of gestational age because there was an increasing breathlessness; both the mother and her baby were alive and were in good conditions.

Conclusion: EA is a complicated congenital anomaly. This case demonstrates not only the role of echocardiography in diagnosing Ebstein’s anomaly, but also its role in evaluating the disease progression and determining clinical management for the patient. The deteriorating clinical status (refractory dyspnea and decrease in amniotic fluid) in addition of high RV pressure and PH made more pressing decision for attending obstetrician and cardiologist toward termination of the pregnancy.

712

PO 266RELATION BETWEEN HYPONALBUMINEMIA AND CLINICAL OUTCOMES IN PA-TIENTS HOSPITALIZED FOR HEART FAILURE

Filsi Elsa Novenda, Naomi Niari Dalimunthe, Sari Harahap, Rahmad Isnanta, Zain-al Safri, Refli Hasan sDivision of Cardiology, Departemen of Internal Medicine

Faculty of Medicine, Sumatera Utara University

Background : Hypoalbuminemia is a common laboratory finding in patients with heart failure (HF), occurring in approximately 20%–30% of patients with HF. Hypoalbuminemia has been shown as independence predictor of morbidity and mortality in patients with heart failure. This study purpose at the prevalence and outcomes in hipoalbuminemia compered normoalbuminemia in patients hospitalized for heart failure.

Methods : Retrospective observational study using hospital medical record data of patients hospitalized with heart failure from 1 January – 31 December 2015 in Adam Malik Hospital, Medan, Indonesia. Hypoalbuminemia is defined as serum albumin concentration <3.5 g/dl; normoalbuminemia is defined as serum albumin concentration ≥3.5 g/dl. Differences in variables between hypoalbuminemia and normoalbuminemia groups were evaluated using chi-square test for categorical variables and independent samples t test or Mann Whitney test for continuous variables.

Result : A total of 321 patients , hipoalbuminemia was present in 205 patients (63.86%) with mean admission serum albumin 2.8±0.48 g/dl. Patient with hypoalbuminemia had significantly of longer hospital stay (p=<0.0001) and higher in hospital mortality compared to normoalbuminemia (p=0.046)

Conclusion : Hypoalbuminemia is common in patients with heart failure. Lower serum albumin on admission is associated with longer hospital stays and higher in hospital mortality.

Key word : hipoalbuminemia, heart failure, mortality

713

PO 267NEUTROPHIL TO LYMPHOCYTE RATIO AS ANOTHER CHANGING FACTOR BESIDES INCREASING TROPONIN T IN PATIENT WITH ACUTE MYOCARDIAL INFARCTION

Pramanta, Mario Steffanus, Yudistira Panji SantosaDepartment of Internal Medicine, Atma Jaya Catholic University of Indonesia / Hospital

Background: Case fatality rate of Acute Myocardial Infarction (AMI) in Indonesia is 13,49%. This number will continue to increase. The neutrophil-to-lymphocyte ratio (NLR) is a simple indicator of the inflammatory response that occurred as the consequences of myocardial damage. The aim of our study was to describe NLR value which will increase, accordingly to the troponin T in patients presented with AMI.

Methods: We performed a preliminary descriptive prospective study on 29 patients with AMI in Atma Jaya Hospital. AMI is diagnosed based on WHO Guidelines. Troponin T and white blood cell count were checked in 24-hour after the onset of chest pain. Total leukocytes were counted, differential count was obtained for neutrophils and lymphocytes, and NLR were evaluated. NLR was described as the absolute number of neutrophils divided by the absolute number of lymphocytes.

Results: Of the 29 patients with AMI admitted and qualified for our study, 58,6% were men and 41,4% were women. The mean age among patients was 58,41 ± 9,47 years. The median troponin T was 131 (50-2000). The median NLR of patients with AMI was 4,29 (1,2-18,4).

Conclusion: NLR value is increased in patients with AMI, along with the increasing troponin T.

714

PO 268CURRENT RISK FACTORS, ECHOCARDIOGRAPHIC, ANGIOGRAPHIC PROFILES AND MACE OCCURENCE IN DIABETIC AND NONDIABETIC ACS PATIENTS

Sally Aman Nasution1, Devi Felicia1, Bhanu1


BackgroundACS is still the most dreaded event in CAD patients, with increasing prevalence annually. All interventions are directed toward reducing MACE, which was high in our center in 2007-2010 (29%). Diabetes was found to carry a differential risk of ACS between men and women. We intend to evaluate current risk factors, notably diabetes, echocardiographic parameters, angiography, and inhospital MACE of ACS patients in ICCU of Cipto Mangunkusumo Hospital, Indonesia.

Methods The case records from January-June 2016 were analyzed retrospectively, and the data were also compared between diabetic and non-diabetic group.

Results148 case records were collected, patients were predominantly male (66.9%), mostly aged more than 45 years old (91.2%). The percentage of male gender was higher than female in the nondiabetic group (74.4% vs 25.6%, p=0.031), while it was similar in the diabetic group. In terms of risk factors, dyslipidemia was most encountered (84.5%), followed by hypertension (49.3%), diabetes (44.6%) and smoking (21%). In angiography, 42.6% patients had 3VD, and 15% had left main disease. From echocardiography, left atrial dimension was enlarged in 20% of patients (45.2 ± 5 mm vs 31.5 ± 5 mm). Right ventricular function was reduced in 17.6% patients (TAPSE 14.3 ± 2 mm vs 21.6 ± 5 mm). Left ventricle is enlarged in 21.6% patients (LVDd 61 ± 5 mm vs 45.3 ± 7 mm). Most patients (57.4%) had reduced ejection fraction (32.7 ± 10 % vs 64 ± 7 %). Diastolic function is only normal in 9.5% patients (E/A ratio 1.7 ± 0.17). Only 6.1% patients experienced MACE.

ConclusionIn our population, diabetes eliminated the protective effect of female gender. The echocardiographic parameters, vessel score, and MACE were the same in both diabetic and nondiabetic groups. Nonetheless, MACE rate has decreased in our center (6.1%).

Keywords: ACS, profile, risk factors, angiography, echocardiography, diabetes, MACE, Indonesia

715

PO 269RELATION BETWEEN SERUM URIC ACID ON ADMISSION AND CLINICAL OUTCOMES IN PATIENTS HOSPITALIZED FOR HEART FAILURE

Lily Hasugian, Naomi Niari Dalimunthe, Zainal Safri, Refli Hasan, Rahmad Isnanta, Sari Harahap

Division of Cardiology, Department of Internal Medicine,

Faculty of Medicine, Sumatera Utara University

Background. The role of serum uric acid (SUA) as an independent risk factor for cardiovascular disease (CVD) remains controversial. The association between elevated levels of SUA and bad outcomes in cardiovascular diseases has been known for over half a century. This study aims to assess the prevalence and outcomes in hyperuricemia patients hospitalized for heart failure.

Methods. This retrospective observational study used medical record data of patients hospitalized for heart failure between January and December 2015 in Adam Malik Hospital, Medan, Indonesia. Data were classified in two groups hyperuricemia and normouricemia; hyperuricemia in male with admission serum uric acid ˃ 7 mg/dl and in female ˃ 6 mg/dl. Differences in variables between two groups were evaluated using chi-square test for categorical variables and independent samples T test or Mann Whitney U test for continuous variables.

Results. Of 269 data, hyperuricemia was present in 205 patients (76.2%) with mean admissions serum uric acid 10.16 mg/dl. Mean admissions SUA in male was 10.42 mg/dl and in female was 9.78 mg/dl. There were no relationships between hyperuricemia and length of stay with p-value 0.826. And there were no relationships between hyperuricemia and mortality with p-value 0.159.

Conclusion. Increased serum uric acid concentrations have consistently been reported to be associated with the progression of CVD. However, no statistically significant associations between patients with hyperuricemia in inceased mortality and length of stay in hospitalized for heart failure in this study.

Key words : Hyperuricemia, heart failure, mortality, length of stay.

716

PO 270Relationship of ischemic stroke with transient “hidden” atrial fibrillation

Martynov A.I., Shmyrev V.I.

A.I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation

Administration of the President of the Russian Federation Central Clinical Hospital, Moscow, Russian Federation

Objective: To determine the incidence of atrial fibrillation (AF) in patients with ischemic stroke.

Material and methods: We observed 122 patients with acute ischemic stroke, who was admitted to the neurology department on the 1st day of stroke. 76 of them were men (62%) with mean age 63.4 y.o., and 46 (38%) women, mean age 67.1 years old. All the patients had sinus rhythm on ECG at admission. On the 2nd day of observation the Holter ECG monitoring was performed. AF was considered as “hidden” in case of registration of one or more episodes of AF with at least 20 minutes duration.

Results: 72 (59%) patients with basic sinus rhythm had episodes of AF with different duration, which we have called as “hidden” AF. 5 patients (4%) had short episodes of AF (with total duration less than 30 min per day), 35 (29%) - had longer duration of AF (between 30 and 60 min) and 32 (67%) – more than 60 min per day. AF episodes were observed more often in men (68%) and at nighttime (in 73% of men and 58% of women).

Conclusions: The findings suggest high frequency of the combination of ischemic stroke with episodes of hidden AF on the background of original sinus rhythm. It was also found that the longer duration of episodes (60 minutes per day or more) are more common in case of stroke in men. AF was more common at nighttime for both sexes, but 1.5 times more often in men. The results of our study could indicate a possible relationship of stroke to the “hidden” AF duration of 60 minutes per day or more. The data can be the basis for further research, which may be evidence of the need for daily ECG monitoring for all patients at an early stage of stroke for the purpose of antiarrhythmic therapy and prevention of recurrent stroke. It can be assumed that in elderly patients performing of routine daily ECG monitoring with the identification of “hidden” AF and timely administration of antiarrhythmic therapy will prevent or delay the stroke occurrence.

717

PO 271ABSTRACTSEVERE MITRAL STENOSIS WITH ORTNER’S SYNDROME AND OTHER SEVERE COMPLICATIONS

Kristinawati, Rofi Irman, Vitri Yenti, Sudarto Jemagam1, Erwin Sukandi2, Norman Djamaludin3, Bermansyah4

1. Division of Pulmonology, Department of Medicine, RSMH, Sriwijaya University, Palembang

2. Division of Cardiology, Department of Medicine, RSMH, Sriwijaya Universi-ty,Palembang

3. Division of Hematology and Medical Oncology, Department of Medicine, RSMH, Sriwijaya University,Palembang

4. Division of Cardiothoracic and Vascular Surgery, Department of Surgery, RSMH, Sriwijaya University, Palembang

Introduction

Rheumatic Heart Disease (RHD) with severe mitral stenosis can cause atrial fibrillation and its thromboembolic complication, non hemorrhagic stroke, or left untreated, a plethora of complication, such as severely dilated left atrium, left atrial thrombus, pulmonary hypertension and even Ortner’s Syndrome, a rare and potentially fatal complication of giant left atrium. Ortner’s Syndrome is characterized by mass effect from enlarged left atrium or pulmonary to adjacent structures, such as recurrent laryngeal nerve, oesophagus and the lungs.

Case Presentation

A 34-year old Indonesian man was referred to MohHoesin Hospital (RSMH) for further management of right pleural effusion and possible underlying intrathoracal malignancy. His past medical history was significant for RHD diagnosed 1 year ago and non-hemorrhagic stroke 3 years ago. He was found with dysfonia, dysarthria, dysphagia, atrial fibrillation, signs of right heart failure, mitral stenosis and precordial lift. Further evaluations with echocardiogram and CT scan of thorax revealed giant left atrium (±12cm x 14cm), severe mitral stenosis (mitral valve area ±0,62cm2) with left atrial thrombus (diameter ±9cm). The intrathoracal mass previously seen on the plain x-ray was due to giant left atrium and pleural effusion due to left lung atelectasis. The clinical picture was consistent with Ortner’s Syndrome. Due to history of stroke and high risk for another thromboembolic event, patient was anticoagulated. His heart failure responded well with treatment. Subsequently he was underwent mitral valve replacement successfully. The left atrial thrombus was eventually removed during the valve replacement.

718

Conclusion

RHD need comprehensive management, early diagnosis with prompt management will prevent devastating complications, extensive repair procedures and rehabilitation.

Key Words

Rheumatic heart disease, severe mitral stenosis, atrial fibrillation, giant left atrial thrombus, giant left atrium, Ortner’s Syndrome, pulmonary hypertension, non-hemorrhagic stroke.

719

PO 272EBSTEIN’S ANOMALY WITH CHRONIC RHEUMATIC HEART DISEASE

Vasista Palnati (India)

Introduction: Ebstein’s anomaly is relatively rare congential heart disease with incidence of 1 per 21,000 live births. Various congenital anomalies of left side of the heart like valvular stenosis, parachute mitral valve, supra-valvular mitral ring, cleft mitral leaflet have been commonly described in association with Ebstein’s anomaly. However, Aquired RHD is an extremely rare association.

Material: Patient is a 41 year old male, presenting with dyspnea and palpitations which progressed over 6 months.

Observation & Investigations: On examination there is irregularly irregular pulse, soft first heart sound and normal splitting of second heart sound with loud P2, multiple clicks. In mitral area pansystolic murmur is heard. ECHO showed rheumatic heart disease with moderate mitral stenosis, moderate mitral regurgitation, apical displacement of septal leaflet of tricuspid valve, severe tricuspid regurgitation. He is being treated conservatively and is being planned for mitral valve replacement and surgical repair of tricuspid valve.

Conclusion & Importance: Rheumatic heart disease associated with ebstein’s anomaly is an extremely rare association & it alters the natural history of the Ebstein’s anomaly, leading to rapid progression of symptoms and early onset of Atrial fibrillation & Pulmonary Hypertension.

720

PO 273RHEUMATIC HEART DISEASE INWARD PATIENT’S PROFILEIN RS. HASAN SADIKIN ON 2010-2015

Dendy Hendriansyah1, Augustine Purnowowati2, Teddy Arnold Sihite2

1PPDS Division of Cardiovascular Department of Internal Medicine2 Division of Cardiovascular Department of Internal Medicine2Department of Cardiology and Vascular MedicineFaculty of Medicine, Padjadjaran University / RSUP dr. Hasan Sadikin Bandung

Abstract: Rheumatic fever (RF) and Rheumatic Heart Disease (RHD) remain a significant cause of cardiovascular disease in the world. Rheumatic heart disease is a sequela of acute rheumatic fever, a multisystem inflammatory disease, immune-mediated, caused by group A streptococcal infection. Acute rheumatic fever can recover itself, but the inflammation of the heart valves at a single episode or recurrent episodes of acute rheumatic fever can cause cicatrix and chronic valvular disease.

This study is conducted to determine how the overview of the patients treated at RSUP Hasan Sadikin with the diagnosis of rheumatic heart disease. It is expected to be the basis of data for scientific research on rheumatic heart disease. This study is retrospective and descriptive study by reviewing the status of medical records of patients with a diagnosis of RHD inpatients at UPF Internal Medicine RSUP Hasan Sadikin Bandung in the period of January 2010 to December 2015.

The study showed the average of patients’ age of 44.4 ± 12.5 years, 171 women (73.4%). Elementary education level of 79 (41.1%), junior high school of 73 (38%), do not work (58.3%). Most symptoms of heart failure are dyspnea on effort in 183 patients (93.5%). The overview of echocardiography showed a combination of MS and MR (45.3%), pure MS (6.7%), the combination of mitral and aortic valve disease (47.5%), the average Wilkin’s score of 6.9 ± 1.13, thrombus or spontaneous echo contrast in 58 patients (32.4%).

In rheumatic heart disease which is widely experienced in developing countries, education and socioeconomic status play a role, in which the most of the educational status of patients is at low educational level, namely elementary school, and most of them do not work. The average value of Wilkin’s score is 6.9 ± 1.13, which still would allow the intervention measures in the form of baloon mitral valvuloplasty (BMV) in patients with moderate to severe MS with the Wilkin’s score of ≤8 (calcification score < 4), there is no thrombus in the left atrium and no history of thromboembolism. Thrombus or SPEC (32.4%) is fairly high, the rates of hospitalization for stroke can also be seen in the 22 patients (11.5%), in this case the mitral valve replacement (MVR) is a selected measure.

RHD inpatients are mostly women, with low education levels and have experienced multivalvular disorders and complications of thrombi/SPEC, so that they require

721

interventions that may reduce disease progression and mortality.

Keyword : RHD, rheumatic heart disease

722

PO 274THE LEVEL OF HIGH SENSITIVITY C-REACTIVE PROTEIN (Hs-CRP), TROPONIN I, CKMB AND MYOGLOBIN BEFORE AND AFTER PERCUTANEOUS CORONARY INTERVENTION (PCI) PROCEDURE ON CORONARY HEART DISEASE

Agoes Kooshartoro1, Teguh Santoso2

Idrus Alwi3, Siti Boedina Kresna4

1. Fellow of Cardiovascular FMUI/RSCM Jakarta2. Division of Cardiovascular Department Internal Medicine FMUI/RSCM Jakarta3. Division of Cardiovascular Department Internal Medicine FMUI/RSCM Jakarta4. Department of Clinical Pathology FMUI/RSCM Jakarta

Background: Percutaneous Coronary Intervention (PCI) procedure is the clinic model that describe the post ischemia inflammation and myonecrosis. Inflammation is measured from the changing of the rates of hs-CRP and heart muscle necrosis compared to the changing of rates of Toponin I, CKMB, and myoglobin.

Aim: The aim of this research is to analyze the rates of hs-CRP and the heart’s enzim (Triponin I, CKMB, and myoglobin) 6 hours and 12 hours after the PCI procedure for safety reasons.

Methods: Analysis reaserch unit is the coronary heart patient that consist of angina pectoris stable, angina pectoris unstable, acute infarct myocardial without ST elevation segment, and acute infarct myocardial with ST elevation segment that fullfill the PCI procedure. The sample is taken in the month of April until August 2002 in catheterization lab at the Medistra Jakarta Hospital.

Results: The total research subject are 106 patients, 82.1% male and 17.9% female, 84.9% diagnosed with stable clinical angina, 10.4% with unstable clinical angina and 4.7% with acute myocardial. The wilcoxon statictic showed the comparison hs-CRP before and 6 hours after the PCI procedure (p=0.220), before and 12 hours after the PCI procedure (p=0.342), and 6 hours and 12 hours after the PCI procedure (p=0.039). The difference of Troponin I level before and 6 hours after, before and 12 hours after, and 6 hours and 12 hours after the PCI procedure showed (p<0.000). The difference of CKMB level before and 6 hours after, before and 12 hours after, and 6 hours and 12 hours after the PCI procedure showed (p<0.000). The difference of myoglobin level before and 6 hours after, before and 12 hours after, and 6 hours and 12 hours after the PCI procedure showed (p<0.000).

Conclusion: The result of the research showed that there isn’t any increase in the rate of

723

hs-CRP 6 and 12 hours after PCI procedure. There is an increase in the rate of Triponin I, CKMB, and myoglobin after 6 and 12 hours after the PCI procedure. It showed the impact of myonecrosis caused by the PCI procedure but the increase isn’t above 3 times of its normal standard.

Keywords:

PCI, inflammation, myonecrosis, hs-CRP, troponin I, ckmb, mioglobin

724

PO 275CLUSTER OF MAJOR TRADITIONAL RISK FACTORS OF CARDIOVASCULAR IN HYPERTENSIVE SUBJECTS IN SOUTH SULAWESI

Haerani Rasyid, Makbul Aman, Hasyim Kasim, Syakib BakriInternal Departement, Faculty of Medicine, Hasanuddin University

Background : There is growing evidence that morbidity and mortality of cardiovascular disease (CVD) and the prevalence of hypertension which is one of the traditional cardiovascular risk factors tend to increase. Various traditional risk factors of cardiovascular could be early evaluated on the health care facilities services in many countries. Stratafication of cardiovascular risks in a person could become a probability of CVD in the next ten years.

Objectives : To determine cluster of major of traditional risk factors of cardiovascular, to determine the components number of major traditional risk factors of cardiovascular in Makassar

Methods: Subjects recruitment started in October 2015 and ended in April 2016 at the Polyclinic of Internal Medicine of Hasanuddin University Hospital, Makassar. Total sample are 153 hypertensive subjects who fill up the inclusion criterias. In this study, the subjects will be undertaken by history taking, physical examination, anthropometric and laboratory examination such as blood glucose and lipid profile. Major traditional risk factors of cardiovascular consisting of diabetes mellitus, dyslipidemia, central obecity, smoking This study was a descriptive design. Data were processed using SPSS version 22.0

Results: Profile of hypertensive subjects were commonly female (n = 92 or 60.1%) with major traditional risk factors of cardiovascular dominantly : central obecity (n = 101 or 66%) and dyslipidemia (n = 82 or 53.6%). Hypertensive subjects commonly had 1 (n = 52 or 34%) to 2 (n = 53 or 34.6%) of major traditional risk factors of cardiovascular

Conclusions: The hypertensive subjects were commonly female that suffering from central obesity and dyslipidemia. They commonly had 1 to 2 major traditional risk factors of cardiovascular.

725

PO 276PREDICTOR FACTOR OF 12 LEADS ELECTROCARDIOGRAPHY IN ATYPICAL CHEST PAIN PATIENTS UNDERWENT DOBUTAMINE STRESS ECHOCARDIOGRAPHY IN DR. CIPTO MANGUNKUSUMO HOSPITAL

Lusiani MD, Sally A Nasution MD, Mohamad Syahrir Azizi MD, Nidya Khaireza MDCardiology Division, Internal Medicine Department, Indonesia University, DR. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: Dobutamine stress echocardiography (DSE) is a non-invasive technique examination for diagnosis of chest pain patients. The predictor factor can contribute to making decision for further evaluation with DSE, particularly in atypical chest pain patients. In this study, we evaluated the ECG finding with the result of DSE in atypical chest pain patients as a predictor factor.

Method: This is a retrospective study that conducted in 23 atypical chest pain patients underwent DSE in Integrated Heart Center from June 2015 until April 2016. The ECG was performed before DSE examination. The result of ECG was divided in normal ECG finding and abnormal or specific ECG finding for CAD such as ST elevation (XI2), ST depression (IV1-3), T inverted (V1-3), Q pathology (I1-3), and Bundle Branch Block (BBB) (V1-8), according to Minnesota criteria.

Result: In total of 23 patients, there were 12 (52,2%) positive result and 11 (47,8%) negative result. There was significant difference between abnormal ECG finding with DSE Result (47,9% in positive and 13% in negative, p=0,002). Abnormal ECG finding were 1 (4,3%) ST elevation, 14 (60,9%) T inverted, 1 (4,3%) Q pathology, 3 (13%) BBB and no ST depression finding. By multivariate analysis, specific ECG finding for predictor factor of DSE was T inverted (p=0,001).

Conclusion: 12 leads ECG could be a predictor factor of DSE result in atypical chest pain patients. The present of T inverted in ECG on atypical chest pain patients could be a consideration for further evaluation with DSE.

Keyword: Atypical chest pain, Dobutamine Stress Echocardiography, Electrocardiography

726

PO 277CORRELATION OF CORONARY ARTERY DISEASE’S RISK FACTOR WITH DOBUTAMINE STRESS ECHOCARDIOGRAPHY IN ATYPICAL CHEST PAIN PATIENTS IN DR. CIPTO MANGUNKUSUMO HOSPITAL

Muhadi MD, Sally A Nasution MD, Lusiani MD, Mohamad Syahrir Azizi MD, Nidya Khaireza MDCardiology Division, Internal Medicine Department, Indonesia University, DR. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: The traditional risk factor of coronary artery disease (CAD) is well known as age, family history, obesity, hypertension, smoking, diabetes mellitus, and dyslipidemia. The main symptom of CAD is typical chest pain, but CAD patient might have an atypical chest pain. Atypical chest pain can be a challenge for clinician to rise diagnosis of CAD. Recently, dobutamine stress echocardiography (DSE) is well known as non-invasive technique examination for CAD. In this study, further investigation was done to have correlation of CAD’s risk factors with DSE in atypical chest pain patients.

Method: This is a correlational study which conducted in 23 patients with atypical chest pain who underwent DSE in Integrated Heart Center Cipto Mangunkusumo Hospital, Jakarta from June 2015 until April 2016. Data of demographic and clinical profile was collected retrospective and analyzed with univariate analysis for categorical variable.

Result: In total 23 patients, there were 9 (39,1%) patients with smoking history and 17 (73,9%) with hypertension. There was a significant difference between smoking and DSE result (OR 20; 95% CI 1,85-216,1; p=0,005), 8 ( 34,8%) patients had positive result and 1 (4,3%) patient had negative result. Hypertension and DSE result also had significant difference (OR 0,294; 95% CI 1,41-0,614; p=0,003), there were 12 (52,2%) patients had positive result and 5 (21,7%) patients had negative result.

Conclusions: Among the risk factors, there were smoking and hypertension have a correlation with DSE CAD positive result in atypical chest pain patients.

Keyword: Atypical chest pain, Dobutamine Stress Echocardiography, Smoking, Hypertension

727

PO 278ABSTRACT POSTERCORRELATION BETWEEN SERUM URIC ACID LEVELS AND SEVERITY CORONARY HEART DISEASE (CHD)

Erwin Sukandi1, Hatina Agsari2, Erwin Azmar1 , Erial Bahar3, Bahrun Indawan Kasim3

1. Division of Cardiology, Department of Internal Medicine, Faculty of Medicine Sriwijaya University, RSMH, Palembang, Indonesia

2. Student of Faculty of Medicine Sriwijaya University, RSMH, Palembang, Indonesia3. Department of Public Health, Faculty of Medicine Sriwijaya University Palembang,

Indonesia

Introduction:Coronary heart disease (CHD) is a atherosclerotic process of the coronary arteries that lead to myocardial infection and sudden death. Degree of stenosis due to the process affects the severity of CHD. Several previous studies suggested that increased level of serum uric acid plays a role atherosclerotic process in coronary heart disease. The purpose of this study was to determine whether there is a correlation between serum uric acid levels and severity of coronary heart disease at RSUP dr. Mohammad Hoesin Palembang.

Method:This study used a cross-sectional design with observational analytic method. The study population was all CHD patients hospitalized at RSUP dr. Mohammad Hoesin Palembang from January to March 2015 whose catheter angiography results available in the medical record. Sampling was done used purposive sampling. Data was processed with SPSS.

Result: The mean serum uric acid levels was 6.59±1.813 mg/dL. The mean severity of CHD using Gensini score was 45±36.186. Results of Pearson correlation test indicates there is a weak correlation between serum acid levels and severity of CHD with p value of 0.332 and r value of -0.133.

Conclusion:Serum uric acid levels do not correlate significantly with the severity of coronary heart disease.

Key words: Serum uric acid levels, severity of CHD

728

PO 279PROGNOSTIC FACTOR OF COMPLICATION DURING DOBUTAMINE STRESS ECHOCARDIOGRAPHY IN INTEGRATED HEART CENTER, DR. CIPTO MANGUNKUSUMO HOSPITAL

Mohamad Syahrir Azizi MD, Sally A Nasution MD, Lusiani MD, Nidya Khaireza MDCardiology Division, Internal Medicine Department, Indonesia University, DR. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: Dobutamine stress echocrdiography (DSE) progressively has been applied to more older, complex, and higher-risk patients suspected with ischemic heart disease. Although DSE generally regarded as safe stress examination, serious complications could be occur. In this study, we figure out the factor prognostic of complication in patients during DSE examination.

Method: This study is a retrospective study that conducted in 36 patients underwent DSE in Integrated Heart Center from June 2015 until April 2016. Major and minor rhytmic complication, hypertension and side effect were recorded in DSE result. Data of this study was analyzed with linear regression anaylisis.

Result: In 36 patients, there were 18 patients had complications (50%). There were 3 (8,3%) major rhytmic complication (2 supraventricular tachycardia and 1 atrial fibrilation raid ventricular response), 16 (44,4%) minor rhytmic complication (14 premature ventricle contraction and 2 premature atrial contraction) and 2 (5,5%) hypertension (systolic >200 mmHg). There were not significant difference in the occurence of complication with age (OR 0,56; 95%CI 0,08-3,28), BMI (OR 2,9; 95%CI 0,53-15,73), blood pressure (OR 0,75; 95% CI 0,04-12,04), heart rate (OR 0,95; 95%CI 0,06-13,91), diabetes melitus (OR 4,27; 95%CI 0,35-50,8), dyslipidemia (OR 0,58; 95% CI 0,05-6,91), hypertension (OR 0,16; 95% CI 0,06-4,59), and patern of ECG (OR 1,05; 95%CI 0,26-4,1). By multivariates analysis, independent predictors of major complication could not be defined.

Conclusion: There is no specific prognostic factor related with complication of DSE. Complications and adverse effects are usually minor and self-limitting. Major rhytmic complication and hypertension are rare complication of DSE.

Keyword: Dobutamine Stress Echocardiography, Complication, Prognosis

729

PO 280COMPARISON OF SERUM ALDOSTERONE LEVEL UNSTABLE ANGINA PECTORIS (UAP) PATIENTS AND NON ST ELEVATION OF MYOCARDIAL INFARCT WITH NON CARDIAC CHEST PAIN AT MOHAMMAD HOESIN HOSPITAL PALEMBANG

Merry, Taufik Indrajaya, Ahmad Yuliandri, Mgs Irsan Saleh

Background : Unstable angina pectoris is defined as angina pectoris with one of the clinical appearance occurs when a break lasting more than 20 minutes. The pain increases but the cardiac enzymes still remains. Myocardial infarction without ST elevation (NSTEMI) causes the elevation of cardiac enzymes while non-cardiac chest pain resembles with agina without evidence of coronary artery disease. The increasing of aldosterone serum accelerates atherosclerosis. There is no publication yet related this research in Indonesia. This study aims to determine the difference of serum aldosterone level of unstable angina pectoris patients compared with NSTEMI and non cardiac chest pain patients at Mohammad Hoesin Hospital Palembang.

Method : Design of this study was a case control study. It was conducted at the ER, wards and Intensive Cardiovascular Care Unit of Muhammad Hosein Hospital Palembang. 48 patients went to this research in which 16 of them were each in UAP group, NSTEMI group and non cardiac chest pain group.

Results : The result showed 36 patients (75%) were men and 12 patients were women (25%) with mean of age was 55.40 ± 6.43 years old. The range of serum aldosteron level was 2.4ng/dl to 18.30ng/dl. Chi square test was done to compare the aldosterone serum level within the groups and P value of UAP patients compared with non cardiac chest pain was 0.001 (OR 18.77; 95% CI = 3.181 to 110.83). P value of aldosterone serum between NSTEMI patient and non cardiac chest pain was 0.033 (OR 5.00; 95% CI = 1.096 to 22.820).

Conclusion: This study reported that serum aldosteron levels of UAP and NSTEMI were higher than non cardiac chest pain in Mohammad Hoesin Hospital Palembang

Keywords: UAP, NSTEMI, Non-cardiac chest pain, serum aldosteron

730

PO 281EVIDENCE BASED CASE REPORT: NON-ALCOHOLIC FATTY LIVER DISEASE INCREASES CAROTID INTIMA MEDIA THICKNESS AS A RISK FACTOR OF CORONARY ARTERY DISEASE

Diba, S. F.,1 & Pratiwi, K. N.,2

1. General Practitioner, Cibitung Medika Hospital, Indonesia2. General Practitioner, Mitra Plumbon Hospital, Indonesia

Background: Non-alcoholic fatty liver disease (NAFLD) is notoriously one of the critical issue in Asia-Pacific. NAFLD is not only associated with liver-related disease but also extra-hepatic disease which includes risk of coronary artery disease (CAD). There are several studies argued that NAFLD is considered as a sole factor of CAD. Consequently, the NAFLD itself expected to be a predictor of CAD with Carotid Intima Media Thickness (CIMT) identification as a standard method for atherosclerosis evaluation.

Aim: This study aims to evaluate the effect of NAFLD to CIMT as a risk factor of CAD.

Method: Patient’s data were obtained from medical history, physical examination, and laboratory examination in Cibitung Medika Hospital. Four papers taken from PubMed, EBSCOhost, and MEDLINE ranging from 2011 to 2016 publication were compared. Referring to inclusion and exclusion criteria, author selected a matched meta analysis research and apprised as an eligible study.

Result: The meta analysis study suggest that 80.4% of NAFLD patients has CAD while 60.7% of patients without NAFLD experienced CAD, p < 0.0001. To an extent, four studies from the paper which conducted to 1947 patients concluded both 35.1% of NAFLD patients and 21.8% of patients without NAFLD presented pathological CIMT, p < 0.0001. Three out of four studies have strong correlation between NAFLD and pathological CIMT [OR 2.04 (95% CI: 1.65-2.51)].

Conclusion: On these grounds, we conclude that strong correlation between NAFLD and CIMT increase the risk of CAD. In accordance to the case, it is fair to suggest that the NAFLD increased patient’s risk towards CAD.

731

PO 282Cardiac tamponade: A reality in hypothyroidism

Authors: Mihaela Cristina Olaru, Dr. Alina Dumitrascu

The objective of this presentation is to address the outcome of pericarditis in patients with hypothyroidism and its therapeutical limits. We are going to discuss a patient with known hypothyroidism. This patient, male, 59 years old, with multiple comorbidities, had stopped taking his substitutive treatment for 3 months. He presented with some typical symptoms of cardiac tamponade – dyspnoea, hypotension and tachycardia. Physical examination and relevant investigations were carried out. The sample collected from pericardiocentesis showed characteristics of transudate. With further investigations(ultrasonography and CT scan) and lab results, we reached the diagnosis of hypothyroidism as the cause of pericarditis, excluding neoplasm, viral and bacterial pericarditis, acute myocardial infarction, tuberculosis , lupus and rheumatoid arthritis , although the characteristics of transudative pericardial effusion narrows down the aetiology of pericarditis .After repeating the pericardiocentesis, we could not get any further long term benefits because of the fast reaccumulation of the pericardial fluid, in spite of the treatment with levothyroxinum. The reaccumulation of the pericardial effusion seem to be determined by the severity of the disease. All these indicate a poor outcome and limit the possible treatments he could receive. The patient responded to the thyroid hormone replacement. From this case, we understand that treating the underlying cause (hypothyroidism) can change the outcome of the condition and avoid the complications. Although rare, cardiac tamponade does happen in patients with hypothyroidism.

732

PO 283CORRELATION POLYMORPHISMS GEN CHAIN 　 FIBRINOGEN AND FIBRINOGEN LEVELS WITH STENOSIS SEVERITY CORONARY ARTERY ON CORONARY HEART DISEASE PATIENTS AT PALEMBANG MUHAMMAD HOESIN HOSPITAL

Yudi Fadilah, Mediarty, Taufik Indrajaya,Yuwono, Ali Ghani

Background: plasma fibrinogen levels are factors that play a role in the incidence of cardiovascular disease. Increased fibrinogen levels are also associated with genetic factors. Fibrinogen β chain gene polymorphisms contribute to plasma fibrinogen levels and correlated with an increased risk of atherosclerosis. This study aimed to examine the correlation between fibrinogen β chain gene polymorphism and serum fibrinogen levels with severity of stenosis in patients with coronary heart disease who performed catheterization at Palembang Dr Mohammad Hoesin Hospital.

Methods: The study was a prospective analytic correlative approach, without comparison carried out from July 2015 until January 2016 at the Cardiac Catheterization Laboratory Department of Internal Medicine Dr Mohammad Hoesin Palembang. A sample of 31 respondents who meet the inclusion and exclusion criteria. Β fibrinogen gene polymorphisms examined by PCR degree of coronary artery stenosis assessed by the score GENSINI and serum fibrinogen levels were examined by ELISA.

Results: Of the 31 respondents showed that respondents had the AA genotype as many as 15 people (48.4%), GA genotype as many as 12 people (38.7%) and GG genotype of 4 people (12.9%). The mean fibrinogen levels of 420.16 ± 100.65 mg / dl and a mean score of 32.03 ± 26.72 GENSINI, with the degree of stenosis weigh as much as 17 people (53.1%), the degree of stenosis medium and light respectively 5 people (15.6%) and 10 men (31.2%). Chi square test showed an association between fibrinogen β chain gene polymorphisms with serum fibrinogen levels (p = 0.039) but there is no significant relationship between gene polymorphisms β chain of fibrinogen with the degree of coronary artery stenosis by GENSINI score (p = 0.512). With Spearman’s rho test positive correlation is very weak between fibrinogen levels and the degree of coronary artery stenosis by GENSINI score (r = 0.142, p = 0.447)

Conclusion: This study obtained a relationship between gene polymorphisms chain of β fibrinogen and fibrinogen levels in serum, but there was no correlation between gene polymorphisms chain of β fibrinogen with the degree of stenosis of coronary artery based on the score GENSINI and there is a positive correlation is very weak between fibrinogen levels and the degree of stenosis of coronary artery by GENSINI score.

Keywords: β gene polymorphisms fibrinogen, fibrinogen, GENSINI score.

733

PO 284RELATION OF BLOOD UREA NITROGEN TO IN-HOSPITAL MORTALITY IN HEART FAILURE GERIATRIC PATIENTS

Sari Harahap, Naomi Niari Dalimunthe, Zainal Safri, Rahmad Isnanta, Refli HasanDivision of Cardiovascular, Internal Medicine DepartmentFaculty of Medicine Sumatera Utara University

Background : The incidence of heart failure turns out to be much higher in geriatric patients. It demostrates worse outcomes compared with younger patients. Blood Urea Nitrogen (BUN) represents renal hypoperfusion secondary to altered hemodynamics and also reflects neurohormonal activation which are common happened in heart failure. This study tends to determine whether hospitalized heart failure geriatric patients with higher BUN will have worse outcomes in hospital than normal BUN patients.

Methods : This is a retrospective observational study using hospital medical records data of geriatric patients hospitalized with heart failure from January until December 2015 in Adam Malik Hospital, Medan, Indonesia. Geriatric patients were defined as aged ≥ 60 years old. Data were categorized according to baseline BUN level into two group, normal BUN (≤20 mg/dl) and elevated BUN (>20 mg/dl). Difference in variables between two groups were evaluated using chi-square test for categorical variables and independent t-test or Mann Whitney U test for continuous variables.

Results : Total 158 data were observed, with mean age 67.82 ± 0.49 years and mean baseline BUN level 25.77 ± 1.46 mg/dl. Elevated BUN level was found in 84 (53.16%) patients and this group significantly had higher in-hospital mortality compared to normal BUN group (p=0.015, OR=8.760, 95% CI 1.082-70.892).

Conclusion : Elevated BUN level was more prevalent in hospitalized geriatric heart failure patients which associated with higher in-hospital mortality and worse prognostic. BUN level should be considered in risk stratification and evaluation of therapeutic strategies in geriatric heart failure patients.

Keywords : BUN, geriatric, heart failure, in-hospital mortality

734

PO 285PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY PATIENTS WITH SUBCLAVIAN-INNOMINATE VENOUS THROMBOSIS

Djallalluddin1Dono Antono2

1. Fellow of Cardiovascular FMUI/RSCM Jakarta. Departement of Internal Medicine FM ULM/RSUD Ulin Banjarmasin

2. Division of cardiovascular Departement Internal Medicine FMUI/RSCM Jakarta.

Introduction: The increased use of central venous access for hemodialysis has led to a significant increase in clinically relevant central venous occlusive disease (CVOD). Due to the unavoidable use of indwelling devices. CVOD has become a serious threat for patients with a history of catheter placements.

Acute upper vein obstruction was emerged as a significant clinical problem. CVOD need emergency treatment the acute event involving the axillary, subclavian, innominate vein.

Methods: We hereby report a case of a 72 year old female patients who was diagnosed with End Stage Renal Disease (ESRD) and right upper-extremity edema. She was maintained on regular hemodialysis via arteriovenous fistula, with history of use dual lumen catheter for 2 times more than 2 months.

Percutaneous Transluminal Angioplasty (PTA) of the superior vena cava stenosis was performed from Subclavian to innominate vein. PTA and stent placement was performed to evacuated stenosis. After intervention give good flow and none of residual stenosis. The patients was discharged in good condition, presenting disabling of upper-extremity edema. Patient maintained on double anti platelets.

Result: Succesful of percutaneous transluminal angioplasty therapy for relieving symptoms and maintaining central venous patency.

Keyword: CKD-Thrombo embolism-PTA

735

PO 286The Prevalence of Coronary Heart Disease Patient with Hypertension and Diabetes Mellitus History in Jakarta Heart Center Hospital

Todung DA Silalahi, Andreas M Siborutorop, Chaidar Muttaqin, Roland Helmizar* Division of Cardiovascular, Department of Internal Medicine, Jakarta Heart Center Hospital, Jakarta, Indonesia.

Background : In developing countries, non – communicable disease such as cardiovascular disease will immediately subtitute communicable diseases and malnutrition as cause of early mortality as well as disability. Coronary Heart disease (CHD) is one of the non – communicable disease that become the world spotlight. It is associated with a change in lifestyle paralel to the era development. WHO in 2012 estimated that 17.5 million people died from CVD ( Cardio Vascular Disease ) and 7,4 million attribute to CHD

Objective : The objective of this study was to describe the incident history of hypertention and diabetes mellitus in patient with CHD in Jakarta Heart Center Hospital.

Method : This was a descriptive study with cross sectional design which carried out in Medical Record of Jakarta Heart Center Hospital from April 2015 until March 2016. The population in this study were 936 medical record had the inclusion and exclusion criteria. All data were processed and analysed by manualy and then the data shown by frequency distribution table.

Result : From 936 patients, who enrolled in this study, the prevalence of CHD patient with Hypertention history is 59.7 %, Diabetes mellitus history is 4.8% and both of hypertention and diabetes mellitus history is 18.26%. The distribution of CHD patient based on age in the group 30 – 40 years 3.84%, 41 – 50 years 17.62%, 51 – 60 years 34.82%, and greater than 60 years 43.4%

Conclucion : The highest distribution of CHD patient based on age is the age group greater than 60 years ( 43.4% ), majority were male (68.1%) and has hypertention history (59.7%)

736

PO 287The Distribution of Coronary Artery Lession in Patient With Hypertention and Diabetes Mellitus History in Jakarta Heart Center Hospital

Todung DA Silalahi, Andreas M Siborutorop, Chaidar Muttaqin, Roland Helmizar* Division of Cardiovascular, Department of Internal Medicine, Jakarta Heart Center Hospital, Jakarta, Indonesia

Background : WHO stated that around 7.4 million people died from Coronary Artery Disease (CAD) in 2012. Based on data released by The Center of Information and Data of Health Secretary Indonesian Republic known that prevalence of CAD in Indonesia on 2013 is 1,5% or arround 2.650.340 cases. Risk factors that contribute to CAD are: non-modifiable (age, gender) and modifiable (smoking, dyslipidemia, hypertension, obesity, and diabetes). The intervention of the risk factors will lead to the accumulation of lipid and fibrous tissue in the coronary artery that progressively narrows the lumen of blood vessels.

Objective : To describe distribution of CAD patients with history of hypertention and diabetes mellitus correlated with location and amount of coronary artery lessions.

Methods : The design was a descriptive cross sectional study, that conducted by collecting data from medical records of patients with CAD, who has CAD with history of hypertention and diabetes mellitus and been catheterized in Jakarta Heart Center Hospital Matraman, Jakarta from April 2015 to March 2016. The number of samples who have fulfil the criteria of inclusion and exclusion is 756 patients.

Result : From 765 patients who enrolled in this study, patients with hypertention history who has CAD1VD is 162 (21.17%), CAD2VD is 130 (16.99%), CAD3VD is 160 (20.91%), CAD3VD+LMD is 61 (7.97%). Patients with Diabetes Mellitus history who has CAD1VD is 12 (1.56%), CAD2VD is 10 (1.30%), CAD3VD is 11 (1.43%), CAD3VD+LMD is 5 (0.01%). Patients with both hypertention and diabetes mellitus history who has CAD1VD is 38 (4.96%), CAD2VD is 17 (2.22%), CAD3VD is 67 (8.75%), CAD3VD+LMD is 33 (4.35%).

Conclusion : The most lession in patients with hypertention history is CAD1VD, whereas the most lession in patients with diabetes mellitus history is CAD1VD, while the most lession in patients with both hypertention and diabetes mellitus history is CAD3VD.

737

PO 288COMBATING DONOR ORGAN SHORTAGE:ORGAN CARE SYSTEM PROLONGING ORGAN STORAGE TIME AND IMPROVING THE OUTCOME OF HEART TRANSPLANTATIONS

Angela Felicia Sunjaya, Anthony Paulo SunjayaFaculty of Medicine, Tarumanagara University

Cardiovascular diseases are the number one cause of death globally contributing to 37% of all global deaths. A common complication of cardiovascular disease is heart failure, a condition where the heart is unable to pump sufficiently to maintain blood flow to meet the body’s need where in such cases, the only solution would be to conduct a heart transplant. Every 10 minutes a new patient is added to the transplant waiting list. However, a shortage of human donors and the short window of time available to find a correct match for the patient and transplant the donors’ heart to the recipient means that numerous challenges are faced by the patient even before the operation could be done, reducing their chances of living even further.

This review aims to evaluate the application of the Organ Care System (OCS) in improving the efficiency of organ storage by prolonging the ischemic time of donors’ hearts. The OCS allows preservation of the donor heart by perfusing the organ at 34°C in a beating state, potentially reducing the detrimental effect of cold storage and providing additional assessment options. Studies have shown that the OCS is capable of extending the ischemic time 120 minutes longer than conventional methods without any detrimental effect on the recipient nor donor’s safety. Another clear advantage is the implanting surgeon can assess the quality of the donor heart before surgery as well as provide a time safety buffer in unanticipated circumstances that will reduce the mortality risk of transplant recipients.

Keywords: Cardiovascular disease, Heart Failure, Organ Care System, Heart aTransplant

738

PO 289PRIMARY PERCUTANOUS CORONARY INTERVENTION: PATIENT CHARACTERISTIC IN 1 YEAR OBSERVATIONAL STUDY IN CIPTO MANGUNKUSUMO HOSPITALIka Prasetya Wijaya MD, Rizky Rahmaniyah MD

Cardiology Division, Department of Internal Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background Primary Percutaneous coronary intervention (PCI) is the most common procedure in invasive treatment of patient with coronary heart disease. The aim of this study was to describe characteristics of patient underwent primary PCI procedure.

Methods In this descriptive observational study, 244 patients who underwent primary PCI procedure in Cipto Mangunkusumo Hospital was identified. All procedures performed from January 2015 to December 2015 were included in this analysis. All data was collected from medical record.

Results From 244 patients, there were 188 (76.7%) males, 56 (22.9%) females, mean age was 59, with standard deviation 59 + 8. Traditional risk factors was identified. Hypertension appeared to be the most common traditional risk factor 187 (76,3%), followed by smoking 120 (49%), diabetes mellitus 89 (36.3%), dyslipidemia 48 (19.6%), and family history of cardiovascular disease 27 (11.6%). The most frequent stent used for primary PCI is drug-eluting-stent 263 (96.3%). Mostly involved single vessel disease 107 (43.7%), and left artery descending 198 (80.8%).

Conclusion Primary PCI patient was dominated with males. Patient age range lies between middle aged (41-59 years old) and elderly (60-74 years old). High prevalence of hypertension as traditional risk factor, used of drug eluting stent, involvement of left artery descending was also observed.

Keywords primary percutaneous intervention, coronary heart disease

739

PO 290CLINICAL AND ANGIOGRAPHIC PROFILE IN PATIENTS OVER 60 YEARS OF AGE WHO UNDERWENT INVASIVE CORONARY PROCEDURE

Rachmat Hamonangan MD, Ika Wijaya MD, Prof. Siti Setiati MD, Kuntjoro Harimurti MD, Rizki Dinar Endartini MD

Cardiology division, Internal Medicine Department - Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

Background : Invasive procedure required critical consideration of benefit and risk prior to performing coronary angiography and or angioplasty in elderly patients. The aim of this study was to present characteristics and demographics profile elderly patient who underwent coronary angioplasty procedure.

Methods: The whole retrospective study population consisted of 143 consecutive elderly patients who underwent coronary angiography and or angioplasty procedure at Cipto Mangunkusumo Hospital from Mei 2013 to Mei 2015. The database includes demographic, clinical, procedural data, and periprocedural complication.

Result: in There were 112 (78.3%) males, mean age 69.1 ± 5.9 years and 19.5% above 75 years age. The most frequent clinical indication was coronary artery disease (CAD) with stable angina (57,2%), 37(25.8%) patients subjected for acute coronary syndrome (ACS) and 3(2.7%) patients with mitral valve regurgitation prior to valve surgical. Seventy-five (53.1%) patients had congestive heart failure (CHF), 41.9% had hypertension, 16% had diabetes mellitus, 4.1% had stroke, and 30% had chronic kidney disease. Ninety (62.9%) patients used radial access. Single-vessel disease was found in 5.5%, two-vessel disease was found in 6.9%, multi-vessel disease in 76.9%, and chronic total occlusion was found in 15.3%, respectively. Thirty-seven patients were referred due to left main disease. Coronary angiography disclosed CAD in 89.5%, among these were 44 patients underwent percutaneous coronary intervention (PCI). Twenty-six (59%) PCI cases had one stent implanted. All the stents used drug-eluting-stent, most frequently used diameter 3.5 in 19 (31.6%). Angiographic success was achieved in 97,79% of PCIs. The peri-procedural complication was acute stent thrombosis in one patient.

Conclusion: The clinical appearance of invasive coronary procedure in elderly patients was mostly stable angina pectoris and ACS. Most common comorbidities were CHF and hypertension. There was predominance of triple-vessel disease. Our study showed 97.7% success in percutaneous revascularization procedure.

Keyword coronary artery disease, CAD, coronary angiography, elderly

740

PO 291IMPACT OF FRAILTY ON 30-DAYS MAJOR CARDIAC VENTS IN ELDERLY PATIENTS WITH CORONARY ARTERY DISEASE UNDERWENT ELECTIVE PERCUTANEOUS CORONARY INTERVENTION

Rachmat Hamonangan MD, Ika Wijaya MD, Prof. Siti Setiati MD, Kuntjoro Harimurti MD

Cardiology division, Internal Medicine Department - Faculty of Medicine Universitas Indonesia, dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

Background: Frailty is commonly found in elderly patients with cardiovascular disease and frailty had a major influence in determining the prognosis of cardiovascular disease in elderly including the outcome of revascularization intervention. PCI (Percutaneous Coronary Intervention) is one method of revascularization. However, frailty research on the effect on the outcome of elderly patients with coronary artery disease undergoing PCI is still limited. The aim of this study was to get the proportion of frailty and 30 days Major Adverse Cardiovascular Events (MACE) incidence and to review impact of frailty in elderly patients with coronary heart disease who underwent elective PCI.

Method: The frailty condition of the elderly patients with coronary artery disease that underwent elective PCI in Cipto Mangunkusumo Hospital was assessed with the Frailty Phenotype criteria. After the patients underwent the elective PCI, they were followed for 30 days to see whether MACE occurred or not.

Result: There are 100 elderly patients with coronary artery disease that underwent elective PCI from September 2014 until June 2015. The mean age of patients is 66.95 ± 4.875 years and 69% of the patients were males. Frail 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 correlation between frailty and MACE could be seen in the result of crude HR 1.6 (CI 95% 0.31-8.24). In this research, the 30 days survival rate is 95% in frail patients and 98% in non-frail patients.

Conclusion: There is a 1.6 fold increased risk of 30 days MACE in elderly frail patients that underwent elective PCI but it is not statistically significant.

Key Word: Coronary artery disease, elderly, frailty, major adverse cardiac events, percutaneous coronary interventions

741

PO 292A RARE CASE OF COMPLEX REGIONAL PAIN SYNDROME (CRPS) BEFORE MYOCARDIAL INFARCTION

Background: CRPS is characterized by severe pain disproportionate to stimuli, associated with sensory, motor and vasomotor symptoms, usually affecting the extremities, most commonly precipitated by a fracture. We present a patient with CRPS as an atypical presentation of Myocardial Infarction (MI).

Case report: A 94-year-old lady with diabetes mellitus, hypertension and coronary artery disease was admitted repeatedly over two years for ACS work-up. Echocardiograms and nuclear stress tests were negative. For six weeks prior to presentation she continuously experienced sharp pains in the left infra-scapular area radiating to the axilla and inframammary regions. There was associated edema, localized hyperhidrosis, warmth, weakness, diminished range of motion, and allodynia over the left shoulder and chest wall. She was diagnosed with CRPS. Her pain partially resolved with pain meds. She strongly believed that, “The pain is coming from my heart.” Three months later she had syncope with severe chest pain lasting two hours and was diagnosed with an inferior STEMI. Emergency catheterization revealed 100% occlusion in the right coronary artery. After stenting, all CRPS symptoms resolved.

Conclusion: CRPS describes an array of painful conditions not related to the degree or duration of tissue damage. Etiology is poorly understood. Peak incidence is in females 61 to 70. The Budapest Criteria for clinical diagnosis includes continuing pain and symptoms in three of the following four categories: 1) allodynia; 2) vasomotor (temperature or skin color asymmetry); 3) localized sudomotor or edema; 4) motor dysfunction or trophic changes in hair, nail or skin. Likewise, signs must be verified in two of the categories. MI in elderly patients with DM usually presents with atypical symptoms. Based on our literature search, CRPS after MI has been reported but has not been reported as a presentation of MI.

742

PO 293The Role of Duke Treadmill Score as A Predictor of Coronary Artery Disease in Patients with Positive Treadmill Test.

Muhammad Ikhsan1, Sally Aman Nasution2, Ika Prasetya Wijaya3, Cleopas Martin Rumende4

1. Internal Medicine Department, Faculty of Medicine, University of Indonesia 2. Cardiology Division, Internal Medicine Department, Faculty of Medicine, University

of Indonesia3. Cardiology Division, Internal Medicine Department, Faculty of Medicine, University

of Indonesia4. Pulmonology Division, Internal Medicine Department, Faculty of Medicine, University

of Indonesia

Background: Coronary Artery Disease (CAD) is one of the disease entity that leading cause of morbidity and mortality in worldwide. The treadmill test is part of the diagnostic modality which readily available to assess the possibility of narrowing coronary artery and guiding us whether we need for the further investigation. Despite that, treadmill test has a limitation in diagnostic accuracy. Duke Treadmill Score (DTS) was also tested as a diagnostic score, and shown to predict significant CAD better than the ST-segment response alone.

Objectives: To determine the potential of DTS as a predictor of significant CAD in patients who showed positive ischemic response during the treadmill test, comparing with coronary angiography as a gold standard.

Methods: This is a cross-sectional study performed in adult patients with stable CAD that underwent treadmill test and coronary angiography in outward patient clinic of the Integrated Cardiac Service in Cipto Mangunkusumo Hospital between January 2011 and December 2013.

Results: A total of 103 patients in this study, thirty-nine patients (37,9 %) had significant CAD in coronary angiography. Based on DTS results, the cut-off point was determined by using Receiver Operator Curve (ROC) method, in which value of -8,85 considering as a cut-off point. Sensitivity and specificity value of DTS were 28 % (CI 95 %: 17 % to 44 %), and 95 % (CI 95 %: 87 % to 98 %). Positive and negative predictive value were 79 % (CI 95 %: 52 % to 92 %) and 69 % (CI 95 %: 58 % to 77 %). Positive and negative likelihood ratios were 6.02 and 0.75.

Conclusion: DTS has good performance in predicting significant CAD at the cut-off point -8,85 in patients with positive treadmill test.

Keyword : CAD, DTS, treadmill test.

743

PO 294AORTIC DISSECTION ASSOCIATED WITH MYOCARDIAL INFARCTION: A CASE REPORT

Muhammad Yamin, Simon Salim

Division of Cardiology, Department of Internal Medicine, Faculty of MedicineUniversitas Indonesia/Cipto Mangunkusumo Hospital

BackgroundChest pain is a common symptom which brings patients to seek medical treatment. However, chest pain can be triggered by a wide range of medical condition. Aortic dissection is one of the differential diagnosis of chest pain. The symptom may mimic myocardial ischemia, leading to misdiagnosis and inappropriate administration of thrombolytic or anticoagulant treatment. We present a case of aortic dissection associated with myocardial infarction.

Case PresentationWe report the case of 55-years old man who developed sudden onset severe chest pain 8 hours before admission. It was initially diagnosed and treated as acute coronary syndrome NSTEMI due to the symptoms, electrocardiography finding of ST depression in lead II, III, aVR, and supportive laboratory finding (CK/CK-MB: 663/84.1; Troponin T: 0.18). This patient then underwent urgent coronary angiography because of his ongoing severe chest pain. From his angiography we found type 1 aortic dissection from aortic root until descendant aorta with severe aortic regurgitation. Both of coronary ostium was not visible because it was covered by the dissection flap.

Discussion and ConclusionThe incidence of aortic dissection is estimated to be 5–30 cases per 1 million people per year with high mortality rate. The classic aortic dissection symptoms are severe, sudden, sharp, chest/back pain and sometimes associated with myocardial infarction and aortic regurgitation. Acute myocardial infarction may result from coronary occlusion due to extension of the dissection. It may result in changes in electrocardiography. Moreover, when aortic dissection is accompanied by coronary malperfusion, it may have a fatal outcome for the patient. Therefore, physicians should be aware of the possibility of aortic dissection in patients with chest pain with or without electrocardiography changes because administration of thrombolytic or anticoagulant treatment due to failure to recognize aortic dissection may result in catastrophic consequences.

744

PO 295CORRELATION BETWEEN SERUM ASYMMETRIC DIMETHYLARGININE (ADMA) LEVEL AND GENSINI SCORE IN CORONARY ARTERY DISEASE PATIENTS AT MOHAMMAD HOESIN HOSPITAL PALEMBANGRazak A, Erwin S, Ghanie AInternal Medicine Department, Faculty of Medicine Sriwijaya University –Mohammad Hoesin General Hospital Palembang

Background: Coronary artery disease (CAD) remains a major health problem in the world because of its morbidity and mortality. One of the methods for establishing diagnosis of CAD is by corangiography, it is to find the presence of coronary arterial stenosis. To determine the degree of coronary arterial stenosis may be assessed by Gensini score. Asymmetric dimethylarginine (ADMA) is a structural analog of L-arginine, competitively inhibits the enzyme NO synthase and thus it has role in endothelial disfunction. Studies showed that serum ADMA has independent association with presence and severity of CAD. There is none publication of this study in Indonesia and especially in Palembang.

Method: Correlative analytic design with a prospective approach without control. The study was conducted at Cardiac Catheterization Laboratory of Internal Medicine RSMH Palembang, started from November 2015 until January 2016. Subjects were CAD patients who undergoing corangiography and the degree of coronary arterial stenosis assessed by Gensini score.

Results: There were 43 subjects with 25 male (79,1%). The mean level of serum ADMA was 0,50±0,10 µmol/L and its cut off point was 0,50 µmol/L. There was relationship among sex (p=0,019), smoking (p=0,005), serum ADMA (p=0,002) and the degree of coronary arterial stenosis. While other risk factors such as age, BMI, hypertension, diabetes, and dislipidemia had not found any relationship. Statistical analysis showed significantly moderate correlation between serum ADMA level and the degree of coronary arterial stenosis assessed by Gensini score (r=0,414; p=0,006).

Simpulan: There is significantly moderata correlation between serum ADMA level and the degree of coronary arterial stenosis assessed by Gensini score in CAD patients at Mohammad Hoesin General Hospital Palembang.

Kata kunci: coronary artery disease, ADMA, Gensini score

745

PO 296THE IN-HOSPITAL MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS WITH ACUTE CORONARY SYNDROME IN INTERNAL MEDICINE WARD

Ahmad Fariz M. Z. Zein, Taufiq M. Waly, Mohamad Luthfi, Irene GunawanDepartment of Internal Medicine, Waled General Hospital, Cirebon, West Java, Indonesia

Background. Acute coronary syndrome (ACS) is still a major health problem, related to mortality and major adverse cardiovascular event (MACE). Moreover, limited facilities including coronary angiography and intensive cardiac care unit are still intriguing issues. The prevalence of in-hospital MACE in patients with ACS in internal medicine ward is unknown yet. This study was aimed to determine the prevalence and the profile of in-hospital MACE in patients with ACS in internal medicine ward in Waled General Hospital, Cirebon, West Java, Indonesia.

Methods. A cross sectional study was conducted using secondary data from medical records of patients with ACS who were admitted to internal medicine ward, due to unavailability of intensive ward, between April 1, 2015-March 31, 2016. The in-hospital MACE encompassed arrhythmias (atrial arrhythmia, supraventricular tacchycardia, ventricular tacchycardia, and high-grade AV block), reinfarction, acute decompensated heart failure (ADHF), cardiogenic shock, cerebrovascular disease (CVD), and mortality, during the hospitalization.

Results. There were 126 subjects in this study, mean age 56.38 years old (SD 10.72). Most of the subjects were women (n=82; 65.10 %). Of total subjects, 58 (46.05 %) were ST-elevation myocardial infarction (STEMI), 58 (46.05 %) were non ST-elevation myocardial infarction (NSTEMI), and 10 (7.90 %) were unstable angina pectoris (UAP). The prevalence of in-hospital MACE in this study was 68.30 %, encompassed arrhythmia 26 (20.60 %), reinfarction 8 (6.30 %), ADHF 26 (20.60 %), cardiogenic shock 12 (9.50 %), CVD 2 (1.60 %), and mortality 12 (9.50 %).

Conclusion. The prevalence of in-hospital MACE in patients with ACS in district general hospital was 68.30 %. The most frequent in-hospital MACE were arrhythmia and ADHF, followed by cardiogenic shock, SCD, reinfarction, and CVD.

Keyword

In-hospital major adverse cardiovascular event, acute coronary syndrome, internal medicine ward

746

PO 297Decrease of Uric Acid Level is Associated with Low Level of Transforming Growth Factor-β1and Left Vetricular Mass Index in Heart Failure Patients.

Frans Wantania, Martino Sutrisno, J. Ongkowijaya, R.L. Lefrandt, and LWA RottyDepartment of Internal Medicine, Faculty of Medicine Sam Ratulangi University, Manado

Background.

Hiperuricemia is an independent mortality factor in heart failure patients. Increased uric acid can stimulate further angiotensin II result in cardiac fibrosis through activation of TGF-β1. Cardiac fibrosis responsible for the occurrence of heart failure. Aim of this study is to determine the association of the low uric acid level with the TGF-β1 level and LV Mass Index in Heart Failure patients.

Methods.

Thirty-seven subjects with heart failure were recruited in this cross-sectional study, and we divided in two groups. There was nineteen patients with low level of uric acid and eighteen patiens with elevated uric acid level. Plasma TGF-β1 level were measured by ELISA and LV Mass Index was calculated according to the American Society of Echocardiography criteria

Results.

Plasma TGF-β1 level in low uric acid group were significantly lower than the elevated uric acid group (48,263 vs vs 56,443; p=0.040). We also found that LV Mass Index in low Uric Acid group were significantly lesser than the elevated uric acid level group (151,2 vs 194,5; p=0,014)

Conclusion.

Decrease of Uric Acid level is associated with low level of TGF-β1 and LVMI in Heart Failure Patients.

Key Words.

Uric Acid, TGF beta, Left Ventricular Mass.

747

PO 298Risk Factors of Left Ventricular Hypertrophy in Male Students at Medical Faculty, Sam Ratulangi University

Ribka L. Wowor, G. D. Kandou, J. M. L UmbohFaculty of Public Health, Sam Ratulangi University, Manado, Indonesia

Background: Left Ventricular Hypertrophy (LVH) is an independent risk factor of heart failure. Previous study reported several cases of LVH in college’s students, so it’s very important to know the risk factors of LVH in young adults. Aim of this study was to determine the risk factors of LVH in the male students at the Faculty of Medicine, Sam Ratulangi University

Methods: This case-control study was conducted in Cardiology Section Prof. dr. RD Kandou Manado Hospital from November 2014 to January 2015. The independent variables were central obesity, hypertension, hyperuricaemia, smoking, lack of physical activity while the dependent variable was LVH. Chi squared test is used to determine the relationship between prehypertension history, smoking, central obesity, lack of physical activity, and hyperuricemia with the LVH.

Results: In this study, central obesity (OR=11,0; p=0.000) and hypertension (OR=7,37; p=0.000) were an independent risk factor for Left Ventricular Hypertrophy. We also found that hyperuriceimia (OR=3,273; p=0.031) and lack of physical activity (OR=6,333; p=0.025) were a risk factor for LVH.

Conclusion: There were a significant association of hypertension, hyperuricemia, central obesity, and lack of physical activity with LVH in male obese students at Medical Faculty, Sam Ratulangi University

Keywords: LVH, Hypertension, Central Obesity, Hyperuricaemia, Physical Activity

748

PO 299THE SUCCESS OF PERCUTANEOUS TRANSCATHETER ANGIOGRAPHY (PTA) ONE STENT IN PATIENT WITH END STAGE RENAL DISEASE (ESRD) ON HEMODIALYSIS (HD)

Agoes Kooshartoro1, Dono Antono2

1. Fellow of Cardiovascular Department Internal Medicine FMUI/RSCM Jakarta2. Division of Cardiovascular Department Internal Medicine FMUI/RSCM Jakarta

Background: The blockage incident of the central vein is increasing during the past few years. That is caused by the increase of catheter instalation on the central vein for the end stage renal disease (ESRD) who undergo hemodialysis treatment (HD). That kind of condition needs the right and fast treatment to prevent further damage.

Case: A 68 years old male has been diagnosed with ESRD, hypertension and Diabetes Militus type II for 18 years. For the past 3 months he has a swollen left arm and receive treatment. The patient has a history of regular HD via simino jugular vein dual lumen for 4 months. During the physical examination, the tension is 154/158 mmHG;hr 84;rr20. Body weight/height is 80kg/162cm. Based on the result from the lab exam HB 7.4; HT 23.4 leukosit 8.2; Trombosit 245; blood sugar at 88mg/dl; ecg normal sinus rythm. The result of usg doppler showed total oklution of vein subclavia sinistra. PTA 1 stent is done to left subklavia and continued by purchasing double antipatelet for 6 months. The intervention result showed that the swollen is getting better and the central vena patency can be maintained.

Discussion: The oklution vena subklavia related with the history of installation of catheter central vein mostly performed on ESRD patient with HD. PTA is the right approach to reduce oklution vena subklavia with the best results and maximum complications.

749

PO 300Impact of Preserved versus Reduced Ejection Fraction on Clinical Outcomes in Female Patients Hospitalized for Heart Failure

Wira Prihatin Siregar, Naomi Niari Dalimunthe,Sari Harahap, Rahmad Isnanta, Zainal Safri, Refli HasanDivison of Cardiovascular,Department of Internal Medicine,Faculty of Medicine,Sumatera Utara University

Background.Several epidemiologic studies have recently shown that about half of all patients hospitalized for heart failure have a preserved ejection fraction (EF). It varies widely from 13 % to 74% and frequently in older patients and women. This study aims to assess the impact of preserved vs reduced ejection fraction on clinical outcomes in female patients hospitalized for heart failure.

Methods.This retrospective observational study used medical record data of female patients hospitalized for heart failure between January to December 2015 in Adam Malik Hospital, Medan, Indonesia.Patients were classified as having preserved ejection fraction of heart failure (HFpEF) when their EFs were ≥ 40 % and as having reduce ejection fraction of heart failure (HFrEF) when their EFs were < 40%. Differences in variables between two groups were evaluated using chi-square test for categorical variables and independent samples t test or Mann Whitney U test for continuous variables.

Results.Of 225 data, female patient with HFpEF was present in 176 patients (78.22%) with mean age of female 48,82±15,42 years. Hypertension and Valvular Heart Disesase (VHD) were the most common comorbidities that most related to preserved EF but there was no different between the two group. Diabetes Mellitus type 2,Coronary Artery Disease (CAD) and Valavular Heart Disease were always related to preserved EF with significant P-value (p=0.007,p=0.000,p=0.009) respectively.There was no different length of stay in the two groups. But in female patients with HFpEF had significantly higher in hospital mortality compared to HFrEF (p=0.016, OR= 2.7, 95 % CI 1.172-6.252).

Conclusion.Most of the female patients with heart failure had preserved EF and it had association with higher in hospital mortality.

Key words : Ejection fraction, heart failure, mortality

750

PO 301THE APPLICATION OF RISK SCORES AS PREDICTOR OF IN-HOSPITAL MORTALITY POST PERCUTANEOUS CORONARY INTERVENTION IN INDONESIAN POPULATIONMatthew Billy,1 Harrison PB Panjaitan,1 Jimmy O Santoso,1 Lukman Z Amin,2

1. Faculty of Medicine, Universitas Indonesia2. Internal Medicine Department, Faculty of Medicine, Universitas Indonesia

e-mail : [email protected]

Introduction. Recently, there is no risk-adjusment model yet available in Indonesia to predict the outcome of percutaneous coronary intervention (PCI) procedure, which means there is no evidenced-based and individualized information about the outcome of procedure both to physician and patient. There are two promising scoring models, i.e. New Mayo Clinic Risk Score (NMCRS) and Michigan Risk Score (MRS) to be applied in Indonesian populaton. We sought to validate NMCRS and MRS models as predictor of in-hospital mortality after PCI procedure. This external validation would support the applicability of those models in Indonesia.

Methods. Between August 1st, 2013 and August 31st, 2014, 275 patients from Rumah Sakit Cipto Mangunkusumo – supspecialistic-level hospital and center of national referral – met our inclusion and exclusion criteria. Predicted mortality were estimated using both models. Receiver Operating Characteristic (ROC) for mortality was used for the comparison of NMCRS versus MRS models.

Result. From 275 subjects, 7 patients (2.54%) died in hospital. Analysis with ROC curve was used to evaluate the discrimination ability of each scoring model. From the analysis, NMCRS and MRS have p-value of 0.030 and 1.113 respectively, indicating that NMCRS has a significant p-value. The area under curve (AUC) of 0.741 indicates that NMCRS has a moderate discrimination ability to predict in-hospital mortality post PCI, when compared with MRS which has an AUC of 0.675.

Conclusion. NMCRS scoring model can be applied to Indonesian population to predict mortality in patients undergoing PCI procedure which has higher discrimination ability compared to MRS. In addition, its clinical and non-invasive simple laboratory data as its prognostic factors strengthen its applicability. With this score, we expect that mortality can be predicted; thereby, enabling the physician to be more prepared and inform the patient as well as family earlier.

Keywords: in-hospital mortality, Indonesia, percutaneous coronary intervention, risk score

751

PO 302Aortic blood pressure in patients having Acute Coronary Syndrome (ACS) assessed in a local hospital

Eduardo J Carvajal (Portugal)Aortic blood pressure in patients having Acute Coronary Syndrome (ACS) assessed in a local hospital. Background High Aortic blood pressure assessed invasively is an independent risk factor of cardiovascular diseases, regarding difference between aortic and brachial blood pressure messuared with sphygmomanometer. Pulse wave as non invasive method might have better correlation with aortic blood pressure. Materials and methods: Coronarygraphies and clinical reports from patients sent by a local hospital for evaluation during an ACS. Aortic blood pressure was assessed invasively during coronarygraphy in patients with different types of ACS. Results were collected using SPS2 application. Results: 76 catheterisms and medical reports from patients sent from a local hospital for ACS. Aortic blood pressure average was 145.6 (from 210 to 97) over 83.3 (From 120 to 50). Medium aortic blood pressure average was 104.60 (from 128 to 57). 28 Patients had medium aortic BP average below 100mgHg. 3 had ACS with ST elevation, 17 of them had ACS without T elevation, 4 unstable angina, 2 stable angina, 1 aortic aneurysm. Conversely, 48 patients had medium aortic BP above 100mmHg, having more ACS with ST elevation (10) with statistically significance (p<0.005) and also more ACS without ST elevation (27), 8 unstable angina, 2 stable angina and 3 syncope episodes. 3 and 2 vassels diseases were also found more often in the group having medium aortic BP above 100mmHg. Conclusión Aortic blood pressure might increase incidence of different types of ACS. Pulse wave could be an alternative messurement. Physicians should be encouraged to keep patients’ BP in primary and secondary care below recommended levels to avoid cardiovascular complications.

752

PO 303The Hume Algorithm : an aid to skilled assessment of chest pains in rural communities.

‘The Hume Algorithm for the management of patients with chest pains or suspected acute coronary syndromes’

Leslie E Bolitho1 AM FRACP on behalf of the Hume Region Clinical Care Network (Jeffrey Robinson2, Mark Ashcroft3and Olivia Stapleton4)

Introduction: The Hume Algorithm has been developed to assist medical (general practitioners and trainees), nursing and healthcare staff in the assessment of people presenting to small rural hospitals and urgent care centres (the Centres) in Northeast Victoria with chest pains or suspected acute coronary syndromes . Many of these centres are staffed after hours and on weekends by nursing staff – with on call medical practitioners available by phone or Telemedicine, and staff may have limited experience in management of acute cardiovascular emergencies. The Hume Algorithm provides staff with a resource that enables patients to be classified into risk categories from high to low risk of acute cardiovascular emergencies.

Method: An evidence based literature review was undertaken and included the National Heart Foundation of Australia documentation. Dr Philip Tideman and colleagues from the Integrated Cardiovascular Clinical Network- Country Health South Australia have described a similar approach to risk assessment for cardiovascular emergencies that has been introduced throughout rural South Australia. The Hume Algorithm was developed by the Hume Region Clinical Care Network, utilising established evidence, to enhance assessment, risk stratification, supported decision making, and early management of potential cardiovascular emergency within the first few hours of presentation at all rural centres throughout the Hume region in North East Victoria, which has a population catchment of 400,000.

Results: The Hume Algorithm has received local support from regional practitioners and has been implemented in more than 20 Centres in the Hume region. There has been an early and consistent improvement in patient care, and timely referral of patients to regional and tertiary centres.

Conclusion: The introduction of the Hume Algorithm provides evidence based guidelines for the early and appropriate management of patients with chest pains or suspected acute coronary syndromes. The Hume Algorithm could be adapted and adopted in other rural regions, especially if limited direct access to percutaneous cardiovascular facilities for definitive diagnosis and treatment. The longer term aim is to improve patient care and reduce cardiovascular morbidity and mortality in the rural setting.

Words 319

753

1Leslie E Bolitho AM MBBS FRACP FACRRM FACP FRCPI (Hon) MAICDAssociate Professor University of Melbourne; Adjunct Associate Professor Monash University2 Jeffrey Robinson MB BS FRACGP FACRRM DipRACOG, Grad Dip Rural GP3Mark Ashcroft RN, RM, A&E cert, Grad Cert Bus Mgt, Grad Dip Bus Mgt, Mstr of Management, Mstr Commerce, PhD Candidate.

4Olivia Stapleton RN, Dip Teaching, Grad Dip Theology Associate Nurse Unit Manager Bright Hospital

754

PO 304THE ROLE OF MOLLUCAS TRADITIONAL FOOD ON THE IMPROVEMENT OF RISK FACTORS OF CORONARY HEART DISEASE

YUSUF HUNINGKOR, IDRUS ALWIDepartment of Internal Medicine, Cardiology Division, University of Indonesia andDr. Cipto Mangunkusumo National General Hospital, Jakarta, IndonesiaCorresponding author: Yusuf Huningkor: [email protected]

Background: More than 75% of coronary heart disease can be attributed to conventional risk factors, most of which is modifiable.

Aim: To assess the correlation between Mollucas Traditional Food (MTF/sago) diet and the risk factors of CHD.

Methods: Cross sectional designed. All participants were men, Mollucas ethnic, aged between 40 and 60 years, . The participants were devided into two group: 73 Ambon citizens with Non-MTF diet, and 73 Taniwel Village residens with Sago diet. Data were collected through measurements of physical and laboratory parameters (glucose, Lipid profile, adiponectin, FFA, oxLDL, hsCRP) and analyzed using univariate, independent - samples T-test, linier regression and double linier regression methods.

Results: The CHD risk factors in non-MTF group compare to Sago group are: waist circumference are 93.35 ± 9.57 and 78.84 ± 7.8 cm respectively (p=0.000); adiponectin level are 5.53 ± 2.83 ng/mL and 12.06 ± 4.64 ng/mL respectively (p=0.000); hsCRP level are 4.52 ± 9.69 mg/L and 3.61 ± 6.37 mg/L respectively (p=0.507); FFA level are 0.43 ± 0.24 mM and 0.37 ± 0.47 mM respectively (p=0.379); Ox-LDL level are 66.14 ± 31.11 ug/mL and 66.09 ± 27.55 ug/mL respectively (p=0.991). The correlation analisis revealed that consumption of Sago have significant impact on waist circumference (r=0,642, p=0.000) and adiponectin (r=0.649, p=0.000); but not with hsCRP (r=0.003; p-0.97), free fatty acids (r=0.073, p=0.379), as well as oxidized LDL (r=0.001, p=0.991).

Conclusion: These results might indicate that Mollucas Traditional Food (Sago) provide better protective value than non-MTF to the risk factors of CHD through prevention of obesity and increasing adiponectin level.

Keywords: mollucas traditional food, sago, risk factors of coronary heart disease, adiponectin, hsCRP, FFA, Ox-LDL

755

PO 305Prognostic value of glucagon like peptide-1, secreted frizzled-related protein-4, dipeptidyl peptidase-4 in coronary artery disease: Role of diabetes and intima media thickness

Abdulhalim Senyigit1, Omur Tabak2, Ilhami Gultepe3, Timur Orhanoglu1, Kenan Celik3, Ramazan Ilyas Oner4, Aytac Karadag A5, Serdal Ugurlu S6, Hafize Uzun7, Dildar Konukoglu71Department of Internal Medicine, Medicine Hospital, Istanbul, Turkey.2Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Internal Medicine Clinic, Istanbul, Turkey3Department of Internal Medicine, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.4Department of Internal Medicine, Faculty of Medicine, Adıyaman University, Adıyaman, Turkey.5Department of Internal Medicine, Faculty of Medicine, Acıbadem University, Istanbul, Turkey.6Department of Internal Medicine, 7Department of Biochemistry, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.

Diabetes is associated with increased cardiovascular and cerebrovascular disease-related mortality. Carotid intima media thickness (CIMT) is used commonly as a noninvasive test for the assessment of degree of atherosclerosis. The study investigated the association between CIMT with clusterin (CLU), amylin, secreted frizzled-related protein-4 (SFRP-4), total and active GLP-1 levels, and dipeptidyl peptidase-4 (DPP-4) and further evaluated the atherosclerotic effects of these parameters and its clinical significance in type 2 diabetes mellitus (T2DM) individuals. Methods: A total of 100 patients (50 women, 50 men) in coronery artery disease (CAD) and CAD + cerebrovascular disease (CVD) groups and 30 healthy controls (14 women, 12 men) were enrolled in the study. Patients in the CAD+CVD group have also T2DM. Results: Circulating novel parameters were similar among CAD and CAD+CVD groups. Both CAD and CAD+CVD groups have significantly lower DPP4 and SFRP-4 levels than controls (p<0.003 and p<0.05; p<0.05 and p<0.005). GLP-1total levels in control group were significantly higher than both CAD and CAD+CVD groups (p<0.001 and p<0.001). Significant positive correlations were found between CLU and amylin, DPP-4 and SFRP-4 levels (for each p<0.001). Amylin levels were correlated with both DPP-4 and SFRP-4 levels (p<0.01 and p<0.001). DPP-4 and SFRP-4 levels were also correlated HOMA-IR levels. No difference was found CIMT values between the studied groups. Conclusion: DPP-4 and SFRP-4 levels are predictive marker for atherosclerosis in diabetes, correlates well with HOMA-IR particularly in diabetes. CIMT has not the potential to be a clinically useful predictor of vascular risk in diabetic patients with CAD and CVD. Large cohorts and at-risk populations are needed to confirm the predictive value of these findings.

756

PO 306The association of potential mediators and biomarkers with conventional risk factors in the metabolic syndrome

Abdulhalim Senyigit1, Omur Tabak2, Ilhami Gultepe3, Timur Orhanoglu1, Kenan Celik3, Ramazan Ilyas Oner4, Aytac Karadag A5, Serdal Ugurlu S6, Hafize Uzun7, Dildar Konukoglu7

1. Department of Internal Medicine, Medicine Hospital, Istanbul, Turkey.2. Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Internal Medi-

cine Clinic, Istanbul, Turkey3. Department of Internal Medicine, Faculty of Medicine, Bezmialem Vakif University,

Istanbul, Turkey.4. Department of Internal Medicine, Faculty of Medicine, Adıyaman University,

Adıyaman, Turkey.5. Department of Internal Medicine, Faculty of Medicine, Acıbadem University, Istan-

bul, Turkey.6. Department of Internal Medicine, 7Department of Biochemistry, Cerrahpasa Faculty

of Medicine, Istanbul University, Istanbul, Turkey.

Backround: Metabolic syndrome (MetS) is defined by a constellation of an interconnected physiological, biochemical, clinical, and metabolic factors that directly increases the risk of atherosclerotic cardiovascular disease, type 2 diabetes mellitus, and all-cause mortality. We investigated the relationships between the levels of clusterin (CLU), amylin, secreted frizzled-related protein-4 (SFRP-4), total and active glucagon-like peptide-1 (GLP-1), and dipeptidyl peptidase-4 (DPP-4) with conventional risk factors in MetS patients. Methods: A total of 100 patients (50 women, 50 men) with MetS and 30 healthy controls (18 women, 12 men) with a body mass index (BMI) less than 25 kg/m2 were enrolled in the study. Results: Serum levels of SFRP-4 and GLP-1active were significantly higher in MetS patients than controls (p<0.0.001 and p<0.005). MetS patients have significantly lower GLP-1total levels than controls (p<0.001). There is significantly positive correlation amongst serum CLU, amylin, DPP-4 and SFRP-4 levels, as well as GLP-1 levels (for each p<0.001). GLP-1active levels were weakly correlated with the value of diastolic and systolic blood pressure (r: 0.265; p<0.01 and r: 0,189; p<0.05). There was no significant difference between novel markers and criteria of MeS including serum glucose or lipids. Conclusion: Increased SFRP-4 and GLP-1active, decreased GLP-1total levels are predictive marker for atherosclerosis in MetS, but does not correlate well with key aspects of the metabolic syndrome. Increased secretion of GLP-1active may contribute to the increased blood pressure, and exaggerated secretion may be responsible for atherosclerosis.

757

PO 307CORRELATION BETWEEN LEVELS OF MATRIX METALLOPROTEINASE-9 (MMP-9) SERUM WITH LEFT VENTRICULAR CARDIAC REMODELING IN PATIENTS WITH HYPERTENSION AT DR. MOH. HOESIN HOSPITAL PALEMBANG

Chodilawati Rukiah1, Indrajaya Taufik2, A. Ghanie3

Division of Cardilogy Departement of Internal Medicine Faculty of Medicine Sriwijaya University/Mohammad Hoesin Hospital Palembang, Indonesia

Background : Structural changes in hypertensive heart disease is hallmarked by cardiac remodeling. Matrix metalloproteinase-9 (MMP-9) as a cardiac remodeling biomarker, has an important role in extracellular matrix degradation. Progressivity that MMP-9 will increase along with cardiac remodeling. The aim of this study is to identify correlation between MMP-9 serum level with left ventricle cardiac remodeling in hypertension patient.

Method: Analytic cross-sectional design, that analyze the correlation between MMP-9 serum level with left ventricle cardiac remodeling in 69 hypertension patients from February 2015 to November 2015. Cardiac remodeling was determined by echocardiography. And the MMP-9 serum level was examined using enzyme-linked immunosorbent assay (ELISA) method.

Results : MMP-9 serum level in subjects with no remodeling left ventricular cardiac was 905,14±583,770 ng/mL in subjects with concentric remodeling 869,55±357,829 ng/mL, in subjects with concentric hypertrophy was 1110,57±588,745 ng/mL and in subjects with excentric hypertrophic was 1132,86±559,414 ng/mL. MMP-9 serum level has very weak correlation with left ventricular cardiac remodeling (r=0,175, p=0,185). MMP-9 serum level in group who receive ARB has significant lower than group who receive other hypertension therapy (p=0,016).

Conclusion : MMP-9 serum level has very weak correlation with left ventricular cardiac remodeling in hypertension patients. And the pattern of MMP-9 serum level increase along with the progressivity of cardiac remodeling. MMP-9 serum level in group who receive ARB has significant lower than group who receive other hypertension therapy.

Keyword : Hypertension, left ventricular cardiac remodeling, MMP-9

758

PO 308THE CORRELATION BETWEEN SERUM ADIPONECTIN LEVELS AND SLOW CORONARY FLOW IN ISCHEMIC HEART DISEASE

Indra Syamsu1, Chodilawati Rukiah2, Indrajaya Taufik3, A. Ghanie4

Division of Cardiology Departement of Internal Mdicine Faculty of Medicine Sriwijaya University / Mohammad Hoesin Hospital Palembang, Indonesia

Background: Adiponectin is a protein hormone with 247-amino acids orginating from most adipose tissues, cardiomyocytes and hepatocytes which regulates the metabolism process especially in glucose regulation and catabolism of fatty acids, cardiovascular regulation and homeostasis as a anti inflammation, anti atherogenic and insulin sensitizing. The levels of adiponectin serum were reported low in both ischemic heart disease and slow coronary flow patients.

Method: The aim of this study ( n=32, male:female : 17:15). The average of men with low and normal adiponectin levels are 50,70 ± 5,54 years and 48,86 ± 8,93 years respectively. The average age of women with low and normal adiponectin levels are 47,12 ± 7,61 years and 51,29 ± 4,50 years respectively. (Age ranges between 35 – 65 years old). Seventeen male ischemic heart disease patients were found to have a mean levels adiponectin serum of 2,79 ± 1,32 µg(1,23 – 6,15 µg/ml range value), 15 female ischemic heart disease patients were found to have a mean levels adiponectin serum of 3,78 ± 1,93 µg/ml (1,41 – 8,89 µg/dl range value).

Results: Triglicerydes levels in male group with low and normal serum adiponectin levels are significant difference : 246,90 ± 24,02 mg/dl versus 183,00 ± 74,35 mg/dl, p=0,02. The significancy was also found for HDL cholesterol: 35,90 ± 10,39 mg/dl versus 55,14 ± 21,94 mg/dl, p=0,03. Low adiponectin serum levels and normal levels adiponectin serum in triglycerides in female group are 241,50 ± 26,06 mg/dl versus 188,43 ± 53,49 mg/dl respectively, p=0,03. And in HDL cholesterol and HDL cholesterol are 36,25 ± 2,25 mg/dl versus 57,43 ± 13,40 mg/dl respectively, p=0,01. As previously reported, this study found that with Pearson’s method, adiponectin serum levels was significant inversely correlated with SCF in ischemic heart disease patients(r=-0,485, p=0,01).

Conclusion: In conclusion, this study suggested that the adiponectin serum levels might be involved in SCF progression in ischemic heart disease patients.

Keyword : Slow coronary flow, ischemic heart disease, adiponectin serum levels

759

PO 309The Risk Factors of Foot Ulceration and its Correlates in Type 2 Diabetic Patients at Internal Medicine Ward of Arifin Achmad General Hospital Pekanbaru

Jazil Karimi1, Marsita Ayu Lestari2, Handayani3

1. Department of Internal Medicine Faculty of Medicine Riau University - Arifin Achmad General Hospital Pekanbaru

2. Writer for correspondence. Faculty of Medicine Riau University3. Department of Public Health-Community Medicine Faculty of Medicine Riau

University

Abstract

Background : Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The foot ulceration in type 2 diabetic patients is chronic complications and it is reported to have risk factors. The foot ulceration also as a major medical, social and economic problem worldwide.

Aim of this study : The aim of this study to determine correlation between level of knowledge about foot care, gender, age, duration of diabetes, body mass index, blood pressure, fasting plasma glucose level, neuropathy, total cholesterol level, HDL level, triglyceride level and level of education with the foot ulceration in type 2 diabetic patients.

Methods : The design of this study was a analysis study with a cross sectional design at Internal Medicine Ward of Arifin Achmad General Hospital Pekanbaru since 2011 February 21 until 2011 March 29. The object of this study was all type 2 diabetic patients. The number of samples were 49 type 2 diabetic patients consist of 11 foot ulceration patients and 38 patients without foot ulceration. This study used quota sampling technique. The data were analyzed by SPSS programme with Chi square and Fisher.

Results : The proportion of diabetic foot ulcer was 18,46%. There were 45,5% men and 54,5% women in foot ulceration patients. There were significant correlation between fasting plasma glucose level (p=0,009) and neuropathy (p=0,004; RP=5; 95%CI=2,08-12,01) with foot ulceration in type 2 diabetic patients.

Conclusion : The most significant factor of foot ulceration was neuropathy. Then followed by fasting plasma glucose uncontrolled.

Keywords : Type 2 diabetic, foot ulceration, risk factors.

760

PO 310Immunoglobulin G4 levels are elevated in patients with Graves’ disease and Graves’ ophthalmopathy

Emre Bozkirli*, Okan Sefa Bakiner* , Emine Duygu Ersozlu Bozkirli**, Filiz Eksi Haydardedeoglu*, Selcuk Sizmaz*** , Aysenur Izol Torun*, Melek Eda Ertorer*

*Baskent University, Department of Endocrinology

**Adana Numune Hospital, Department of Rheumatology

***Baskent University, Department of Ophthalmology

Background: Recent studies have shown close association between serum Immunoglobulin G4 (IgG4) levels and forms of autoimmune thyroiditis. However there are limited data about the relationship between IgG4 and Graves’ ophthalmopathy(GO). In the present study, we aimed to determine the possible association between IgG4 and GO.

Methods: Our study was designed as a cross-sectional study. Sixty-five patients with Graves’ disease(GD) and 25 healthy controls were recruited into the study.Thirty-two of these patients had GO.

Serum IgG4 levels, thyroid functions and thyroid volumes were measured in all participants. Ophthalmological examination including Hertel’s exophthalmometer readings(HER), Schirmer’s test(ST), “NO SPECS” classification and clinical activity score evaluation(CAS) were performed to all patients with GD.

Results:IgG4 levels were significantly elevated in patients with Graves’ disease compared to controls (P=0.0001). Also, IgG4 levels were significantly higher in patients with and without GO when compared to control subjects(P=0.0001 and P=0.002 respectively).Furthermore, IgG4 levels were significantly higher in the GO group compared to GD patients without GO(P = 0.024). IgG4 levels were observed to increase in parallel to CAS. Compared to other GD patients, 15 GD patients with serum IgG4 levels ≥ 135 mg/dL had higher CAS scores(P = 0.012).None of the factors including; TSH, T3,T4 levels, thyroid volume, HER and ST measurements affect IgG4 levels as an independent factor.

Conclusion:IgG4 levels are evidently increased in patients with GD and there is a possible relationship between IgG4 and GO. Our results suggest that IgG4 may be helpful in screening GD patients with high risk for GO and may well become a good indicator for the selection of right medica

761

PO 311Correlation between Soluble Thrombomodulin with Insulin Resistance in Type 2 Diabetes Mellitus

Dinda Aprilia, Eva Decroli, Asman Manaf

Endocrinology and Metabolic Subdivision,Internal Medicine DepartmentMedicine Faculty of Andalas University / Dr. M. Djamil Hospital

Background

Diabetes mellitus is associated with an increasing risk of cardiovascular disease. Substantive clinical and experimental evidence suggest that both diabetes and insulin resistance cause a combination of endothelial dysfunctions, which may diminish the anti-atherogenic role of the vascular endothelium. Increasing evidence suggests that the progression of insulin resistance to type 2 diabetes is parallel with the progression of endothelial dysfunction to atherosclerosis. Thrombomodulin(TM) , an integral membrane glycoprotein, is a high-affinity receptor for thrombin on the endothelial cell surface and has been implicated in the endothelial regulation of fibrinolysis and coagulation. After proteolytic cleavage from the endothelial surface, soluble TM can be detected in the circulation and its concentration has been considered to reflect endothelial damage. Glucotoxicity, lipotoxicity, and Inflammatory cytokines decrease the expression of thrombomodulin on the endothelial cell surface by suppression of TM transcription and translation or internalization with subsequent degradation. Evaluation of the soluble TM can be used to predict , diagnostic, evaluation of the effect of treatment and prognosis of cardiovascular complications in type 2 diabetes

Methods

Cross sectional study carried out on 30 people with type 2 diabetes to determine the correlation between the levels of soluble thrombomodulin with the degree of insulin resistance . Soluble thrombomodulin was measured by ELISA , and insulin resistance by HOMA - IR . Analysis correlation between trombomodulin with HOMA- IR value .

Result

The results show there is correlation between the levels of soluble thrombomodulin with HOMA- IR value . ( P = 0.003 , r = 0.519 ) .

Conclusion

There is a positive and significant correlation between the level of soluble thrombomodulin with the level of insulin resistance in type 2 diabetes mellitus patients.

762

PO 312FISSURE TONGUE IN TYPE 2 DIABETES MELLITUSRio Wironegoro, Hermawan Susanto, Jongky Hendro P

Internal Medicine Department – Endocrinology DivisionMedical Faculty of Airlangga University-Dr. Soetomo General HospitalSurabaya, Indonesia

Background: Type 2 diabetes mellitus remains one of the leading cause of mortality and morbidity worldwide. Chronic complications regarding its complication either microvascular or macrovascular had been widely documented. Oral soft tissue lesions such as fissure tongue has been reported as a complications of type 2 diabetes mellitus, but there is lack of data regarding association between oral soft tissue lesions in type 2 diabetes mellitus.

Objective: The aim of this study is to study the correlation of fissure tongue in type 2 diabetes mellitus with glucose concentration and the duration of type 2 diabetes mellitus.

Material & Methods: A cross sectional study was conducted in January 2016. This study used a secondary data from medical record of patients in endocrinology clinic of Dr. Soetomo General Hospital. All patients were evaluated for the presence of fissure tongue.

Results: There were 195 patients admitted to endocrinology clinic in Dr. Soetomo General Hospital with type 2 diabetes mellitus and oral problems (75 males and 120 females) in January 2016. Median fasting glucose concentration was 152 (54-496) mg/dL, 2-hour glucose concentration was 225.00 (51-562) mg/dL, and fissure tongue was observed in 131 patients (67.2%). Positive correlation was observed between 2-hour glucose concentration with the presence of fissure tongue (=0.19, p<0.01) and duration of type 2 diabetes mellitus (=0.16, p<0.03).

Conclusion: Fissure tongue which is the manifestations of oral soft tissue lesions is associated with the duration type 2 diabetes mellitus. It is also associated with the uncontrolled 2-hour glucose concentration. Therefore, regulating blood glucose concentration is important in order to prevent fissure tongue.

Keyword: Type 2 diabetes mellitus, fissure tongue

763

PO 313CABERGOLINE THERAPY ON PROLACTINOMA PATIENT : A CASE REPORTNenfiati, Olivia Cicilia Walewangko, Dante Saksono Harbuwono

Division of Metabolic Endocrine Diabetes, Department of Internal Medicine, Faculty of Medicine University of Indonesia

Background : Prolactinomas are the most common type of secretory pituitary tumor. Serum levels of prolactin in patients with prolactinomas are usually proportional to the tumor mass. Dopamine-agonists are the primary therapy for both microadenomas treatment required and macroprolactinomas.

Case : SW, 34 years old man presents with headaches and left visual-field problem. He reports no complaints in libido, galactorrhea and other symptoms. He takes cabergoline 0,5 mg orally twice a week, resulted to his prolactin serum levels, decreased from 9400 μg per milliliter to 134 μg per milliliter in 2 months, and cortisol serum levels increased from 0,2 ηg per deciliter to normal cortisol serum levels 13 ηg per deciliter. Magnetic resonance imaging (MRI) reveals a sellar mass 4,5x3,6x5 cm and after 1 month cabergoline therapy, shows pituitary mass reduction to 3,1x3,5x4,2 cm.

Disscussion : In patients with macroadenomas, goal of treatment are decrease or stabilize the tumor mass and to prevent neurological complications. In this case, by giving carbogoline therapy to patient with large macroadenoma and very high serum levels of prolactin, the prolactine level decline markedly but not normalize, even though their effects in tumor are shrinkage and his visual-field problem improve.

Conclusion : Cabergoline, one of dopamine-agonists are recommended for first line therapy to decrease both prolactine level and tumor mass.

Key Words : prolactinomas, macroadenomas, cabergoline

764

PO 314ASSOCIATION OF A1C AND CREATININE SERUM IN PATIENTS WITH DIABETIC FOOT ULCER IN DR.SOETOMO GENERAL HOSPITAL

Denada A.Syalini, Jongky Hendro Prajitno, Ari Sutjahjo

Internal Medicine Department - Endocrinology DivisionMedical Faculty of Airlangga University - Dr.Soetomo General HospitalSurabaya, Indonesia

Background: Diabetic foot ulcer is a major disabling complication of Diabetes Mellitus and often precedes lower extremity amputation. The descriptive correlational study aimed to identify the relationship of A1C, and creatinine serum in diabetic foot ulcer attending Dr. Soetomo General Hospital, Surabaya East Java, Indonesia.

Patients and methods: One hundred and sixty six patients were separated between survived (116 patients) and non-survived (32 patients) of varying ages, data were collected from past medical record hospitalized patients. The A1C and creatinine serum were measured with standard methods. These data along with the information of patients age and gender were subjected to different statistical analysis by SPSS to evaluate the association of those parameters in diabetic foot ulcer patients.

Results: It was found that approximately all diabetic foot ulcer patients have uncontrolled A1C level with 93,7% of them having A1C level > 8%. Unlike non-survived patients, 71% of survived patients have A1C level > 8%. The data analysis also revealed that A1C and creatinine serum levels are significantly higher in non-survived patients with diabetic foot ulcer (10.4±1.36%, 2.78±1.8 mg/dl respectively, p=0,011) compare to survived patient (9.8±2.36%, 1.58±1.97mg/dl respectively, p=0,107). The correlational study confirmed a positive correlation among the values of A1C and creatinine serum in diabetic foot ulcer dead patients.

Conclusion: A1C and creatinine serum may be major factors in diabetic foot ulcer management.

Keywords: Diabetic Foot Ulcer, A1C, Creatinine

765

PO 315A CASE REPORT OF LADA PRESENTING WITH DIABETIC KETOACIDOSIS AT OLDER AGE

I. CETINDAGLI1, S.A.AY2, K. BASKOY2, A. YILDIRIM2, F. DENIZ2, A. YONEM21 Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY2 Gulhane Military Medical Faculty, Haydarpasa Training Hospital, Department of Endocrinology and Metabolism, Istanbul, TURKEY

BACKGROUND: Latent autoimmune diabetes in adults (LADA) is an autoimmune diabetes characterized by the presence of Beta cell destructing antibodies as seen in Type 1 Diabetes Mellitus (DM). While Type 1 DM usually presents before the age of 30, LADA is seen at an older age. Therefore, it is miscible with Type 2 DM. We here report a case of diabetic ketoacidosis (DKA), after a follow up with a misdiagnosis of Type 2 DM, and finally diagnosed as LADA.

CASE: A 54 year old female patient with the diagnosis of DM, was admitted to the emergency department with the complaints of nausea, vomiting, abdominal pain, polyuria and polydipsia. Laboratory findings showed hyperglycemia (350 mg/dl), glycosuria and ketonuria and asidosis. With the blood gas analysis representing severe acidosis (pH 7, HCO3: 9), patient was diagnosed as DKA. After a proper insulin infusion therapy he recovered from DKA and the quartetly insulin therapy was initiated. C peptide level was low. Anti-insulin antibodies were positive but not Anti-GAD and islet cells antibodies. She was diagnosed as LADA. After the dose adjustment, she was discharged.

CONCLUSION: LADA is often seen in adults and may be misdiagnosed as Type 2 DM. In fact, LADA is more similar to type 1 DM. Actually in these cases, it is not necessary to start an immediate insulin therapy. But in some cases, insulin requirement may arise in short period. Therefore, it should be kept in mind that dependence of insulin will develop in the later stages.

766

PO 316A COMPELLING CASE OF THYROID CANCER: IS IT ‘SETTLE’ OR NOT?

I. CETINDAGLI1, K. BASKOY2, S.A.AY2, F. DENIZ2, A. YONEM21 Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY2 Gulhane Military Medical Faculty, Haydarpasa Training Hospital, Department of Endocrinology and Metabolism, Istanbul, TURKEY

BACKGROUND: ‘Spindle epithelial tumor with thymus-like differentiation (SETTLE)’. is one of those rare types of thyroid cancer, in which evaluation, follow-up and treatment approach are not clear yet. We here report a case of malignant mesenchymal tumor localized to the thyroid bed, after a 2-year follow up with a misdiagnosis of ‘SETTLE’, and finally diagnosed as ‘synovial sarcoma’.

CASE: A 27-year-old male patient with a diagnosis of multinodular goiter was performed a thyroid fine needle aspiration biopsy(TFNAB) two years ago. Cytology results were consistent with papillary carcinoma. After bilateral total thyroidectomy,pathology was reported as ‘SETTLE’. Two years after surgery and ablation therapy, the patient was admitted for a rapidly growing mass.Sonographic examination showed a large semi-solid hypoechoic lesion at the left thyroid bed. FNABS of those masses were reported as the primary tumor,‘SETTLE’.In MRI, a 64x45x34mm sized cystic necrotic lobulated mass lesion was observed. It was invading the posterior wall of trachea, encircling around left carotid artery and extending to the prevertebral field. In scintigraphy,iodine uptake was not observed. Laboratory findings showed normal fT3,fT4,TSH,thyroglobulin and calcitonin levels. The mass was totally extirpated. The specimen’s immunohistochemical staining and FISH analyses were reported to include a malignant mesenchymal tumor,a biphasic synovial sarcoma.

CONCLUSION: SETTLE,an epitelial tumor,is one of the rare tumors of thyroid,reported only 41 cases in the present literature. However, malignant mesenchymal tumors should be considered in the differential diagnosis. It should taken into consideration,in some of the thyroid tumors reported as ‘SETTLE’ before the distinction could be made improperly,as in our case.

767

PO 317WHAT IS THE HIGHEST VALUE OF HBA1C YOU REMEMBERED IN THE DIAGNOSIS OF DIABETES MELLITUS? (HBA1C: 20.5%)

S. DEMIRBAS1, H. SARLAK 2, T. KURT1, I. CETINDAGLI1, K. SAGLAM11 Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY2 Diyarbakir Military Hospital, Department of Internal Medicine, Diyarbakir , TURKEY

BACKGROUND: Diabetes Mellitus (DM) can be diagnosed in patients with ≥ 6.5% HbA1c levels. In uncontrolled DM patients with long-term high blood glucose, too high HbA1c values can appear. Here we present a case with the highest HbA1c level that we have ever seen.

CASE: 76-year-old female patient was admitted with complaints of dry mouth, drinking a lot of water, frequent urination and weight loss for 3-months. She had a history of hypertension. In physical examination her tongue was dry and tenderness was present in each quadrant of abdomen. In her assays plasma glucose: 858 gr/dL, urea: 70 mg/dL, creatinine: 1.6 mg/dL, serum sodium: 125.1 mmol/L, uric acid: 7.68 mg/dL, ALT: 69 IU/L, AST: 57 IU/L, ALP: 174 IU/L, GGT: 114 IU/L, HbA1c: 20.5% and three positive glucose in urinalysis were observed. In blood gas analysis; pH: 7.33 and HCO3: 19.0 mmol/L was detected. Abdominal ultrasound was normal. The patient was diagnosed as DM, and basal-bolus insulin therapy and hydration were started rapidly. Glycemic regulation of the patient was not achieved in the beginning. Metformin and pioglitazone added to the treatment, respectively. After the additional treatments the regulation of glycemia was achieved.

CONCLUSION: Severe elevation of HbA1c that we have detected in the newly diagnosed patient is a rare condition. Mostly it indicates that the diagnosis is delayed. Therefore periodic blood sampling is important for early diagnosis of DM in healthy individuals.

768

PO 318CORRELATION OF BLOOD GLUCOSE WITH NON PERIODONTAL ORAL MANIFESTATIONS IN TYPE II DIABETES MELLITUS

Diar Meitha Wardhana, Rio Wironegoro, Ari Sutjahjo

Endocrinology Metabolic Division - Internal Medicine DepartmentMedical Faculty of Airlangga University - Dr. Soetomo General HospitalSurabaya, Indonesia

Background: Type 2 Diabetes Mellitus (T2DM) is one of the most common metabolic disorders in the world and the prevalence in adults has been increasing in the last decades. There is strong evidence that supports the relationship between oral health and T2DM. However, oral health awareness is lacking among T2DM patients and health professionals. Data regarding association of blood glucose and oral manifestations in T2DM is rare. Aim of this study is to study correlation between oral maifestations in T2DM and blood glucose.

Method: Cross sectional study was conducted in diabetic outpatient clinic in Dr. Soetomo General Hospital in February - March 2016. All patients of T2DM are included in this study. Patient who refused to participate, newly diagnosed, had preexisting oral problems prior to the presence of T2DM, were excluded from this study. Data were analyzed using Spearman test.

Result: There were 143 patients (60 males and 83 females) included in this study. Median fasting glucose concentration was 132 mg/dL, post prandial glucose was 200 mg/dL, and duration of T2DM was 5 years. Increased fasting glucose was associated with burning mouth syndrome (p 0,001), fisured tongue (p=0,00), benign migratory glossitis (p=0,008), median rhomboid glossitis (0,008). Increased post prandial glucosed was associated with burning mouth syndrome (p 0,004), fisured tongue (p=0,00), benign migratory glossitis (p=0,035), median rhomboid glossitis (p=0,017). Duration of T2DM only associated with fissurd tongue (p=0,013).

Conclusion: Non periodontal oral manifestation of T2DM was associated with poor glycemic control and does not correlate with duration of sickness. Therefore every patients with uncontrolled T2DM should be aware of oral complication and seek for advance medical advice as early as possible.

769

PO 319Managing postprandial hypoglycemia due to late dumping syndrome in a direct percutaneous endoscopic jejunostomy patient using miglitol and isomaltulose

AUTHORS: Wong Toh Yoon, Haruna Nakamura, Hisaaki Morishita

AFFLILIATIONS: Department of Internal Medicine, Hiroshima Kyoritsu Hospital. Hiroshima City, Japan

Background/Rationale:

One of the postoperative complications of gastric resection is postprandial hypoglycemia which is often referred to as late dumping syndrome. The loss of gastric reservoir function leads to the rapid inflow of carbohydrates into the small intestine, which in turn causes high amount of insulin secretion. This condition may be more prominent in post gastrectomy patients on enteral nutrition with direct jejunal feeding.

Methods:

We report a case of postprandial hypoglycemia in a 70-year-old bedridden woman who had been receiving jejunal feeding via a direct percutaneous endoscopic jejunostomy (D-PEJ) performed 9 years ago.

Results:

The patient was treated at a nursing home for urinary tract infection but because of marked glucosuria, blood glucose was also frequently measured. During monitoring, hypoglycemia was often observed and she was referred to our hospital for further evaluation. Continuous glucose monitoring (CGM) confirmed postprandial hypoglycemia. Because of a previous gastric resection, the patient received percutaneous tube feeding via a D-PEJ and enteral feed was infused directly into the jejunum without the assistance of a pump. A diagnosis of late dumping syndrome was made and she was treated with miglitol and an isomaltulose-containing enteral formula. After commencement of this regimen, her blood glucose normalized and she was discharged without further complications.

Conclusion:

Postprandial hypoglycemia due to late dumping syndrome in patients with direct jejunal feeding may be very much under-reported because patients are often bedridden and do not complain. However, once a diagnosis is established, the condition can be easily managed using alpha-glucosidase inhibitors such as miglitol and isomaltulose-containing enteral formula.

770

PO 320ACUTE THYROID STORM COMPLICATED WITH SEPSIS AND LIVER FAILURE – A CASE IN A RESOURCE-LIMITED HOSPITAL

Faisal Parlindungan

Department of Internal MedicineAnuntaloko General District Hospital, Parigi-Moutong Regency, Central Sulawesi

Background

Thyroid storm is a rare and life-threatening complication of thyrotoxicosis. The simultaneous treatment of thyroid storm and its precipitant is needed, otherwise they can exacerbate each other. We report a case of thyroid storm complicated with sepsis and liver failure in a hospital with limited resources.

Case report

A 24 year-old woman was admitted with dyspnea, vomiting, fever, worsening palpitations, sweats and exhaustion. She had a tender enlarged lymphnode at the colli regio. During hospitalization, the patient experienced loss of consciousness and hypotension. Burch-Wartofsky criteria scoring was 70. Working diagnosis was acute thyroid storm complicated with sepsis. Laboratory investigations revealed markedly increased white cell blood count and grossly deranged liver biochemistry. ECG revealed sinus tachycardi. Thyroid function tests confirmed hyperthyroidism (TSH 0.14(0.4-4.2 mU/L), T3 2.97 (1.23-3.08 nmol/L), T4 186.48pmol/L (60-120nmol/L)). She was managed with IV fluid resuscitation, beta blocker, high-dose of propylthiouracil (PTU), IV dexamethasone, and broad spectrum antibiotic. The patient regained consciousness the next day and her condition was beginning to stabilized. The patient was discharged a day later due to family’s request.

Conclusion

This case highlights the various multi organ dysfunction seen in acute thyroid storm and the importance of prompt diagnosis and treatment in a resource limited setting. Clinicians should be aware that a diagnosis of thyroid storm is mainly based on clinical judgement. Prompt management should be initiated and not wait for laboratory confirmation which may take a long time to get.

771

PO 321FRUCTOSAMIN LEVEL IN TYPE 2 DIABETES MELLITUS PATIENTS WITH DEPRESSION SYMPTOMS BEFORE AND AFTER THERAPY WITH FLUOXETINE, LATIHAN PASRAH DIRI, AND COMBINATION OF FLUOXETINE AND LATIHAN PASRAH DIRI

Vina Yanti Susanti, Agus Siswanto, Bowo Pramono, Hemi Sinorita, Robikhul Ikhsan

Endocrinology and Psychosomatic, Internal Medicine Departement ,Faculty of Medicine, Universitas Gadjah Mada/ RSUP Dr. Sardjito Yogyakarta

Study background: Diabetes mellitus (DM) and depression are 2 conditions closely linked. Depression contributes to progression of DM. Fructosamine is used to monitor blood sugar control for 2-3 weeks (according to age of protein). Latihan Pasrah Diri (LPD) is a combination of relaxation of body and soul with a focus on respiratory and remembrance in order to reach physiological state of relaxation, and through decreased activation of the sympathetic nervous system may decrease the levels of fructosamine .

Objective: To determine the level of fructosamine in type 2 diabetes mellitus patients with depression symptoms after administration of fluoxetine, therapy with LPD, and combination therapy of fluoxetine and LPD.

Methods: The participants are type 2 DM patients with depression symptoms in outpatient clinic internal medicine departement RSUP Dr. Soeradji Tirtonegoro Klaten which matched the inclusions and exclusions criteria. Fructosamine data was taken before and after 21 days of fluoxetine administration, LPD therapy, and combination therapy of fluoxetine and LPD. The decrease in fructosamine level between groups were compared by Anova analysis. Differences were considered significant if p <0.05 with a confidence interval of 95%.

Results: There is a trend of decreasing in fructosamine levels in all groups. Fructosamin level on fluoxetine group decreased from 260±153,122 to 215,88±147,23, (p=0.069), LPD group from 318,25±153,17 to 271,46±131,08, (p= 0,297), and group of combination fluoxetine and LPD from 296,82±144,37 to 247,74±12,27, ( p=0,148). The decrease of delta fructosamine levels before and after treatment were not differ in between groups. Fructosamin level of fluoxetine group was 45,07±85,13, LPD group was 46,79±178,98, and combination of fluoxetine and LPD group was 49,09 ± 128,88, with p=0.997.

Conclusion: Fructosamin level in type 2 diabetes melitus patients with depression symptoms, before and after therapy with fluoxetin, LPD, dan combination of fluoxetine and LPD was not statistically different.Key words: Type 2 DM, depression, fluoxetin, latihan pasrah diri, fructosamine

772

PO 322When the alarm to action is missing: type of diabetic foot is matters in determining its outcomes after hospitalization

Tjokorda Gde Dalem Pemayun,1 Diana Novitasari,2 Nurmilawati Amin,2

Tani Tedjo Minuljo,2 Ridho M. Naibaho3

1. Division of Endocrinology, Department of Internal Medicine, Medical Faculty of Diponegoro University / Dr. Kariadi General Hospital;

2. Endocrinology Fellow, Medical Faculty of Diponegoro University, Dr. Kariadi General Hospital;

3. Research Assistant

Background: Foot ulceration is a prominent cause of diabetes morbidity in developing countries. Peripheral neuropathy and peripheral arterial disease (PAD) were common links for the development and progression of an ulcer.

Aim: To determine the frequency of peripheral neuropathy and PAD in patients with diabetic foot ulcers (DFU) who were referred to a tertiary care hospital in Semarang, Indonesia.

Methods: This is an observational study in which 168 consecutive diabetes patients with foot ulcers were studied over a 3-year period. Each patient’s medical history, physical examinations, laboratory, and associated outcomes were documented. Stratification were done according to type of foot ulcers. Data were analyzed using SPSS version 21.

Results: All patients have type 2 diabetes mellitus where the majority are female aged over fifty years old. The patients showed poor glycemic control i.e. HbA1c ≥ 8%. More than 50% were present with severe ulcers (Wagner grade ≥ 3) and 70.8% of patients have peripheral neuropathy. The prevalence of neuropathic ulcers was 39.3 %, ischemic ulcers was 10.7% and 31.5% of cases have both neuropathy and PAD, i.e. neuro-ischemic ulcers. In the presence of PAD, more patients were associated with major LEA (ischemic ulcers: 11.1%; neuroischemic ulcers: 15.1%) compared to pure neuropathic ulcers. In the absence of PAD, foot ulcers has better outcomes regarding only 2 patients be necessary for major LEA. The duration of hospitalization was slightly longer in PAD cases.

Conclusions: DFU often occurs in middle-aged patients where most of cases were attributed to neuropathy. The studied population have poorly controlled diabetes and the ulcers have been develop to more advanced stage. The outcome of the patients i.e. major LEA and duration of hospitalization are determined whether PAD were present or not.

Keywords: Diabetic foot ulcers, peripheral neuropathy, PAD, major LEA.

773

Table 1. Characteristics of diabetic foot patients, n=168.

Neuropathic

N= 66

Ischemic

N= 18

Neuro-ischemic

N= 53

Unclassified

N= 31p

Age, mean ± SD

(years)54.3 ± 7.9 56.4 ± 9.1 56.5 ± 8.3 50.8 ± 6.9 0.140¶

Male sex, n (%) 36 (54.5) 8 (44.4) 15 (28.3) 14 (45.1) 0.505‡

BMI, median (min-max)

(kg/m2)22.3 (13.7-32.4) 21.4 (16.0-30.2) 21.8 (15.7-31.9) 21.9 (18.6-29.3) 0.436¥

Systolic BP, mean ± SD

(mmHg)133.4 ± 22.4 134.3 ± 25.1 136.8 ± 23.7 129.7 ± 21.5 0.588¶

Diastolic BP, median

(min-max)

(mmHg)

80.0 (55-110) 80.0 (70-110) 80.0 (60-120) 80 (60-100) 0.660¥

Hemoglobin level, mean ±

SD (gr%)9.8 ± 1.8 10.1 ± 1.7 9.7 ± 1.8 10.0 ± 1.8 0.806¶

Leukocytes count, median

(min-max) (x103/µL)16.9 (5.0-35.8) 19.1 (8.8-34.1) 15.3 (5.7-56.0) 14.3 (4.9-37.6) 0.389¥

Albumin level, mean ± SD

(g/dL)2.5 ± 0.6 2.4 ± 0.4 2.4 ± 0.5 2.4 ± 0.8 0.797¶

Creatinine level, median

(min-max) (mg/dL)1.1 (0.5-7.0) 1.1 (0.6-8.1) 1.3 (0.3 – 8.0) 1.0 (0.8-4.7) 0.827¥

GFR, median (min-max)

(mL/1.73 m2/min)63.0 (6.0-122.0) 72.5 (6.0-100.0) 52.0 (5.0-150.0) 63.9 (10.0-98.0) 0.836¥

RPG, median (min-max)

(mg/dL)284 (113-740) 273 (134-536) 276 (121-766) 325 (153-627) 0.647¥

FPG, mean ± SD (mg/dL) 210.4 ± 89.7 200.4 ± 64.3 194.1 ± 62.0 215.1 ± 68.0 0.559¶

HbA1c, mean ± SD (%) 11.3 ± 2.6 9.8 ± 2.7 11.1 ± 2.7 11.8 ± 2.6 0.086¶

Duration of diabetes,

mean ± SD (years)5.7 ± 5.0 5.6 ± 4.8 6.6 ± 4.9 5.5 ± 5.2 0.745¶

Ulcers duration, median

(min-max) (weeks) 2.0 (1.0-11.0) 2.5 (1.0-9.0) 4.0 (1.0-12.0) 3.0 (1.0-12.0) 0.885¥

Previous DFU,

n (%) 16 (24.2) 5 (27.7) 12 (23.1) 6 (19.3) 0.611‡

Wagner grade ≥ 3,

n (%)44 (66.7) 11 (61.1) 29 (54.7) 15 (48.3) 0.014‡

774

Moderate-severe infection

(PEDIS grade ≥

3), n (%)

46 (69.7) 7 (38.9) 23 (43.4) 19 (32.2) 0.082‡

Osteomyelitis,

n (%)26 (39.3) 5 (27.7) 16 (30.2) 10 (32.3) 0.602‡

LEA rate, n (%) 27 (40.9) 9 (50.0) 25 (47.1) 10 (32.3) 0.006‡

Major LEA, n (%) 2 (0.3) 2 (11.1) 8 (15.1) 0 (0) <0.001‡

Hospital stay, median

(min-max) (days)14 (5-52) 16 (6-51) 17 (5-69) 14 (7-50) 0.530¥

Mortality, n (%) 3 (4.5) 0 (0) 1 (1.9) 3 (9.6) 0.388‡

Abbreviations: BMI, body mass index; BP, blood pressure; DFU, diabetic foot ulcer; FPG, fasting plasma glucose; GFR, glomerular filtration rate; RPG, random plasma glucose; HbA1c, glycated hemoglobin; LEA, lower extremity amputation; PEDIS, acronym for Perfusion, Extent, Depth, Infection, and Sensibility.

¶One-way ANOVA

¥Mann Whitney u-test

‡Chi-square for trend

775

PO 323Diabetes specific infectionsProf.Dr.Khwaja Nazim Uddin

People with diabetes mellitus are exceptionally prone to develop infections like Emphysematous pyelonephritis(EPN),Mucormycosis,Malignant otitis externa and Melioidos.We have series of 28 cases with Melioidosis,15 cases Emphysematous pyelonephritis , 6 case Mucormycosis and 20 case of Malignant otitis externa.Majority of this cases were detected and treated in a 700 bed tertiary care hospital in Dhaka ,Bangladesh.

Cases were collected through local journal,hospital registry and personal communication. Clinical presentation,urine examination imaging abdomen confirmed emphysematous pyelonephritis.Rhynoorbital /Rhynoorbitocerebral infection in DKA could easily be picked as Mucormycosis by tissue diagnosis.Multiple site abscess of chronic infection with culture positive (Burkholderia pseudomelli)specimen confirmed Melioidosis cases.Malignant otitis externa occurs exclusively in Diabetes mellitus.Prolonged severe aural pain with ENT examination picks up cases.

All cases of EPN were with grossly uncontrolled (Hb A1C 9.1 to 15.2%)DM .E.Coli was the commonest organism.Treated with antibiotic and drainage (20%).Survival rate 93.3%.Cases of otitis externa were mostly due to pseudomonas aerogenisa (80%)needing long term hispitalised treatment.All mucormicosis presented with nasal mucosal involvement with rapidly invasing and necrosis of sorrunding tissues.Instant and follow up ENT drainage was main option of treatment.

Meliodosis is an emerging new infection in Bangladesh.This 28 (all with uncontrolled DM)are out of 31 reported cases since 1988 .Mortality rate was 50%.

We ,not infrequently encounter this type of cases

because of professional involvement in a tertiary care hospital dedicated to people with Diabetes mellitus.Delayed presentation,cost of treatment and followup warsen the prognosis.

776

PO 324DIFFERENCE OF BLOOD GLUCOSE LEVELS BETWEEN SMOKING AND NONSMOKING MEN IN BAYAN DISTRICT PURWOREJO 2014

Dewi, P. F., Marfianti, E

1. Program Studi Pendidikan Dokter Fakultas Kedokteran Universitas Islam Indonesia2. Departemen Ilmu Penyakit Dalam Program Studi Pendidikan Dokter Fakultas

Kedokteran Universitas Islam Indonesia

ABSTRACT

Background : Smoking has become major lifestyle worldwide. Smoking prevalence has declined in developed countries but it rises in developing countries such as Indonesia. Based on Global Adult Tobacco Survey (GATS) 2011 data, Indonesia is the 5th-biggest tobacco manufacturer with the 4th highest number of smokers. World Health Organization (WHO) also declared that Indonesia was lead as the 3rd highest cigarettes consumption in the world. These things should get special attention because smoking can cause many negative effects for health. One of them is the change of blood glucose level regulation as the beginning form of type 2 diabetes mellitus.

Objective : To find out the difference of blood glucose level in smoking and nonsmoking men in Bayan District, Purworejo 2014.

Methods : A total of 107 subjects divided into smoker (n = 54) and nonsmoker group (n = 53) were enrolled in a cross-sectional study. Random blood glucose test was used to measure the blood glucose level and analyzed by using the Mann-Whitney U test in SPSS 17.0 for Windows.

Results : No statistically significant difference were found between smoking and nonsmoking group (p = 0.706). Mean of blood glucose level in smoking group was higher (117.43 mg/dL) compared to nonsmoking group (111.34 mg/dL).

Conclusions : No statistically significant difference were found for blood glucose levels between smoking and nonsmoking men in Bayan District, Purworejo 2014.

Keywords: blood glucose difference, smoking, men

777

PO 325CORRELATION OF HbA1C CONCENTRATION AND ORAL MANIFESTATIONS IN TYPE 2 DIABETES MELLITUSHendra Gunawan, Rio Wironegoro, Ari Sutjahjo

Internal Medicine Department - Endocrinology DivisionMedical Faculty of Airlangga University-Dr. Soetomo General HospitalSurabaya, Indonesia

Background: Type 2 diabetes mellitus (T2DM) remains one of the leading cause of mortality and morbidity worldwide. The variability of HbA1C is associated with poor glycemic control and the development of T2DM complications. Oral complications such as oral dryness, burning mouth syndrome, median rhomboid glossitis, tooth loss, and atrophic tongue are oral manifestations in T2DM but data regarding the association of HbA1C and oral manifestations in T2DM is rare.

Objective: The aim of this study is to study the correlation of HbA1C with oral manifestations of Type 2 Diabetes mellitus.

Material & Methods: This is a cross sectional study from April 2016 – June 2016 with inclusion criteria were T2DM patients who had one or more of non periodontal oral manifestations such as oral dryness, median rhomboid glossitis, tooth loss, and atrophic tongue were included in this study. Patients who had a pre-existing oral problems prior to the presence of T2DM, diabetic kidney disease, liver cirrhotic, infarct myocard, or hemoglobin <10 g/dL were excluded from this study.

Results: There were 233 patients with oral manifestations of T2DM in December 2015 - April 2016. Thirty eight patients were excluded from this study (3 refused to participate, 15 had pre-existing oral problems, and 17 with hemoglobin <10 g/dL). Therefore, 195 patients were included in this study (75 males and 120 females) in which 115 patients had HbA1C levels <7.0 g% and 80 patients had HbA1C ≥7.0 g%. Median fasting glucose concentration was 152 mg/dL, 2-hour glucose concentration was 225.00 mg/dL, HbA1C was 6.35 g%, and duration of T2DM was 9 years. Increased HbA1C level was associated with oral dryness (=0.68, p=000), burning mouth syndrome (=0.54, p=0.02), median rhomboid glossitis (=0.58, p=0.00), tooth loss (=0.61, p=0.00), and atrophic tongue (=0.61, p=0.00). Duration of T2DM was associated with oral dryness (=0.3, p=0.00), atrophic tongue (=0.25, p=0.00), and tooth loss (=0.27, p=0.00).

Conclusion: Poor glycemic control was associated with oral manifestations in T2DM. Therefore, patients with oral manifestations of T2DM should be evaluated thoroughly to detect the presence of long term complications.

Keyword: Type 2 diabetes mellitus, oral manifestations, oral dryness, burning mouth syndrome, median rhomboid glossitis, tooth loss, atrophic tongue

778

PO 326Hypokalemic Periodic ParalysisIrawan Fajar Kusuma*, Probosuseno** Iri Kuswadi***,

*Resident of Internal Medicine, Faculty of Medicine Gadjah Mada University / Sardjito Hospital Yogyakarta

*Staff at Geriatric Division, Department of Internal Medicine, Faculty of Medicine Gadjah Mada University / Sardjito Hospital Yogyakarta

*Staff at Nephrology Division, Department of Internal Medicine, Faculty of Medicine Gadjah Mada University / Sardjito Hospital Yogyakarta

Introduction

Hypokalemic periodic paralysis can cause muscle weakness and can be in time of hypokalemic status in the serum. The condition can affect the quality of life of a person since its episodic and periodical attacks. The disease is congenital and it is inherited as an autosomal dominant disorder. There is no specific treatment of this disorder. It can be managed by controlling its triggers and risk factors.

Case Presentation

A 31 year old man come to hospital with the chief complain of weakness of both legs. It last for about 48 hours. There is no symptoms of seizure, palpitation, vomitting, diarrhea and his appetite is normal. Three weeks before, he was admitted to hospital with the same complain. He suffered the attack of weakness first time about 2 years ago and counted for nine times admissions. His brother also has the same symptom of periodic attack of muscle weakness. The attack came when he suffered from a sudden cold weather. In the previous admission, his serum potassium level was 1.66 mmol/L. The physical examination showed that the vital signs are normal but it muscles strength is 4 (of 0-5 scale) at both legs and is flaccid. The physiologic reflexes are normal, and no pathologic reflexes found. There is also no muscular atrophy. On admission, his potassium level is 1.66 mmol/L. The renal function was normal (BUN 7,6 mg/dL and serum creatinin 0.99 mg/dL). The excretion of potassium through the urine is not increase (urine potassium of 13,58 mmol/L). Patient has been worked up for head CT scan that there is no abnormal structure. The Electro Neuromyography (ENMG) showed a decrease of Compound Motorneuron Action Potential (CMAP). The thyroid function is normal. After 48 hours of weakness, the symptoms was relieved. The management of this patient is giving daily 50mEq of Potassium chloride intravenously and evaluation after the corrections. After four days patient was going home with the potassium level of 2.8 mmol/L. The patient get medication of oral slow released potassium, acetazolamid and has been educated for avoiding carbohidrate loading, cold weather and stress.

779

Conclusion

A patient with hypokalemic periodic paralysis is triggered by cold weather and has been admitted to hospital nine times in two years. The prophylaxis medication of acetazolamide is administered. An oral is also given beside adequate education to avoid triggers and risk factors.

Keywords: hypokalemia, periodic paralysis, acetazolamide

780

PO 327Correlation between Pancreatic β Cell and Lipid Profile in Subjects with Normal Glucose Tolerance

Dian Anindita Lubis, Farik Zarmal, Santi Syafril, Dharma Lindharto

Division of Endocrinology, Metabolism, and Diabetes Internal Medicine Department, Faculty of Medicine Sumatera Utara University

Background. Dyslipidemia is marked by an increase of total cholesterol, low density lipoprotein (LDL) cholesterol and tryglicerides (TG), and a decrease of high density lipoprotein (HDL) cholesterol. A few studies have reported that pancreatic β cell dysfunction due to dyslipidemia could lead to type 2 diabetes (T2D) and a constitute risk of T2D. Diabetes is a complex, heterogenous condition that has β cell dysfunction at its core. The homeostatic model assessment (HOMA) is a method to examine the function of pancreatic β cell. The aim of this study is to explore the correlation between pancreatic β cell dysfunction and lipid profile in subjects with normal glucose tolerance.

Methods. Subjects were recruited from the outpatient endocrine clinic in Adam Malik General Hospital, Medan, Indonesia from July 2015 to November 2015. All subjects with normal glucose tolerance, by fasting plasma glucose, were included. Current use of dyslipidemia drugs, or secondary dyslipidemia served as an exclusion criterion, since this could act as a confounder at pancreatic β cell. A cross sectional study was conducted to 32 subjects. Spearman test was conducted to assess the correlation between HOMA-B and lipid profile.

Results. A total of 32 participants constituted the study population. We found a significant correlation between decreased of pancreatic β cell function with total cholesterol (r=-0,601; p=0,0001) and LDL (r=-0,555; p=0,001). There is no significant correlation between pancreatic β cell function with HDL and TG in this study.

Conclusion. In subjects with normal glucose tolerance, it was shown a correlation between pancreatic β cell function with total cholesterol and LDL. This finding could be used as an early predictor of pancreatic β cell dysfunction.

Key words: Lipid profile, total cholesterol, LDL, HDL, trygliserida, HOMA-B.

781

PO 328COMPARISON OF GLYCEMIC STATUS BETWEEN GLYCATED ALBUMIN AND GLYCATED HAEMOGLOBIN IN DIABETIC KIDNEY DISEASE SUBJECTS

Hasyim kasim, Sari Juniar , Haerani Rasyid, Makbul Aman, Syakib Bakri

Department of Internal Medicine, Faculty of MedicineHasanuddin University

ABSTRACT

Background Diabetic kidney disease (DKD) is a common complication of chronic diabetes mellitus (DM) and about 30-50% will have End-Stage Renal Disease. Anemia on Chronic Kidney Disease (CKD) associated with iron deficiency and eryhtropoietin. Many studies have been focused on importance of glycemic control to prevent micro and macrovascular complications. One mostly used parameter in glycemic control is glycated hemoglobin (HbA1c), but has limitation due to variation of Haemoglobin (Hb). Glycated Albumin (GA) is another glycemic control parameter, can be evaluated in shorter time (2-3 weeks) and not influenced by erythrocyt life-span.

Objectives This study aimed to compare glycemic control between GA and glycated HbA1c

Patients and Methods This study was descriptive-analytic with Cross-sectional approach among in-patients and out-patients with DKD subjects at Dr. Wahidin Sudirohusodo Hospital, Makassar from May-August 2015. Diabetic Kidney Disease severity classified based on Glomerular Filtration Rate (GFR) : GFR 30-59 ml/min, 15-29 ml/min, <15 ml/min. Uncontrolled DM diagnosis defined as HbA1c level ≥ 7%. Glycated Albumin was measured using GA-L reagent (Asahi Kasei Pharma Corporation, Japan) through enzymatic procedure. Data were processed using SPSS version 22.0 for Windows

Results This study involved 27 subjects with mean (range) HbA1c 7,9 (4,3-14,0). Mean (range) GA 24,6 (14,5-47,7). Uncontrolled and controlled HbA1c subjects are 15 and 12 subjects, respectively. Subjects with high and normal GA are 23 and 4 subjects, respectively. There was significant positive correlation between HbA1c level and GA level with R=0,427, p<0,05. The correlation between GA level and DKD severity based on GFR is not significant (p>0,05). From the comparison between GA level and HbA1c level in glycemic control, we found 13 subjects (86,7%) from 15 subjects with uncontrolled HbA1c also has high GA level.

Conclusion We found compatibility of glycemic control between GA level and HbA1c level in DKD

782

PO 329EFFECT OF ROUX-EN Y GASTRIC BYPASS OPERATION ON BLOOD PRESSURE REGULATION IN TYPE 2 DIABETIC OBESE PATIENTS

Background/rationale: Roux-en-Y gastric bypass surgery (RYGB) has been shown to be effective therapy for the treatment of morbid obesity and related comorbidities. Increasing data indicate that RYGB may improve blood pressure regulation. .

Methods: Clinical records of those who underwent RYGB operation at Inonu University Hospital between 2006 and 2015 were reviewed. 46 obese (BMI>40 kg/m2) diabetic patients (26 women, 20 men) were included in the study. Relevant preoperative and postoperative data at last visit including BMI, fasting plasma glucose and A1C were analyzed.

Results: Postoperative mean follow-up period was 14.9 months, ranging from 3 to 102 months. Mean preoperative BMI was 47.3 ± 8.2 kg/m². After surgery, body mass index significantly decreased to 30.5.5±4.4 (p<0.05). Systolic and diastolic blood pressures, fasting plasma glucose and A1c parameters were decreased compared to the preoperative values (p < 0.05).

Preoperatively all patients were using antihypertensive treatment. After surgery, number of patients using antihypertensive therapy decreased to eleven. Twenty-five patients were not using antihypertensive any more.

Conclusions: Our findings suggest that RYGB has favorable effects on blood pressure and also decreases the need for antihypertensive in type 2 diabetic obese patients.

783

PO 330Clinical Characteristics, Glycemic Profile and Obstetrical Outcomes among Pregnant Mothers with Diabetes Mellitus in Hermina Podomoro Hospital

Anthony Paulo Sunjaya1, Samuel Halim2

1. Faculty of Medicine, Tarumanagara University2. Head of Department of Internal Medicine, Faculty of Medicine, Tarumanagara

University

Background. The International Diabetes Federation reported that 16.8% of all pregnant mothers suffers from diabetes. Pregnancy is a diabetogenic state wherein there’s increasing pressure on the mother’s metabolism marked by insulin resistance and hyperinsulinemia due to the various hormones secreted during pregnancy. This study aims to investigate the characteristics of Indonesian pregnant diabetic mothers.

Methods. Medical records of pregnant-patients within the period of January 2013-December 2015 in Hermina Podomoro General Hospital were examined. Diagnosis of diabetes was based on clinical and laboratory results recorded in the medical records. Data items of interest were clinical profile, glucose profile, comorbidities and maternal outcomes.

Result. Forty-five patients were found to suffer from diabetes with the mean age of 31 years. Twenty-one suffers from high risk pregnancy (age >30 years). There were no maternal mortalities, 2 mothers suffer complications of preeclampsia and 6 encounters fetal death. Various other comorbidities were found such as anemia, hypertension and urinary tract infection. Insulin was found to be the treatment of choice for these patients followed by non-pharmacological and anti-diabetic drugs. Thirty-three of them delivered through caesarean section, only 5 was delivered normally. Comparison between patients with normal and fetal death outcomes showed that higher glucose profiles were obtained in those with fetal death.

Conclusion. The above results showed that diabetes-mellitus-in-pregnancy was associated with increased rate of neonatal mortality. Insulin remains the main therapy among pregnant-patients which is inline with various guidelines. Anti-diabetic drug prescription is not recommended as it provided poorer glucose control compare to other modalities. Most of patients were able to undergo pregnancy safely without significant morbidity. This outcome maybe a result of the greater monitoring and prenatal care given to those with diabetes-mellitus-in-pregnancy as well as excellent glucose control due to lifestyle changes and patient compliance with therapy.

Keywords: gestational diabetes mellitus, pre-gestational diabetes mellitus, pregnancy

784

PO 331Marine-Lenhart Syndrome

Monica S, Eva Decroli, Asman Manaf, Syafril Syahbuddin Sub division metabolic, endocrine and diabetes, Division of Internal Medicine Medical Faculty of Andalas University / dr. M.Djamil Padang Hospital

ABSTRACT

Introduction : Graves’ disease and toxic nodular goiter, both causing thyrotoxicosis by different pathophysiological mechanism. Rare cases associates both disease entity are called Marine-Lenhart syndrome.

Methods : Case observation

Results : A 51 years old man, with chief complaint lack of movement of both eyes. The diagnosis was certified by enlargement of thyroid nodule, ophtalmopathy NOSPECT grade IV, suppresed Thyroid Stimulating Hormone (TSH) level, elevated Thyroid Peroxidase Autoantibodies (TPO) and elevated Free Thyroxine (FT4). The USG thyroid found the multiple nodul thyroid in the left side and difuse thyroid in the both side. The patient was treated with PTU and injection of 40 mg Triamcinolone peri bulbar. After following 1 months there’s improvement in both eyes movement but the position of the eye balls can not be restored to normal.

Conclusion : A rare cases with underlying autoimmune mechanism has been reported. The mechanism might be involved in the development of thyroid nodules with variable function and proliferation activity.

Keywords : Graves ophtalmopathy, Multi Nodular Goiter, Marine-Lenhart syndrome.

785

PO 332DIABETES KNOWLEDGE AND BEHAVIOR LEVEL IN RELATION WITH DIABETIC FOOT ULCER COMPLICATIONS

A.S. Soetjitpo1, A. Stella Soetjipto1, F.M.W. Sondakh1, H. Hiesmantjaja1, R. Thioris1, S. Sumantri2

1. Faculty of Medicine, Universitas Pelita Harapan, Lippo Village, Tangerang, Indonesia2. Internal Medicine Department, Faculty of Medicine, Universitas Pelita Harapan,

Siloam Hospital Lippo Village, Tangerang, Indonesia

Background Foot ulceration in Type 2 Diabetes (T2DM) is common, disabling and frequently leads to leg amputation. Diabetes knowledge, especially foot care among diabetic patients is essential for optimal diabetes management. This study explores the association of general and specific diabetes knowledge and behavior level to diabetic foot ulcer.

Methods This is a cross sectional study conducted in the inpatient ward of Rumah Sakit Umum Siloam (RSUS), Tangerang between January-May 2016. Patients were divided into two groups (intact skin, n=71; foot ulcer, n=45) and were measured for T2DM duration, level of foot care knowledge (FCK), Diabetic Foot Self Behavior Scale (DFSBS), Self Care Inventory–Revised (SCI-R), Diabetes Knowledge Questionnaire (DKQ), Wagner classification, Ankle-Brachial Index (ABI) and Peripheral Neuropathy. Chi-square and independent T-test were used in bivariate analysis and logistic regresion in multivariate analysis for qualified variables (p<0.2).

Results This study consisted of 116 subjects (41.4% male vs. 58.6% female). We found the relation of knowledge and behavior level to Wagner classification as follows (DFSBS, p=0,284; FCK p=0.910; SCI-R, p=0.124; DKQ, p=0.150). We found that Peripheral Artery Disease (PAD) status [OR 2.083 (95% CI 0.947-4.582, p=0.073)], duration of DM [OR 3.198(1.199-8.529, p=0.025)], and foot deformity [OR 2.989(1.146-7.794,p=0.028)] significantly related with wagner. Patients with PAD showed better foot self care (p=0.006). Subject with longer duration of DMT2 tend to have better diabetes knowledge (DKQ) but didn’t affect behavior levels. Female gender have a protective effect against foot ulcer. Logisitic regression showed these results, foot deformity (p=0.009), PAD (p=0.017), T2DM duration (p=0.033), gender (p=0.666), DKQ (p=0.688), SCI-R (p=0.250).

Conclusion Knowledge and behavior level didn’t correlate directly with foot ulceration. Increase in general and specific foot knowledge without good behavior will not prevent foot ulcer. Assesment of behavior change is needed in addition to good patient education.

786

PO 333Abstract

Hypophysectomy on Pituitary Adenoma and its consequenciesMunirulanam, R Bowo Pramono, Hemi Sinorita, M Robikhul IkhsanEndocrinology, Metabolic and Diabetes Sub DivisionInternal Medicine Division, Faculty of Medicine Gadjah Mada University/Dr. Sardjito Centre Hospital - Jogjakarta

Tumors of the pituitary gland and sellar region represent approximately 10-15% of all brain tumors, of which the great majority in this region are pituitary adenomas. The symptomps depends upon several factors, size of the tumor pushes on surrounding brain structures and compress the optic chiasm, leading to vision loss. Headache are common and may not correlate with the size of the adenoma. Pituitary apoplexy is a potentially life-threatening disorders due to hemorrhage of the pituitary gland. The transsphenoidal microsurgical approach is the procedure of choice to alleviate local compressive mass effects and preserve normal pituitary function. Here we present a 59-years old man with a 2 years history of fatigue, cephalgia, neck stiffness, and visual disturbances. Past history of illness: 2 years ago he had been hospitalized with cephalgia, and from Head CT Scan there’s no found of mass. Now at the time of admission he underwent Head CT Scan again and the results showed lobulated mass with calcification intraseller sticky to optic chiasm (suspect pituitary macro adenoma). Consult to Department of Opthalmology there’s a papil atrophy ODS. This patient underwent transsphenoidal hypophisectomy and after that the result of endocrine hormone (pituitary) normal.

Key words: pituitary adenoma,transsphenoidal hypophisectomy,endocrine hormone

787

PO 334POEMS syndrome: A rare progression of monoclonal gammopathy of undetermined significance

Authors: Inês Ferraz de Oliveira, Joana Urzal, Iuri Correia, Fernando Aldomiro

Introduction: POEMS syndrome is a rare paraneoplastic syndrome associated with a monoclonal plasma cell neoplasm. Most cases present with neuropathy, endocrinopathy and volume overload. Diagnosis is based on two mandatory major criteria (plasma cell disorder and polyneuroradiculopathy) associated with one other major criterion (osteosclerotic bone lesions, vascular endothelial growth factor (VEGF) production or Castelman’s disease) and one minor criterion (organomegaly, extravascular volume overload, endocrinopathy, skin changes, papilledema and polycythaemia or thrombocytosis).

Case Report: The authors present the case of a 72-year-old male patient with a medical history of monoclonal gammopathy of undetermined significance (MGUS) with a 6-months history of asthenia, persistent low grade fever, steppage gait, loss of cognitive abilities and peripheral oedema. Physical examination documented the presence of temporo-spacial disorientation, weakness of the distal muscles of the lower limbs (grade 4) and anasarca. Blood analysis revealed anaemia (haemoglobin 10,8 g/dL) and thrombocytosis. Free light chains (IgG kappa and lambda) were high in urine samples. Blood immunofixation revealed a monoclonal IgG kappa gamopathy. Bone marrow biopsy documented 30% of mature plasmocytes. Electromyogram confirmed moderate to severe distal polyneuropathy. VEGF levels were high (1549 pg/mL). Thoracic, abdominal and pelvic computed tomography revealed a bilateral pleural effusion and discrete ascites with no evidence of organomegaly or osteosclerotic bone lesions. The diagnosis of POEMS syndrome was made and treatment with corticosteroids and lenalidomid was initiated. The initial response to treatment was good, but the patient developed febrile neutropenia and died of Acinetobacter baumanii septicaemia 6 months after initiating treatment.

Conclusion: With this case the authors wish to emphasize the importance of careful monitoring of all patients with MGUS. These patients may have progression of the disease, presenting with less frequent paraneoplastic alterations such as POEMS syndrome, rather than evolving to multiple myeloma with bone pain and renal dysfunction.

788

PO 335Langerhans Cell Histiocytosis in Adult, comorbid with Diabetes Mellitus : Rarecase

Maya Hestiningtyas, Cosphiadi Irawan

Division of Hematology and Medical Oncology, Departement of Internal Medicine, Faculty of Medicine University of Indonesia Cipto Mangunkusumo National Hospital;

ABSTRACT

Introduction

Langerhans cell histiocytosis (LCH) is a rare histiocytic disorder of unknown etiopathogenesis. Its clinical presentation is variable and ranges from isolated skin or bone disease to a life-threatening multisystem condition.

Case Illustration

A 20 years old female was diagnosed Langerhans cell histiocytosis since December 2015, she also suffered from mild hearing loss and seboroic dermatitis. She also had diabetes mellitus, treated with insulin but then interrupted. There are multiple erythematous plaque, confluens discrete lenticular accompanied with white squama, hiperpigmentous lesion, fragile nail; and erosion with white yellowish fluid at mayor labia. Laboratory result reveals high TSH, LH, prolactin level, with low fT3 and anti TPO positive. Chest and abdominal CT-scan shows pulmonary langerhans cell histiocytosis, diffuse struma, and osteoporosis. Bone survey shows multiple lytic lesion. Histopathologic examination confirmed Langerhans cell histiocytosis. She is undergoing treatment chemotherapy with Vinblastin, prednisone and 6-mercaptopurine since March 2016. She shows good clinical response until now.

Discussion

In multisystem LCH, the disease presents in multi¬ple organs or body systems, including bone, the ab¬domen, the gastrointestinal tract, lung, bone marrow, the endocrine and central ner¬vous systems, skin, and lymph nodes. In these patient, we conclude that she suffered from multi organ-system LCH. Patients with multisystem LCH at diagnosis may have a variable clinical course. Combination prednisone/vinblastine has been proven to be an effective treatment with minimal toxicity; therefore, it is the standard initial therapy for all patients in whom systemic therapy is indicated.

Conclusion

We reported a good clinical response of Langerhans cell histiocytosis’s treatment in adult.

Keywords : Langerhans cell histiocytosis, diabetes mellitus, vinblastin

789

PO 336Glycosylated Haemoglobin Levels and the Severity of Sexual Dysfunction in Diabetic Women

Febri Andini, Yenni Fitrika, Hendra Zufry, Krishna W SuciptoDivision of Endocrinology, Metabolism & Diabetes-Thyroid CenterDepartment of Internal Medicine, School of Medicine Syiah Kuala University/Dr. Zainoel Abidin General Teaching Hospital, Banda Aceh- Indonesia

Background : Diabetes is known to cause multiple medical, psychological, and sexual problems. Sexual dysfunction is a well-established complication of diabetes. The sexual functioning of women with diabetes has received much less attention in clinical research. Herein we reported the association between the levels of glycosylated haemoglobin (HbA1c) and the severity of sexual dysfunction (SD) in women with type 2 diabetes mellitus (DMT2).

Methods : This cross-sectional study included sexually active women with a diagnosis of DMT2 attending an Endocrinology, Metabolism & Diabetes-Thyroid outpatient centre in Indonesia’s Aceh Province from November 2013 to January 2014. The 51 women completed Female Sexual Function Index (FSFI) questionnaire, and fasting serum glucose and HbA 1c serum levels were measured. The relationship between the severity of SD and serum HbA1c levels was assessed.

Results : According to the FSFI, from 51 samples found 5 (9.80%) of people who experienced mild sexual dysfunction. Of the total women with type 2 diabetes who experience mild sexual dysfunction encountered 1 (20%) of people with HbA1c under control (<7% HbA1c with the category of being), the remaining 1 (20%) of people with HbA1c category of moderate and 3 (60%) people with poor HbA1c category.

Conclusion :This study suggests that the severity of SD is associated with increasing HbA1c levels in diabetic women.

.

790

PO 337Neutrophil to Lymphocyte Ratio as Amputation Predictor in Patient with Diabetic Foot Infection in Banda Aceh

Sylva Nazly, Syamsul Bahri, Hendra Zufry, Khrisna W. SuciptoDivision of Endocrinology, Metabolism & Diabetic-Thyroid CentreDepartment of Internal Medicine, School of Medicine Syiah Kuala University/Dr. Zainoel Abidin General Teaching Hospital, Banda Aceh-Indonesia

Background: Diabetic foot infection may leads to foot amputation. Neutrophil to Lymphocyt Ratio (NLR) is a practical indicator of long-term inflammation. It is currently an eminent research for predicting the incidence of foot amputation in patient with diabetic foot infection and correspondingly, it is economical and easy. This research aimed to describe the relationship between NLR as the amputation predictor for the infected diabetic foot in patients with Type 2 Diabetes Mellitus (T2DM).

Method: An analytic observational with a prospective cohort approaches was conducted in 47 patients who visited the Endocrinology, Metabolism and Diabetic Clinic, the Accident and Emergency Unit, and all in-patients in the Zainoel Abidin General Hospital, Banda Aceh from February to October 2015. A three months observation, after the patients NLR checked, was conducted.

Results: Forty-seven patients were tested and amputation occurred in 15 patients (31,9%) with cut off point at 7.38. It was found out that the NLR was high in 22 patients (46.8%) and low in 25 patients (53.2%). Out of 15 amputated patients, 14 patients (93.3%) with high NLR and 1 patient (6,7%) with low NRL. Further, in the 32 non-amputated patients, 8 patients (25%) with high NRL and 24 patients (75%) with low NLR. NLR showed 93.33% sensitivity value, 75% specifity value, 63.34% positive predictive value, and 96% negative predictive value.

Conclusion: This study demonstrated significant relationship between NLR and foot amputation incidence in diabetic foot infection (p<0,005). This ratio could be used as the amputation predictor for T2DM patients with diabetic foot infection.

791

PO 338THE RURAL-URBAN DIFFERENCES IN ADIPOSITY AND ADIPOKINES PROFILES AMONG INDONESIANS

Farid Kurniawan*1, Dicky L. Tahapary*1,2, Karin de Ruiter2, Yenny Djuardi3, Em Yunir1, Dante S. Harbuwono#1, Pradana Soewondo#1

1. Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

2. Department of Parasitology, Leiden University Medical Centre, Leiden, The Netherlands

3. Department of Parasitology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

*These authors have contributed equally, #These authors have contributed equally

Background:

Indonesia is a developing country with increasing rate of urbanization. Urbanization is characterized with changes into more sedentary lifestyle and westernized diet. These changes lead to the increase of non-communicable diseases such as obesity and type 2 diabetes (DMT2). This study aims to characterize the different profile of adiposity and adipokines level in urban and rural population of Indonesia, and their association with insulin resistance (IR).

Methods:

A cross-sectional study involving male subject with Flores ethnic background from rural (Ende, East Nusa Tenggara) and urban area (Jakarta) was conducted. Measurements of body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-hip ratio (WHR), 4-sites skinfold (SF) [biceps, triceps, supra iliac, subscapular (cm)], and body fat composition (bioimpedance analyzer/BIA) were performed. Sera concentration of leptin (ng/mL), adiponectin (g/mL), and resistin (ng/mL) were measured using ELISA. Insulin resistance, as assessed using homeostasis model assessment (HOMA-IR), was calculated from fasting level of glucose (mg/dL) and insulin (IU/L).

Results:

We recruited 86 rural and 47 urban subjects in this study. Urban group was associated with higher BMI, WC, WHR, and subscapular SF, even after age adjustment. Urban group was also associated with higher leptin [4,898(1,842-7,955); p=0,002] and resistin [3,217(2,327-9,761); p=0,002] level. Leptin level was correlated with BMI in both groups [r=0,591,p<0,001; r=0,564,p<0,001; urban and rural, respectively]. However, after further

792

adjustment for BMI, urban group was still associated with higher leptin level. Despite the higher adiposity, leptin, and resistin level, there is no significant difference in HOMA-IR between groups [(-0,259-2047),p=0,128]. After adjustment for age and BMI, in rural group, HOMA-IR was associated with subscapular SF [0,081(0,025-0,137);p=0,005) and leptin level [0,054(0,001-0,108);p=0,046]. Meanwhile, in urban group, it was only associated with leptin level [0,464(0,229-0,580);p<0,001].

Conclusion:

Living in urban area is associated with having unfavourable adiposity profile and a shift towards a more proinflammatory adipokines profile. Although these changes were not significantly associated with higher IR in our relatively small number of subjects, these unfavourable profiles might then lead to higher IR and increase risk of DMT2 in the future.

793

PO 339Correlation between Body Mass Index and Glycemic Control in Obese Type 2 Diabetes Mellitus Patients who was Received Metformin Monotherapy at dr. Zainoel Abidin General Hospital Banda Aceh

Sabarina, Kurniadi Abdullah, Hendra Zufry, Krishna W SuciptoDivision of Endocrinology, Metabolism & Diabetes-Thyroid CenterDepartment of Internal Medicine, School of Medicine Syiah Kuala University/Dr. Zainoel Abidin General Teaching Hospital, Banda Aceh- Indonesia

Background: Type 2 Diabetes Mellitus (T2DM) is characterized by the present of insulin resistance and relative deficiency of insulin. Metformin is an oral hypoglycemic drugs, known to lose weight in obese patients or healthy people. This study is to examine the association between obesity and glycemic control among patients withT2DM.

Methods:It was an open label clinical trialin 41 T2DM subjects with obesity who was received metformin, were collected by consecutive sampling from patients visiting the Endocrine, metabolic and diabetic (EMD) outpatients department of the dr.Zainoel Abidin General Hospital during June – September 2014. Fasting serum glucose, post prandial serum glucose, and body mass index (BMI) were measured. From the data obtained, the relationship between variables were analyzed by Pearson correlation and linear regression analysis.

Result: This study obtained 41 samples consisted of men 7 (17%) and women 32 (78%), found a positive correlation, which is statistically not significant between BMI with HbA1C (R² = 0.078, ß = 0.279, P = 0.085), fasting plasma glucose (R² = 0.10, ß = 0.316, P = 0.05) and post prandial plasma glucose (R² = 0.01, ß = 0.098, P = 0.553), the results were statistically significant when P <0.01,relationship between BMI and fasting plasma glucose seemed stronger than the HbA1C and post prandial plasma glucose.

Conclusion: Glycemic control is positively associated with body mass index, even toughit was not statistically significant, which fasting glucose givena stronger influence on the BMI in patients with T2DM with obesity

794

PO 340Adiponectine Level in Obese-Diabetic Patients: treated vs. untreatedA case series study

Tania Tedjo M*, K. Heri Nugroho**, Tjokorda GD. Pemayun**, Tony Suhartono**, Darmono****Specialist trainee, **Internist-Endocrinologist, *** Professor of Endocrinology and Metabolism, Sub Div. of Endocrinol. Met., Dept. of Internal Medicine, Diponegoro Univ., Semarang-Indonesia

BackgroundLower serum adiponectine level found in obese patient with insulin resistance. Administration of oral hypoglycemic agent (OHA) causing alteration in serum adiponectin level.

ObjectiveThe aim of this case series is to figure out whether the adiponectine level differ between treated obese diabetic patients and the naive one.

Case seriesFive patients were having so much in common. They were obese, diagnosed for having diabetes, and also fulfilling the criterias for metabolic syndrome based on NCEP-ATP III1 (See Table 1). The firts four patients already received OAD metformin based-with various combination. The fifth patient was newly diagnosed and hasn’t received any treatment yet.

Table 1. Physical condition and metabolic profiles Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Normal rangeAge (year) 63 33 23 42 34Sex Male Female Male Male FemaleTime of diagnosis (year) 25 7 5 2 NaiveBMI† (kg/m2) 31.8 33.6 34.9 36.3 26.2 18.5-23 (Asian)WC‡ (cm) 109 104 116 119 96 Male ≤102; Female ≤88FPG* (mg/dL) 201 188 234 189 140 <110PP BG# (mg/dL) 288 267 306 322 304 140-200Tg¥ (mg/dL) 173 190 311 180 311 <150Creatinin (mg/dL) 1,1 0.88 0.96 1,05 0,81 0.7-1.3

795

Treatment Metformin + + + + - Basal insulin + - - - - SU + + + + - Acarbose - - - + -†Body Mass Index‡Waist circumference*Fasting plasma glucose#Post prandial blood glucose¥Trigliceride

In such thypical diabetic obese patients, we calculate the stage of insulin resistance and the level of serum adiponectine. We figure out is there any differences in the level of serum adiponectine between treated obese diabetic patients and the naive one (See Table 2).

Table 2. Insulin resistance and adiponectine level among offspring Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Normal rangeFPG† (mg/dL) 214 168 131 189 96 <100Fasting Insulin (µIU/mL) 8.3 14.2 16.0 15.5 12.2 3.2-28.5HOMA IR‡ 4.23 5.81 5.18 7.23 2.89 ≤ 2 (Asian) Adiponectine (µg/mL) 4.52 10.31 3.11 6.45 1.78 3.58-9.66†Fasting plasma glucose‡Homeostatic model assessment-insulin resistance

Discussion

Adiponectine is a product of the adipose tissue, its levels have been demonstrated to be decreased in obese individuals. This paradoxical situation seems to be related to the effect of other adipokines, mainly tumor necrosis factor alpha (TNF-α).2 Excessive body fat mass, primarily at the abdominal location, would induce an increase in TNF-α which down-regulates adiponectin synthesis by the adipocytes.3,4

The result regarding adiponectine level was enormous. Despite of their remain high BMI and insulin resistance condition, adiponectine level among treated patients were normal or even slightly increased compare to the naive patient. This result was similar to

796

what has been stated by Kong et all that Metformin administration was associated with increased serum adiponectin concentrations.5 Naive patient which never been given any treatment showed a very low serum adiponectine level despite of her slightly increased insulin resisten stage.

Conclusion Treated obese diabetic patients shows a relatively higher serum adiponectine level compare to the naive one, but the clinical implication of this serum adiponectine level remain unclear since all patient still show unsatified metabolic profile.

Referrences

1. US Department of Health and Human Service. National Cholesterol Education Program. National Institute of Health. 2001.

2. Bruun JM, Lihn AS, Verdich C, Pedersen SB, Toubro S, Astrup A, Richelsen B. Regulation of adiponectin by adipose tissue-derived cytokines: in vivo and in vitro investigations in humans. Am J Physiol Endocrinol Metab 2003;285:E527–533.

3. Li L, Yang G, Shi S, Yang M, Liu H, Boden G. The adipose triglyceride lipase, adiponectin and visfatin are downregulated by tumor necrosis factor-alpha (TNF-alpha) in vivo. Cytokine 2009;45:12–9.

4. Maeda N, Takahashi M, Funahashi T, Kihara S, Nishizawa H, Kishida K, et all. PPAR gamma ligands increase expression and plasma concentrations of adiponectin, an adipose-derived protein. Diabetes 2001;50:2094–9.

5. Kong W, Niu X, Zeng T, Lu M, Chen L. Impact of Treatment with Metformin on Adipocytokines in Patients with Polycystic Ovary Syndrome: A Meta-Analysis. PLOS ONE 2015;10.1371:1-20.

797

PO 341Aspergilloma with hemoptysis in Young Female Erni Erdoris Ginting

Division of Pulmonology Allergy ImmunologyDepartment of Internal Medicine of North Sumatera

Background:

Aspergillus species have emerged as important cause of morbidity and mortality in imunocompromised patients, this is unusual cause of infection. Pulmonary aspergilloma is a saprophytic fungal infection in the form of colonization in the lung cavity that can be caused by various underlying disease. Aspergillus fumigatus is a fungus species that most commonly caused aspergilloma. Fungus colonization formations like mass called Fungus Ball. The most clinical manifestations was hemoptysis. Hemoptysis can be massive and life threatening. There are differences opinion regarding the optimal therapy in aspergilloma, surgery is recommended as the primary choice of therapy in most patients.

Method:

Female, 26 years old, complained of coughing up blood repeatedly in the past year, every coughing, sputum mixed with blood was found. In the last 2 months volume of blood coughing quite a lot about one cup, frequency 3 times in two months. Patient also complain shortness of breath and pain in the left chest that felt penetrating to backs, fever is not encountered, decreased appetite, weight loss is unclear. History of tubercullosis was denied. Patient hospitalized at ADAM MALIK hospital and conducted investigations. In addition to clinical symptoms, physical examination was not much help. Laboratory test: Hb 11 g%, leukocytes 13.760 / mm3, platelets 278. 000/mm3. From thorax radiology looked round with halo mass picture in the left middle lung field. Impression: aspergilloma. From thorax scan, looked solitary homogeneous picture, solid mass in the left lung. Conclusion: aspergilloma. On bronchoscopy , at branching superior lobe and lingula seen spotting bloodstains. Lumen segment of lower lobe of the left half was closed by white secretions, other mucosal well. Result of the examination BAL (Broncho Alveolar Lavage): Looks like the fragment hiffa incomplete and spores with a background of necrotic mass, found no signs of malignancy in this preparation.Conclusion: a chronic inflammatory process that can be suspected as aspergilloma. Patients are given therapy Codeine 3 x 10 mg , Vorikonazole 2 x 200 mg and follow up. After 1 month she back for control, hemoptysis was decreased.

798

Result:

An aspergilloma cases in young female, defined as an aspergilloma and have done therapy Codeine 3x 10 mg , Vorikonazole 2 x 200 mg.

Conclusion:

A case of aspergilloma that have been treated with anti fungal and must follow up.

799

PO 342THINK ABOUT POSSIBILITIES OF DENGUE INFECTION BEFORE YOU PLAY YOUR SURGERY KNIFE (THINK ABOUT POSSIBILITIES OF DENGUE INFECTION BEFORE WE AGREE TO DO THE OPERATION)

Taufiq Muhibbuddin Waly

Internal Medicine Department Waled General Hospital, Cirebon, West Java, Indonesia

Aim :

As a matter of consideration for internist in answering question of operation consultation

Shows the comparison between Hematocrit and Hemoglobin (Ht/Hb) more than 3x can be considered as a sign of Dengue Infection without symptoms (no sickness) in a person.

Case Report:

An obese women (Height: 165 cm, BW: 78 kg), Registration Number 184982. With FA Mammae measurement: 4x5x2 cm, operated in May 8th 2012 as 1 PM.

Laboratory result before operation:

• Hb: 11.3 • Natrium: 138

• Ht: 35 • Kalium 4.3

• Leukocyte: 6300 (0/0/0//52/42/6) • Chloride: 109

• Platelet: 296000 • GOT/GPT: 16/17

• Erythrocyte: 4.8 • Ureum/creatinin: 15/0.7

• LED: 24 (0-10) • Total Cholesterol: 218

• Clotting Time: 7 • LDL: 146

• Bledding Time: 2 • Triglyceride: 70

• Blood Sugar random: 101 mg% • HDL: 58

In May 9th 2012 at 10 AM, patient was shocked, blood pressure 80/ palpation, RR: 28x/minute, HR: 140x/ minute, T:38,9o C, RL: (+), bleeding (-), Laboratory test: Hb: 9.0, Leucocyte 18100, (0/0/0/95/2/3), admitted to ICU, because the shock couldn’t be stopped even after she was given 5 bags of Ringer Lactate liquid and 1 bag of Widahees colloid liquid. Patient was consulted to an internist. During treatment, platelet count even reached as low as 27000 and could only reach 100.000 on the 10th day of treatment.

800

Patient was sent back on 11th day with good overall condition, platelet count was 109000, and underwent Dengue blot inspection again with the result of IgG(+), IgM(-). During treatment the patient was never given any transfusion.

Discussion:

Fever, with positive Rumple leed test, severe thrombocytopenia, shock and Dengue blood IgG(+) on the 11th day showed us the diagnosis of said patient was severe Dengue (WHO 2009) or grade IV DHF (WHO 1997). So when patient underwent operation in May 8th 2012 she had been already infected by Dengue even if it’s still without any symptoms. Laboratory test showed no abnormalities except LED , hypercholesterolemia and Ht/Hb > 3x. Increased LED can be caused by hypercholesterolemia. Ht/Hb > 3x, can be caused by deficiency in intravascular fluid. As the biggest Dengue hyperendemic region, deficiency of intravascular fluid can be considered as caused by Dengue infection at the bottom of the iceberg. Rumple leed test need to be done. Patients who are suspected to be infected by Dengue virus, their operation needs to be postponed if we learned something from this case.

801

PO 343Correlation Of Neutrophil-Lymphocyte Ratio And Procalcitonin Level In Septic Patients

Akhmad Nurdani, Usman Hadi, M Vitanata Arfijanto, Bramantono, Erwin Astha T, Purwati, Musofa Rusli, Nasronudin, Suharto

Division of Infection-Tropic Disease, Department of Internal Medicine, Medical Faculty of Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: Microbiology blood culture test is the gold standard to diagnose sepsis. Unfortunately, it needs time several days to show its result. Currently, procalcitonin is a reliable biomarker to diagnose and predict the outcome of septic patients. Whereas, neutrophil-lymphocyte ratio have been tested as a diagnostic marker for bacterial infection. This study determined the correlation between neutrophil-lymphocyte ratio and procalcitonin level in septic patients.

Methods: this study was a cross-sectional analytic observational study in septic patients age 18-60 years old. There were 30 participants in the study. Neutrophil-lymphocyte ratio was calculated by dividing the numbers of absolute neutrophil count with the numbers of absolute lymphocyte count, measured using Sysmex XN 1000 hematology analyzer. Procalcitonin level was measured using VIDAS®BRAHMS PCT Test (ELISA). The Spearman correlation test was used to analyze the statistic correlation between neutrophil-lymphocyte ratio and procalcitonin level.

Results: Microbiology blood culture test showed 63,3% of all sample were gram negative bacteria. The median of neutrophil-lymphocyte ratio result was 12,05 (6,48-24,27). The median of procalcitonin result was 2,85 ng/ml (0,75-88,42 ng/ml). Average range of neutrophil-lymphocyte ratio in gram negative bacteria was 12,07±3,52 ng/ml and average range of procalcitonin in gram negative bacteria was 10,34±22,92 ng/ml. Whereas average range of neutrophil-lymphocyte ratio in gram positive bacteria was 15,76±4,36, and average range of procalcitonin in gram positive bacteria was 6,02±4,26 ng/ml. Based on disease severity, Neutrophil-lymphocyte ratio and procalcitonin level in sepsis was 10,08±3,34 ng/ml and 1,79±1,39 ng/ml, in severe sepsis was 12,11±4,08 ng/ml and 3,56±2,79 ng/ml, in septic shock was 15,78±6,10 ng/ml and 23,19±31,33 ng/ml. Spearman correlation test showed significant correlation between neutrophil-lymphocyte ratio and procalcitonin level in septic patients (rs = 0,68; p <0,01).

Conclusion: There is significant correlation between neutrophil-lymphocyte ratio and procalcitonin level in septic patients.

Keywords: neutrophil-lymphocyte ratio procalcitonin, sepsis

802

PO 344PATTERN LEPTOSPIRA STRAIN CAUSE OF LEPTOSPIROSIS EPIDEMI IN SAMPANG MADURA EAST JAVA INDONESIA

1Purwati, 1Usman Hadi, 1Musofa Rusli, 2Etik Widiasari, 3Hendrianto, 3Fedik Abdul Rantam

1. Tropical and Infectious Diseases Division- Depart. of Int. Med – Fac. of Med. Dr. Soetomo Teaching Hospital

2. Sampang General Hospital3. Institute of Tropical Disease Airlangga University

Background: Strain infectivity of leptospira determinate of clinical manifestation, morbidity and mortality of leptospirosis patiets. The virulence of microorganism will multiplicity in the blood and tissue. Based on virulence of the microorganism so this research will to investigate of outcome (survival and mortality) leptospirosis patients in Sampang Outbreak in period of April to May 2014 base on strain infectivity with the method using MAT

Method: Observasional analytic, cross sectional study. Population of all patients in Internal Medicine ward at Sampang Hospital, during outbreak, April to may 2014 with clinical manifestation of leptospirosis, laboratory result and RDT positive leptospirosis, and than it had been cross-checked with MAT to determine of leptospira strain.

Result: Twenty patients was diagnosed with leptospirosis, 15 men (75%) and 5 women (25%), survival 45%, mortality 55%. Laboratory result was showed mean of Hb count was 11,91 g/dL, mean of leucocyte count was 15, 19 x 103/L, and mean of thrombocyte count was 157,25 x 103/L, mean of AST result was 65,35 IU/L , mean of ALT result was 64,6 IU/L, mean of direct bilirubin was 6,58 mg/dL, mean of total bilirubin was 8,53 mg/dL. The frequent of clinical feature were fever, headache, shock, dypsneau, vomiting, icterus, conjunctival suffocation, epigastric pain, gastrocnemeus pain, and bleeding. From MAT result found that strain L. icterohaemorrhagie-Naam sv, L. shermani sv, L. icterohaemorrhagie –copenhageni sv, L. sejroe sv, L. australis sv, L. australis-brasilava sv, L. tarasovi sv, L. bataviae sv, L. icterohaemorrhagie-lai sv. L. icterohaemorrhagie-Naam sv was the most frequent strain which caused mortality (p=0.000) in Sampang leptospirosis outbreak.

Conclusion : The most frequent strain was caused mortality in this research was Icterohaemorrhagie serogroup – Naam Serovar (p=0.000)

Keywords: outbreak, mortality, leptospirosis, MAT, sampang madura

803

PO 345CASE REPORTHIV Infection Mimicking Autoimmune and Rheumatic Disease: The Diagnostic Challenge

Yovita Hartantri. Ining Kartika Tarmidi, Laniyati HamijoyoInfection and Tropical Disease Subdivision, Department of Internal MedicineHasan Sadikin Hospital/Universitas Padjadjaran

ABSTRACT

Introduction

Human immunodeficiency virus (HIV) infection is a global pandemic affecting millions of people. HIV infection is reported to have many immunological and rheumatic manifestation. HIV infection have multisystem manifestations throughout the various stage of infection. Progression from HIV infection to AIDS is associated with gradual loss of immunocompetence and the occurence of opportunistic infections and malignancies, and also associated with immune dysregulation and persistent, prolonged immune activation that leads to autoimmune phenomena.

Case Reports

In this case report will be reported 4 case of HIV patients in Hasan Sadikin Hospital/ Teratai HIV Clinic Bandung, with initial presentation of autoimmune and rheumatic manifestation. First patient, female 36 years old with stage IV HIV infection, presents with autoimmune hemolytic anemia, renal insufficiency with proteinuria, and a history of seizures, with positive ANA test, initially diagnosed and treated as systemic lupus erythomatosus (SLE) with hematologic, renal, and neuropsychiatric involvement. Second case, a 39 years old man presents with joint pain, prolonged fever and wasting syndrome, initially diagnosed as rheumatoid arthritis. Two other patients, male 32 and 43 years old, presents with prolonged fever, oral ulcers and wasting syndrome, with positive ANA test, treated and diagnosed as SLE for 1 year, apparently has a stage IV HIV infection with very low CD4 counts. HIV infection can resembles autoimmune disorder in that there is a high incidence of antiphospholipid and antinuclear antibodies. Rheumatic manifestations can be found in these HIV-infected patients. Arthritis may occur at any stage of HIV infection and has been the initial manifestation in our patients.

Conclusion

In people who are infected with HIV, recognition of autoimmune disorder, their differentiation from infections and their treatment using immunosuppressive drugs is a challenging clinical scenario. Early diagnosis, antiretroviral drugs and prompt treatment

804

of opportunistic infection can change the clinical profile of HIV patients.

Keywords: autoimmune and rheumatic manifestation, human immunodeficiency virus (HIV) infection, diagnosis

805

PO 346CLINICAL PRESENTATION AND COURSE OF DENGUE INFECTION AMONG PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A CASE SERIES

Ma. Imee Lynne C. Esquibel MD, Sandra Navarra MDUniversity of Santo Tomas Hospital, Manila

Background/Rationale: To describe the manifestations and course of Dengue infection in a group of patients with systemic lupus erythematosus (SLE)

Methods:

This is a case series, in a tertiary care hospital (private). Charts of ten adult patients with SLE who developed Dengue infection were reviewed and analyzed.

Results:

This series includes a total of 10 SLE patients (all females) who developed Dengue infection. The age ranged was from 16-33 years old with an average of 25.9 years old, and a disease duration of 2-9 years before Dengue infection. During the course of dengue infection, there were 8 who had thrombocytopenia whereas 9 had hemoconcentration. Seven tested positive for Dengue NS1 and IgM, and one tested both positive for IgG and IgM, 2 patients had negative serology but met the criteria for Dengue. Seven patients experienced lupus flare, with an increase in SLEDAI scoring (thrombocytopenia and fever were NOT scored) of 4 to 10 points from baseline/ before Dengue infection. Five flares included musculoskeletal and mucocutaneous involvement while 2 were renal; CNS flare could not be excluded in

1 patient who developed behavioural changes which resolved with steroid increase. Six patients required increase in oral prednisone dose and 1 patient with nephritis flare received methylprednisolone pulse therapy. One patient received 6 units of platelet concentrate due to profuse vaginal bleeding. The 3 other patients received supportive treatment alone.

Conclusion: This case series of Dengue infection in 10 patients with SLE illustrates the diagnostic and management challenges posed by a clinical situation where one disease can confound or complicate the other.

Research funding: None

806

PO 347LOW YIELD OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS NASAL CARRIAGE IN ELECTIVE SURGERY ADULT PATIENTS IN CIPTO MANGUNKUSUMO HOSPITAL, JAKARTA, INDONESIA

Erni Juwita Nelwan1, Robert Sinto1, Decy Subekti2, Randy Adiwinata1, Lia Waslia2, Tonny Loho3, Dodi Safari4, Djoko Widodo1

1. Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Indonesia

2. Eijkman Oxford Clinical Reseach Unit, Jakarta, Indonesia3. Department of Clinical Pathology, Faculty of Medicine, Universitas Indonesia,

Indonesia4. Eijkman Institute for Molecular Biology, Indonesia

Background: Methicillin-Resistant Staphylococcus aureus (MRSA) has been known as main cause of surgical site infection. Numerous studies found association between the presence of colonization and fore-coming surgical site infection in high-risk patients. However burden of MRSA colonization might be different in each setting, therefore local data is required.

Methods: Cross sectional study was conducted between April-September 2015 in Cipto Mangunkusumo Hospital, national referral, Indonesia. Patient aged >18 years old, eligible to receive nasal swab and assigned for elective surgery were screened; risk of colonization was evaluated including co-morbidity. The nasal swab specimens were tested for Staphylococcus aureus using blood agar and serial chemical identification test. Furthermore MRSA was determined by cefoxitin diffusion test and the presence of mecA gene from Staphylococcus aureus isolates.

Results: From 384 patients, 65 (16.9%) underwent orthopaedic surgery, 60 (15.6%) for digestive surgery, 60 (15.6%) for ear-nose-throat surgery and 58 (15.1%) for oncology surgery. There are 158 (41.1%) patients had a history of hospitalization within the previous one year and 197 (51.3%) had received antibiotics within the previous 3-month. A total of 83 (21.6%) patients were on invasive devices within prior to 48 hours, 93 (24.2%) had open wound, and 74 (19.3%) patients were referred from other hospitals. The most common comorbidity was solid tumor without metastasis (38.3%), followed by diabetes (10.4%), and congestive heart failure (7.6%). Nasal colonization of Gram-positive bacteria was detected in 295 (76.8%) while Staphylococcus aureus in 60 (15.6%) of patients. Three isolates shown MRSA determined by cefoxitin diffusion test and PCR therefore given the prevalence rate of 0.78%.

807

Conclusions: A very low prevalence of MRSA nasal carriage was found among patients performed elective surgery in the national referral hospital in Indonesia. This finding supports the recommendation of not routinely apply mupirocin for nasal decolonization on patient plan for surgery in Indonesia.

Keywords: Methicillin-Resistant Staphylococcus aureus, nasal colonization, pre-operative

808

PO 348Advanced Disease at Enrollment in HIV Care Over Twelve Years of HAART in Sanglah Hospital

A.A.Ayu Yuli Gayatri, Dewi Dian Suksmawati, Made Susila Utama, Ketut Agus Somia, Tuti Parwati MeratiDivision of Tropical and infectious disease -Internal Medicine,Medical Faculty Udayana University /Sanglah Hospital Denpasar.

ABSTRACT

Background: Enrollment in HIV clinical care at advanced disease (CD4 cell count 200 cells/µl or less; or WHO stage 3-4) denotes critical missed opportunities to improve the health and well being of HIV- positive people and limits the potential of treatment at earlier stages to reduced HIV transmission and an potentially attenuated incidence.

Material & Method: Cross sectional overtime study. Data were obtained from the HIV cohort database at Sanglah Hospital. Information was extracted and statistic analysis were performed on patients initiating ART in 3 times periods; I (2004-2006), II (2007-2010) and III (2011-2015) matching availability of different WHO ART guidelines

Results: Total of 3748 ARV-naïve patients enrolled, the proportion initiating ART with advanced HIV disease was 96.7% in I period, 94.9% in II period and 70.5% in III period,(p <0.001). Proportion of functional status; (I) 30% were able to working (W) and 70% were only able to perform activity of daily living or bedridden (NW), (II) 31.4% W: 68.6% NW, (III) 52.2% W: 47.8% NW. Over the same periods; females 16.3%(I) up to 35.9%(II) and 42.3%(III). Older adult patients (age 50 and older) constitute; 2.8% (I) increase to 3.1% (II) and 4.9% (III). Six months mortality and lost of follow up in ART were respectively; (I) 28.9% and 10.2%, (II)11% and 12.5%, falling to (III) 6.2% and 1.7%.

Conclusions: This evaluation indicate a substantial decrease proportion of advanced HIV disease and the mark improve in functional status on ART initiation patients following the expansion of ART eligibility criteria. One issue has been addressed successfully in HAART is dramatic decline mortality and loss of follow up during six months follow up-visit, although a substantial elimination of new HIV infection among women and older adult remains an important challenges in our setting.

Keyword : Advanced HIV disease, WHO ART guidelines, treatment outcome

809

PO 349PREVALENCE OF MULTI-DRUG RESISTANT GRAM POSITIVE BACTERIA CAUSED BACTEREMIA FROM INTERNAL WARD, DR SOETOMO HOSPITAL SURABAYA, INDONESIA (SIX YEARS SURVEILLANCE STUDIES)

Bramantono1, Agung Dwi Wahyu Widodo2, Muhammad Vitanata Arfijanto1, Eddy Bagus Wasito2

1. Division of Tropical Infectious Disease, Department of Internal Medicine, Faculty of Medicine, Airlangga University - Dr Soetomo Hospitals Surabaya

2. Departement of Clinical Microbiology, Faculty of Medicine, Airlangga University - Dr Soetomo Hospitals Surabaya

3. Background : The use of antibiotics in hospitals in line with the emergence of microbes resistant to antibiotics. The resistant microbes may cause infection in patients for example that bacteremia. Bacteremia is condition that found bacteria on the blood flow, and these conditions can be threatening. The purpose of the study was to determine the prevalence of gram-positive bacteria causing bacteremia in internal medicine wards along sensitivity of antibiotic .

Material and Method : Data Tabulation from Microbiology Laboratory result and antibiogram between 2010-2016, especially from blood specimen.

Result : The study shows a change in the prevalence of Gram Positive circulating on bacteremia. Two species of germs in 2010 sorted from the most was CONS and Staphylococcus aureus. In 2012 were CoNS, Staphylococcus aureus, Streptococcus spp, Corynebacterium spp, and Enterococcus spp. In 2013 and 2014 was CoNS, Staphylococcus aureus, Streptococcus spp, Enterococcus spp and Corynebacterium spp. In 2015, CoNS, Staphylococcus aureus, Enterococcus faecalis, Corynebacterium sp, Streptococcus spp and Bacillus spp. In 2016, there was a change, CoNS, Staphylococcus aureus, Corynebacterium sp, Enterococcus faecalis, Bacillus sp and Streptococcus spp. Antibiotics for MDR cases like MRSA with high sensitivity: Vancomycin and Linezolid , very good for MRSA bacteremia. .

Conclusion : The prevalence of MDR Gram-Positive change each year, with dominance by CONS. Some antimicrobial still has a high sensitivity

Key words: Gram Positive Bacteria, Bacteremia, Multidrug-resistant (MDR)

810

PO 350Mortality risk of Human Immunodeficiency Virus associated Pneumocystis Pneumonia: The short term survival estimation

Dewi Dian Sukmawati, Tuti Parwati MeratiTropical and Infectious Diseases’ Division of Internal Medicine DepartmentSanglah Hospital – Medical Faculty of Udayana University Denpasar, Bali, Indonesia

ABSTRACT

Background:

Three decades since the first HIV case in Indonesia being detected in Bali, and despite the effort in bridging gap between case detection and actual HIV cases, more than half patient presenting to the HIV care were in later stage. Pneumocystis pneumonia, one of the opportunistic infections typically seen in cases with severe imunosuppression, poses a big challenge on diagnostic and treatment for HIV treating physicians in resources limited setting. Severe PCP has high morbidity and mortality either due to failure of respiratory system or complication following hospitalization. Unfortunately there is no firm data establishing that represent the burden of HIV associated Pneumocystis pneumonia in Indonesia. This study represent the data on mortality among those with HIV associated PCP.

Objectives:

To measure 6 months survival rate of HIV associated PCP among newly diagnosed HIV in year 2015 cohort

Methods:

Observational study on cohort of newly diagnosed HIV seropositive patients at Tropical and Infectious Diseases division – Internal medicine department, Sanglah Hospital Bali Indonesia. The patient cohort started from 1 January 2015 to 31 December 2015 and followed up at least 28 days from the last attended appointment. Presumptive PCP diagnosis based on clinical, laboratory and radiologic finding. Event defined as all cause mortality or censored. The difference of survival by severity of HIV associated PCP were estimated with Log Rank method and survival risks measurement were using Cox proportional hazard.

Results:

There were 836 newly diagnosed HIV infections between study periods of 1 January 2015 – 31 December 2015. Of those, 69 (69/836; 8.25%) were diagnosed with HIV associated PCP. Two third of the case were male with median age 33 year old (range 21 – 65 year) and severe immunodeficiency state (median CD4 17 cells/uL; range 1 – 114 cells/uL).

811

Half of the cases were moderate PCP (34/69; 49.3%) the rest were mild PCP (21/69; 30.4%) and severe PCP (14/69; 20.3%). The median follow up was 150.50 days (range 6 – 390 days)

The greatest number and proportion of terminal event occurred within the first 60 days from HIV diagnosis. Estimated 6 months survival rate were 99.5 % for those without HIV associated PCP; 81.0 % for mild PCP; 61.8 % for moderate PCP and 0% for those who suffered from HIV associated severe PCP at HIV diagnosis. Estimated median survival time for severe PCP was 27 days (95% CI 10.50 – 43.50 days). The survival probability were lowest for severe PCP compared to moderate, mild or without PCP, at any given time points. Log rank test shows significant difference in the survival distributions among different PCP severity, x2(2)= 756.303, p< 0.000. After controlling for age and CD4 levels, the hazard for severe PCP was 202.04 times (95% CI = 45.18 – 903.56) compared to those without HIV associated PCP.

Conclusion:

The six month survival rate was lowest for HIV associated severe PCP with hazard 202.04 times compared to those without HIV associated PCP.

Keywords: HIV, Pneumocystis pneumonia, PCP, 6 month survival rate

812

PO 351Myiasis in a Man with Sepsis Due to Skin and Soft Tissue infection Suwita CS1, Ahani AR1, Rinaldi I2, Nelwan EJ3

1Internal Medicine Department, 2Division of Hematology Oncology, 3Division of Tropical and Infectious Disease, Internal Medicine Department, Faculty of Medicine, University of Indonesia

Introduction. Myiasis is defined as the infestation of live vertebrates (humans and/or animals) with dipterous larvae. The distribution of human myiasis is worldwide, with more prevalence in poor socioeconomic regions of tropical and subtropical countries. Poor hygiene and low socioeconomic status are the most important risk factors for acquiring myiasis. Another important factor is an abundance of exposed preexisting suppurative lesions that attract and stimulate the deposit of eggs by the female insect. Epidemiological data on human myiasis are scant, and registration of the cases is not usually obligatory. Therefore, health care professionals often judge myiasis to be a disease of minor importance, leading to an inadequate registration of the case: the larva and dressings are normally discarded without further examination.

Case Presentation. A 52-year-old man was admitted to hospital with loss of consciousness for three days. Three weeks before admission, he suffered numeral wounds on his left arm and thigh in motorcycle accident, particularly on the thigh. He was brought to a traditional healer (dukun), where he received massage and herbs rubbed on his wounds for two weeks. The wound on the thigh became increasingly painful, purulent, and malodorous. His wife said that there was one larvae seen on his wound on left thigh. The larvae was removed by himself and the wound was left opened. He also had hypertension that was poorly controlled.

On admission, the patient was somnolent with Glasgow Coma Scale (GCS) 11 (E3M4V4). His blood pressure was 160/100 mmHg, pulse 100 bpm, respiratory rate of 20 /minutes, and temperature of 37.20C. Oxygen saturation was 98% with 2 lpm supplemental oxygen via cannule. He had no nucchal stiffness. Thoracal and abdominal examination was normal. Arterial pulsation on left extremities was normal; a purulent wound on left thigh with size approximately 15cmx5cm and no larvae to be seen. Laboratory test on admission showed leucocyte 24.400 cell/μL, differential count of 0/0/3/86/8/1 and Procalcitonin of 2.77 ng/ml. Ureum 266 and creatinin 4.8 mg/dl. Other tests such as coagulation test, blood glucose, serum electrolyte, and blood gas analyses were within normal range. Chest x-ray also showed normal lung. Extremities imaging showed left humerus shaft fracture with caput dislocation and tibiofibular fracture; there was no osteomyelitis

Infection control was delivered by intravenous antibiotics (Moxifloxacin), wound necrotomy and daily wound care. Patient was also planned to be given Ivermectin 1x15 mg per oral. Laboratory examination up to tenth day of care revealed improvement of leucocytes

813

to 8.300 cell//μliter, neutrophil of 65,5% and eosinophil of 7,1%. Procalcitonin became normal (0.18 ng/ml). Ureum and creatinine serum also became normal (35 and 2.5 mg/dl).

Discussion

This patient had a increase risk for myasis such as poor wound hygiene and exposure of suppurative wound to open air. The larvae, as definitive evident, was no longer found. Therefore diagnosis was made based on patient’s history and eosinophilia which suggested parasitic infection. Patient The most common agents of wound myasis, such as Cochliomyia hominivorax and Chrysomya bezziana, are typically very painful –the symptoms of pain with malodourous suppurating lesions on this patients could be due to myasis. Cavernous lesions in the wounds can also be formed – sometimes it is difficult to visualize and extract the larvae. This may explain why there’s no larvae seen on clinical examination and surgical necrotomy. Treatment of wound myasis requires removal of all visible larvae and debridement if there’s necrotic tissues. Ivermectin is the most commonly used drug for human myasis, it may cause migration of the larvae out of the skin and may kill the larvae inside the lesion. Typical oral dose is 200 μg/kg. Nevertheless, systemic treatment with oral ivermectin was not done routinely, but tailor-made in each case separately. Topical treatment with 1% ivermectin in a propylene glycol solution is another option.

Keywords: wound myasis, sepsis

on admission

after surgical necrotomy and debridement

814

PO 352S. AUREUS BACTEREMIA WITH CAVITARY LUNG LESSIONS AND INTRAABDOMINAL ABSCESS

Güleren Yartaş Dumanlı¹, İrem Kıraç Utku¹, Berrak Sahtiyancı¹, Abdullah Yolcu,1 Belgin Boran1, Aysun Aksoy¹, Ömür Tabak¹, Abdulbaki Kumbasar¹, Ayşe İnci1

1. İstanbul Kanuni Sultan Suleyman Education and Research Hospital, Department of Internal Medicine

Introduction: Diabetic patients are susceptible to infection because of their insulin injections, impairment of leukocyte function and too much colonization rate.

Case: A 69-year-old female patient was admitted to hospital with fatigue and fever. She had type 2 diabetes mellitus, asthma and hypertension in her medical history. In physical examination; fever: 38,5°C, pulse:110/min, BP: 110/70mmHg, extensive murmur in both lungs, prolonged expiration, rals in lung bases were detected. Also she had left hip pain, flexion and external rotation limitation in left hip, tenderness and warmness in the left knee. In Thorax CT diffuse caverns, cystic necrotic areas and nodular areas were detected at both lung bases. Lomber Spinal MRI showed spondylodiscitis at the level of intervertebral disc L5-S1. Left knee MRI revealed myositis and septic arthritis. P-ANCA, C-ANCA, ANA, Anti-dsDNA were negative. As treatment, ceftriaxone and clarithromycin were ordered first. In abdominal USG abscess was detected in iliac area. S. aureus (MRSA) was isolated in both cultures of blood and abscess. According to these results S. aureus bacteremia (SAB) was diagnosed and the patient was placed to antibiotic therapy with linezolid. In 14th day of treatment, control Thorax and Abdominal CT were performed. Regression in cavitary lung lessions and abdominal abscess was detected. We presented this patient to take attention to differential diagnosis of cavitary lung lessions which should be investigated in terms of S. aureus .

Conclusion: In differential diagnosis of cavitary lung lessions metastatic neoplasms, hematogenous spread of infections (bacterial, fungal and mycobacterium), pneumoconiosis, eosinophilic granuloma and Wegener’s granulomatosis come to mind. If a diabetic patient has HbA1c> 8%, there are many data showing the increase in wound infections after surgery, length of hospital stay and septic status. Our case was a well- controlled diabetic patient for 7 years and she had no predisposing factors for SAB. Although there are no risk factors SAB, the fact that diabetic patients (even well- controlled) may experience serious S. aureus infections should be kept in mind.

815

PO 353Chronic Conditions among Care Support and Treatment (CST) Clients at Sanglah General Hospital due to Antiretroviral Treatment: a cross-sectional study

Muhammad Faisal Putro Utomo1, Edwind Rakatama Fahlevie1, Anindia Reina Yolanda1, Pande Mirah Dwi Anggreni1, Made Ayu Widyaningsih1, I Nyoman Sutarsa2

1. Medical Student, Faculty of Medicine, Udayana University2. Department of Community and Preventive Medicine, Faculty of Medicine, Udayana

University

Background:

The availability of antiretroviral therapy (ART) has resulted in prolonged life and improved quality of life among people living with HIV and AIDS (PLWHA). The cause of death among PLWHA is now mainly contributed by chronic disease. However the majority of this report is generated from developed countries. In addition, long term ARV use may cause metabolic disturbances and organ dysfunction which leads to chronic disease.

Methods:

A cross-sectional study with a total of 110 CST clients were conducted in Bali Province. Samples were consecutively selected from VCT/CST Clinic at Sanglah General Hospital. Data were collected by extracting it from the medical records using extraction form. Data were then analyzed using univariate and bivariate analysis (Chi-square test).

Results:

Our study found a high proportion of anemia (21.4%), liver dysfunction (28.1%), and kidney problems (28.1%) among CST clients. Anemia mostly occurs in women while liver and kidney dysfunction mainly affecting men. Our study showed that the dominant type of anemia among PLWHA is normo-chromic normo-cytic and hypo-chromic micro-cytic. Our study indicated a moderate association between liver dysfunction and duration of ART (r=0.315; p=0.0188). Our study has also documented hepatitis/HIV co-infection (3 cases of HBV/HIV and a case of HCV/HIV). Theres is a moderate negative association between renal dysfunction and HIV infection period (r= -0.302; p=0.004). The ART regimens mainly consumed by those with anemia, liver and kidney dysfunction is AZT/3TC/NVP.

Conclusions:

The use of ART, especially AZT/3TC/NVP, in 7 years period may increase the risk of anemia, liver and renal dysfunction among CST clients. This indicates the importance of regular monitoring for chronic diseases markers including liver, renal, and cardiovascular disease.

816

PO 354ASSOCIATION BETWEEN DENGUE VIRUS SEROTYPE AND CLINICAL MANIFESTATIONS IN DENGUE INFECTION ADMITTED AT WANGAYA AND SANJIWANI HOSPITAL BALISri Masyeni DAP,1 Dewi Megawati AA,1 Asri Lestarini AA,1 Suryana K, 2 Budyasa Besang DGA,3 Sasmono T,4 Mynt KS, 4Tangking Widarsa,1Tuti Parwati Merati5

1. Medical Faculty of Warmadewa University, Denpasar Bali2. Wangaya Hospital Denpasar, Bali3. Sanjiwani Hospital Gianyar ,Bali4. Eijkman Institute, Jakarta5. Medical Faculty of Udayana University

Background: Dengue virus infection is one of the most general arboviral infection in the world. It caused by one of four dengue virus serotype, DEN-1,DEN-2,DEN-3 or DEN-3. In the recent time, there are no data reported about dengue serotype in Bali.

Methods: We conducted a cross sectional prospective study about molecular surveillance of dengue virus and its association with disease severity in Bali from during 2015 to 2016. Clinical data including clinical sign, symptoms and physical examination were collected. Blood sampel were obtained from acute febrile cases, on day 1-5, tested for NS1 and Reverse-Trasncriptase PCR or Real-Time PCR. Second blood were taken after day 7 of onset to detect IgM and IgG anti dengue. The data were analysis with Chi-square test.

Results: The rest of the laboratory analysis is still on progress, in which among 283 samples involved, there are 55% female. Constitusional manifestation found 98.1%, gastrointestinal manifestation 89.8%, musculoskeletal manifestation 75.9%. Mean lowest platelet is 37.1(6-123). NS1 positive rate 94.5%. Dengue fever found in 53,2% of the samples. Serotype confirmed by reverse-transcriptase PCR or real-time PCR in 211 samples which are DEN-1 :56 (26.5%), DEN-2 : 33 (15.6%), DEN-3: 110(52.1%) , DEN-4:7(3.3%) and the rest of samples are under investigation. At the moment, analysis result are between the serotype DEN-3 is the most DHF diagnosed ,33% that is statistically not significant (p>0.05) , statistically significant were found in constitusional manifestation with DEN-4(p=0.002), respiratory with DEN-1(p=0.018). Bleeding manifestation found mostly in DENV-3 (p>0.05). The most bleeding is gum bleeding, 12%. Length of stay in DEN-3 is longer than other serotype, p=0.004.

Conclusion: All dengue serotype have been detected, with DEN-1 and DEN-3 accounting for the majority. Clinical manifestation between dengue serotype almost the same, but DEN-1 gives more association with some clinical manifestation .

Key word : dengue serotype, clinical manifestation, length of stay

817

PO 355RECURRENT PULMONARY ASPERGILLOSIS IN A PATIENT WITH CARCINOMA OF THE TONGUEHadianti, EJ Nelwan*

*Division of Tropical and Infectious Disease. Faculty of Medicine University of Indonesia

Abstract

Patient with malignancy had immunocompromised status that increase a risk of fungal infection such as systemic aspergillosis. We present a case of recurrent pulmonary aspergillosis in a patient with squamous cell carcinoma of tongue.

A 63-year-old woman came to Cipto Mangunkusumo hospital emergency room with complaints of exhausted since five days after her fifth chemotherapy cycle for tongue squamous cell carcinoma. She complained of having dry cough for one week, without blood and shortness of breath. Since two months ago, there was a red and black spots with squamation appearance in the skin of her back and buttocks area. Her nails was fragile, yellowish and thickened. Her first laboratory test showed the unspecific signs of infection with Pro-calcitonin level was 2.46. The result of AFB sputum smear test was negative with the isolation of Acinetobacter baumanii (anitratus) and Candida albicans. After being adequately treated with antibiotics for pneumonia, her general condition was not improved. The patient then consulted to Infectious Disease Department. The re-evaluation of Chest X-Ray suggested a multiple nodules alike in the right lung; from the CT-scan the appearance of fibrosis and minimal ground glass opacity in the 9th to 10th thoracic segments was found. Serum Galactomannan was also positive. Therefore, intravenous antifungal Voriconazole 2x200mg was given daily. Clinical improvement was shown within 7 days of treatment. She recovered after 21 days of Voriconazole therapy with negative Galactomannan result during the follow up. Afterwards, the sixth chemotherapy cycle was started, 10 days after chemotherapy she complained of having general weakness with repeated positive galaktomanan serum, voriconazole was again started. Within one month followup, patient reported of no significant clinical improvement and in addition to that the serum Galaktomannan was also still positive.

Conclusion: Malignancy increases a risk of fungal infection and giving chemotherapy in malignancy patient increases the probability of relapse for fungal infection and challenges for a succesful treatment

Keywords: Recurrent Aspergillosis, Malignancy, Galaktomanan Serum

818

PO 356CHARACTERISTIC OF CO-INFECTION HIV-TB AT SANGLAH HOSPITAL DENPASAR BALImade susila utama, tuti parwati merati

tropic and infectious disease division, internal medicine dept, medical faculty, udayana univ/sanglah hospital, denpasar, bali

TB remains the most common opportunistic infection in HIV and also as a commonest caused of death in HIV infected patients. Clincal presentation of TB in HIV was wide variation so the diagnostic must be based on clinical, acid fast bacilli sputum examination and chest x-ray. Objective of this study to know clinical presentation of HIV-TB, results of sputum and chest x-ray.

There were 27 co-infected TB-HIV patients in this study, mostly male (59,2%) and heterosexual as risk factor (77,8%). Symptoms of TB were fever (88,9%), cough (88,9%), decreased of body weight (85,2%), malaise (74,1%) and night sweat (48,1%). Results of acid fast bacilli in sputum was negative in 23 patients (85,2%). Chest x-ray results were military fibroinfiltrat (8,5%), lymphadenopathy hiller (11,1%), infiltrate in upper lobe (7,4%) and infiltrate and lower lobe (7,4%)

TB-HIV coinfected patients is more common male, heterosexual, fever and cough, negative in acid fast bacilli sputum and chest x-ray with military fibro infiltrate.

819

PO 357THE IMPORTANCE OF HIV TESTING IN TB PATIENTS ESPECIALLY IN HIV EPIDEMIC AREA: A CASE REPORT FROM SITUBONDO, EAST JAVAChristian Jonatan1, Timotius J2, Achmad Baihaqi3

1. Panarukan Health Community Center, Situbondo, Indonesia2. Department of Neurology, Abdoer Rahem General Hospital, Situbondo, Indonesia3. Department of Internal Medicine, Abdoer Rahem General Hospital, Situbondo,

Indonesia

BACKGROUND: People living with HIV have a much higher risk for developing TB, 26-31 times greater than among those without HIV infection. TB-HIV co-infection will accelerate the progress each other so appropriate treatment is needed as soon as possible to reduce mortality.

CASE PRESENTATION: A 30-year-old male with his wife and 1-month-old son came to hospital. He had history of uncompleted lymphadenitis TB treatment. He presented fever, vomiting, and headache since 3 days ago. Vital sign: BP=110/80mmHg, HR=88bpm, temperature=38.0oC, RR=20x/minute. The level of consciousness was somnolent. From neurological examination, there were nuchal rigidity, weakness of all extremities, ankle clonus, and babinski in both feet. Chest X-Ray(CXR) showed infiltrates at the right lung. The findings of cerebrospinal-fluid examination were clear xanthocromic fluid with high protein, low glucose, positive nonne and pandy. Formerly, his brother was angry and reject HIV examination. But his wife finally agreed for the patient’s HIV examination and the result was reactive. After 12 days of treatment, there was significant improvement with Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, Streptomycin, Levofloxacin, Meropenem, and Methylprednisolone. Antiretroviral therapy(ART) was scheduled to be given after the second week of TB treatment.

DISCUSSION: The treatment for this patient was tuberculosis and bacterial meningoencephalitis therapy. Tuberculosis treatment was given although there was no acid fast bacilli because the immunocompromised state of this patient makes TB-HIV co-infection is most likely possible, moreover the history of lymphadenitis TB and CXR examination also support the diagnosis. ART was planned to be given after TB treatment is well tolerated.

CONCLUSION: Delay in diagnosis and therapy from TB-HIV will increase mortality rate. Consequently, it is very important to check HIV state in TB patients and TB state in HIV patients so an appropriate and early treatment can be given to reduce mortality.

Keywords: HIV, TB, meningoencephalitis

820

PO 358CORRELATION OF TOTAL LYMPHOCYTE COUNT AND THE NUMBER OF LYMPHOCYTE T CD4+ IN MEN WHO HAVE SEX WITH MEN GROUP OF HUMAN IMMUNODEFICIENCY VIRUS INFECTED PATIENTS WITH CONDYLOMA ACUMINATA

Muh Nur Ikhsan Liwang, Sudirman Katu, Syakib Bakri, A. Makbul Aman, Faridin HP, Haerani Rasyid, Harun Iskandar

Department of Internal Medicine, Medical Faculty of Hasanuddin University, Makassar, Indonesia

Background. The incidence of genital wart increased in recent years, linked to infection with the human immunodeficiency virus (HIV) and primarily affects men who have sex with men (MSM). This research aimed to investigate the correlation of the TLC with number of CD4 in MSM HIV-infected patients with condyloma acuminata, as a basis for initiating ARV therapy in the setting where CD4 examination is not available.

Method. The research was conducted at Dr. Wahidin Sudirohusodo General Hospital, Makassar, South Sulawesi, Indonesia, from January through March 2016. The research was an observational study with the cross sectional design.

Result. A total of 20 patients, aged between 21-43 years, with a mean of 30 ± 6 years. Value TLC has a value range 218 - 3078, with a mean 1161.1 ± 637.0. CD4 value has a value range 2-255, with a mean of 101.5 ± 86.3. The entire sample has a value of CD4 <350 cells / mm3, which are divided by the value of TLC <1200 cells/mm3 was 12 (60%) and TLC >1200 cells/ mm3 was 8 (40%). Here was a significant and positive correlation between CD4 and TLC (p<0,001).

Conclusion. The value of TLC <1200 cells/mm3 can be used as a basis for initiating ARV therapy in the setting where CD4 examination is not available.

Keywords. CD4, condyloma acuminate, HIV, MSM, TLC.

821

OP 359HISTOPLASMOSIS IN BANGLADESHMuhammad Abdur Rahim1, Shahana Zaman2, Md. Robed Amin3, Khwaja Nazim Uddin1, MA Jalil Chowdhury41BIRDEM, 2NICVD, 3DMCH, 4BSMMU, Dhaka, Bangladesh

Presenter: Muhammad Abdur Rahim

Background/Rationale: In recent years, histoplasmosis has gained importance in clinical practice in Bangladseh, as evidenced by increasing number of case detection and published case reports. Histoplasmosis mimics tuberculosis in clinical presentation, imaging and histo/cytopathology. Our aims were to describe socio-demographics, clinical presentations, investigations, treatment and outcome of histoplasmosis in Bangladesh.

Methods: Retrospective data retrieval was performed from published literatures between 1962-2014 containing information of histoplasmosis in/or from Bangladesh. Unpublished but well documented histoplasmosis cases were added. Cases with inadequate information and possible repetitions were excluded.

Results: All 23 patients were male, aged 8-75 years. Seven were cultivators, four were diabetic, one was renal-transplant recipient and four had human immunodeficiency virus infection/acquired immunodeficiency syndrome. Fever (19) and weight loss (16) were common presentations. Other features were anaemia (15), lymphadenopathy (9), hepato-splenomegaly (10), abnormal chest radiograph (5) and bilateral suprarenal enlargement (7). Diagnosis was confirmed by histo/cytopathology from skin (1), oro-pharyngeal ulcers (7), lymph nodes (2), suprarenal glands (7), paravertebral soft-tissue (2) and bone marrow (4). Cultures of representative samples and antibody were detected in five and two cases respectively. Twenty patients had disseminated histoplasmosis and three had localized oro-pharyngeal disease. Thirteen patients were prescribed anti-tuberculosis drugs empirically before diagnosis of histoplasmosis. Treatment consisted of amphotericin B and itraconazole. Three patients expired in hospital, 13 patients recovered with relapse in one and outcome of rest of the cases could not be ascertained.

Conclusion: Histoplasmosis is thought to be endemic in Bangladesh, but few cases are reported till date; may be due to many asymptomatic, undiagnosed, misdiagnosed or under-reported cases. However, incidence has increased recently. Histoplasmosis should be considered as differential in appropriate clinical scenario.

822

PO 360WCIM 2016 Case abstract

Category: Poster presentation

Authors: Dr Lim Ju Yee and Dr Tan Poh Yong Singapore General Hospital, Department of Internal Medicine

Title: A CASE OF PARVOVIRUS ASSOCIATED HAEMOPHAGOCYTIC LYMPHISTIOCYTOSIS

Introduction: Haemophagocytic lymphhistiocytosis (HLH) is an aggressive disease caused by over activation of the immune system. It occurs most commonly in infants but can also present in adults. Infection is one of the possible triggers of HLH.

Case description: A twenty-two year old male was admitted for one month history of daily fever associated with cough, chills and weight loss. His temperature on presentation was 38.2°C with tachycardia of 99 bpm. No localizing signs of infection or autoimmune processes were demonstrated on physical examination. Admission blood tests revealed pancytopenia with haemoglobin of 12.9 g/dl, absolute neutrophil count of 1.19x10^9/l and platelets of 109x10^9, transaminitis with alanine aminotransferase of 115 IU/L and aspartate aminotransferase of 171IU/L and prolonged clotting time with low fibrinogen of 1.5g/l. There was no consolidation on chest radiograph. Dengue fever, an endemic local infection was ruled out. HIV, Hepatitis A/B/C screen, respiratory viruses throat swab and three sets of blood cultures were also negative.

Despite antibiotics, he continued to be febrile with worsening pancytopenia: haemoglobin of 8.2g/dl, absolute neutrophil count of 0.80x10^9/l and platelets of 149x10^9/l. Echocardiogram did not show vegetations. PET-CT scan showed mild hepatosplenomegaly. Autoimmune screen were negative, but blood Parvovirus B19 PCR test was positive. Diagnosis of Parvovirus associated HLH was made in view of patient meeting five out of eight HLH diagnostic criteria: fever, pancytopenia, low fibrinogen, splenomegaly and high ferritin of 1460ng/ml. Subsequent bone marrow analysis showed trilineage hypocellularity with no haemophagocytosis. He remained clinically stable hence no immunosuppressive treatment was started. Blood counts improved on day eight of admission and normalized two weeks after discharge.

Discussion : This case illustrates a young adult with Parvovirus induced HLH who recovered well without immunosuppressive treatment. Although HLH occurs less frequently in adults, this case highlights the importance of considering HLH as a possible differential in a patient with pancytopenia, fever and splenomegaly.

823

PO 361Q FEVER: A diagnosis to consider when in the presence of persistent fever.

Q fever is a zoonosis with worldwide distribution, and is responsible for a variety of clinical manifestations, some of which are non-specific. This disease can be transmitted through contact with infected animals, ingestion of unpasteurized products and inhalation of contaminated aerosols.

The authors present a case of a 55 years old male patient (a firefighter) who was admitted to the emergency department due to persistent (7 days) high fever (39.5°C), anorexia, weight loss (5 kg), hepatomegaly and myalgia.

The initial laboratory tests showed increased cholestatic enzymes [alkaline phosphatase: 295 U/L (normal: 45-117 U/L), γ-GT: 586 U/L (normal: 15-85 U/L)], increased hepatic enzyme levels [ALT: 91 U/L (normal: 16–61 U/L), AST: 85 U/L (normal: 15–37 U/L), LDH: 295 (normal: 87–241 U/L)], elevated creatinine 3.30mg/dL (normal 0.7-1.3 mg/dL) and elevated serum C-reactive protein 16.3 mg/dL (normal <0.3).

Due to his profession, it was considered that the risk of exposure to Coxiella burnetti was significant and for this reason empiric Ceftriaxone was initiated. The diagnosis of acute Q fever was later confirmed by indirect immunofluorescene assay (IFA). The clinical evolution was favourable with the regression of all the symptoms and normalization of laboratory parameters within one week.

Q fever can be a difficult diagnosis to make in patients with persistent fever and altered liver function tests. When the clinical and epidemiological findings are compatible with a diagnosis of Q fever, infection with C. burnetti should always be considered.

824

PO 362THE ASSOCIATION OF ACUTE KIDNEY INJURY BASED ON RIFLE AND AKIN CLASSIFICATIONS WITH MORTALITY IN LEPTOSPIROSIS

Veronika Dyah Setiyarum*, Muhammad Hussein Gasem**, Nur Farhanah**, Dwi Lestari Partiningrum***, Lestariningsih***

*Fellow, ** Div. of Infectious Disease and Tropical Medicine, *** Div. of Nephrology, Department of Internal Medicine, Dr. Kariadi Hospital, Diponegoro University

Background: Clinical presentations of Leptospirosis vary, from mild to severe complicated disease with (multi) organ involvement. Renal involvement is one of clinical factors predictive to mortality. Acute kidney injury (AKI) is a complex clinical syndrome for which there was no accepted definition for quite sometimes. No study comparing RIFLE and AKIN classifications to predict mortality in leptospirosis with AKI.

Methods: The study was conducted by retrieving and analyzing case-report forms of 97 confirmed leptospirosis patients by micro-agglutination test (MAT), hospitalized in Dr Kariadi Hospital, from 2010 to 2014. Baseline creatinine estimated based on MDRD formula, assuming normal GFR 75 ml/min/1,73m2. Serum creatinin was measured on admission and after rehidration at 24-48 hours later for RIFLE and AKIN respectively. Bivariate and multivariate logistic regression were performed.

Results: Overall mortality was 21.6%. Prevalence was high among men (69.1%). Based on RIFLE, there were 24 non-AKI, 10 Risk, 9 Injury, and 54 Failure patients. There was no significant association between RIFLE and mortality (p=0.124), Risk vs Non-AKI (p=1.00), Injury vs Non-AKI (p=1.00), Failure vs Non-AKI (p=0.56). Based on AKIN, there were 24 Non-AKI, 9 AKIN stage 1, 10 AKIN stage 2, and 54 AKIN stage 3 patients. There was significant association between AKIN and mortality (OR=8.68; p=0.035; 95%CI =1.1-68). AKIN stage 1 vs non AKI (p=0.477), AKIN stage 2 vs non AKI (p=0.508), AKIN stage 3 vs Non AKI (OR-11.5; p=0.013; 95%CI=1,43-92). The sensitivity and specificity of RIFLE was 81% and 58%; AKIN was 91% and 50%. RIFLE (AUC=0.702; p=0.03; 95%CI=0,6-0,8) and AKIN (AUC=0.729; p=0.02; 95%CI=0,6-0,8) showed high capacity in predicting mortality, both showed high area under the ROC curve.

Conclusion: There was a significant association between AKIN, but not with RIFLE, with mortality. AKI based on AKIN was better than RIFLE classification to predict mortality.

Keywords: Leptospirosis, AKI, RIFLE, AKIN, mortality

825

PO 363BACTERIAL SEPSIS OF UNKNOWN SOURCE IN IMMUNOCOMPETENT PATIENT WITH DENGUE HEMORRHAGIC FEVER:A CASE REPORT

Melisa 1, Ronald Irwanto Natadidjaja1,2

1. Pondok Indah Puri Indah Hospital, Jakarta, Indonesia2. Division of Tropical Medicine and Infectious Disease, Department of Internal

Medicine, Trisakti School of Medicine, Jakarta, Indonesia

Background. Dengue Hemorrhagic Fever (DHF) is currently defined by WHO: fever or recent history of fever lasting 2-7 days, any hemorrhagic manifestation, thrombocytopenia (platelet <100.000 mm3), evidence of increased vascular permeability. Prolonged thrombocytopenia is unusual in the course of this disease. So does administering antibiotics, yet it showed good responses in our patient.

Objective. To present an interesting case of prolonged thrombocytopenia in DHF caused by bacterial translocation.

Case. A 38 year old man came with a chief complaint of fever for 5 days prior to hospital and afterward was diagnosed with DHF. During hospitalization his thrombocytopenia persisted, whereas during that time, his platelet count was expected to have risen. Malaria, HIV, Hepatitis, Autoimmune, malignancy were already excluded. DIC profile was normal. He received fresh frozen plasma and platelet apheresis transfusion, but the platelet counts failed to reach the normal range. A serial tests were performed to find out caused of his prolonged thrombocytopenia. PBF shows changing characteristic from blue lymphocyte predominant into segmented neutrophils which indicates bacterial infection. Steroid administration did not elicit any improvement. His Procalcitonin level and leucocytes were escalating which indicates bacterial infection. No clinical symptom of lung, skin and soft tissue, urinary tract, intra abdominal infection. We treated the patient for sepsis with antibiotics and he displayed good response. Subsequently, his platelet level slowly increased and leucocytes began to drop.

Conclusion. Prolonged thrombocytopenia in DHF is uncommon when the platelet counts will automatically raised into normal range with clinical improvement. Elevation of Procalcitonin and better response to antibiotics in this case confirms that prolonged thrombocytopenia in DHF predominantly was caused by bacterial sepsis, that we predict caused by bacterial translocation from gut. Therefore, physicians should consider bacterial translocation as differential diagnosis for prolonged thrombocytopenia in DHF.

Keywords. Bacterial, Sepsis of unknown source, Dengue

826

PO 364Correlation of The Clinical profile and CD4 level of HIV Infection after six month Antiretroviral treatment at the HIV Infection Center Ward Makassar January – June 2016

Sudirman Katu*, Risna Syauqi*, A.Halim Mubin*

Divisi Tropik Infeksi, Internal Medicine Departement,

Faculty of Medicine Hasanuddin University/Wahidin Sudirohusodo General Hospital

Background. In Indonesia, HIV prevalence rates aged 15-49 years is increasing. To start antiretroviral therapy (ARV) necessary to check the number of Cluster of Differentiation 4 (CD4) and the determination of the clinical stage of HIV infection. Six months since the start of antiretroviral therapy is an important and critical period. This study investigates Correlation of The Clinical profile and CD4 level in patients with HIV / AIDS who have received ARV therapy.

Method : An observational study with cross sectional design in Wahidin Sudirohusodo Hospital during the period of January to June 2016. Results. Total sample is 136 subject, male > female (78,5% vs 21,5%), age 31-40 years (40%), 50,8% Senior high school and 40% non government occupation. CD4 before treatment < 200 cell/mm3 and 201 - 350 cell/mm3 after 6 month treatment ARV significant increased 25,0% and 16,1%. CD4 in males (47.1%) > female (42.9%). CD4 < 200 cell/mm3 > at age 40 years (63,2%). CD4 > 350 cell/mm3 > at Normal Nutritional status (41,2%) and CD4 < 200 cell/mm3 > at undernutritional status (58,8%). CD4 >350 cell/mm3 > at Regiment ARV 3TC+AZT+NVP .Analysis of relationships regimens of antiretroviral combination therapy with a CD4 cell count after 6 months of treatment, no significant difference between the four types of combination regimens (p> 0.05). The percentage of CD4> 350 highest in the no opportunistic infections (36.4%), while the percentage of CD4 <200 highest in TB coinfection + other (64.3%). The relationship between the sexes variables with CD4 status after 6 months, found no significant difference. CD4 percentage increase was found highest in the age of 31-40 years (57.7%) compared to other age categories, but was not significant.

Conclusion. Found significant differences in CD4 cell count after 6 months of therapy antiretroviral , It does not show a significant correlation between the variables of age , sex , nutritional status , employment , education , initial CD4 count , antiretroviral combination regimen and opportunistic infections with an increase in CD4 cell count after 6 months of antiretroviral therapy

Key word : clinical profile, CD4 before & after, ARV 6 month

827

PO 365NERVOUS SYSTEM LYME DISEASE – CAUSE OR EXACERBATION FACTOR?

Authors: Vera Frazão Vieira, Joana Leite, Cláudio Quintaneiro, Ana Valverde, Maria do Rosário Barroso, Célio Fernandes

The authors present the case of a 51-year-old Portuguese male patient, living in a rural area, previously healthy, presenting with asthenia, anorexia, weight loss, fever, headache, neck pain and paresthesia of the lower limbs for 4 weeks (starting during the month of April). The physical exam revealed hypoesthesia of the anterior surface of both legs.Blood analysis showed anemia (hemoglobin 10.3 g/dL), thrombocytosis (551000x103/µL), leukocytosis (17100x103/µL) and elevated C-reactive protein (102.7 mg/L).The urine analysis, chest X-ray and brain CT-scan were normal. Tuberculosis screening was negative.Blood cultures and serologies for atypical pneumonias and zoonosis were performed and empirical therapy with ceftriaxone was started.Borrelia antibodies were present (both IgM >100U/mL and IgG 172 U/mL).Considering the headache and paresthesia of the lower limbs as neurologic manifestations, a lumbar puncture was performed, even though the patient had already undergone antibiotic therapy for 7 days.In the cerebrospinal fluid, the Borrelia antibodies were also positive (both IgM and IgG).Brain and spine MRI showed a lumbar disc herniation (L4-L5). After 14 days of ceftriaxone, he was discharged presenting only a slight hypoesthesia of both legs.Lyme disease is a tick-borne, multisystem illness caused by the spirochete Borrelia. Neurologic manifestations are present in 10-15% of cases. Acute neurologic involvement usually occurs weeks to several months after tick bite and may be the first manifestation of Lyme disease. Radiculoneuritis is diagnosed less commonly than other neurologic manifestations as facial palsy or meningitis, being reported in only 3% of cases.In this case, despite having positive Borrelia antibodies in the cerebrospinal fluid, we also have a structural pathology of the spine. Therefore, the authors cannot be 100% certain that the paresthesia was caused by the spirochete. However, there is a good time to symptoms correlation and a large improvement after antibiotic therapy.

828

PO 366TOXOPLASMA ENCEPHALITIS IN HIV/AIDS PATIENT IN H ADAM MALIK REFERRAL HOSPITAL MEDAN : 14 CASE REPORTS

Tambar Kembaren, Yosia Ginting, Franciscus Ginting, Armon Rahimi, Endang, Restuti H. Saragih

Division of Tropical Medicine and Infectious Diseases, Departement of Internal Medicine,University of Sumatera Utara/ Haji Adam Malik Referral Hospital Medan/Indonesia.

Background: Toxoplasma encephalitis (TE) is the most common central nervous system opportunistic infection in Human Immunodeficiecy Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS). It is caused by reactivation of latent infection in advance stage of HIV infection with CD4 level usually less than 200 cell/mm3. Fever, headache, and neurological deficit are the main symptomp. Other symptoms caused by cerebral edema is confusion, lethargy, dementia, decrease of consciousness and coma. The aim of this study was to find out the clinical manifestations of (TE) in HIV/AIDS patients in Haji Adam Malik Referral Hospital Medan.

Method: This is a case report of fourteen TE patients which was conducted by collecting the data from medical records of inpatients by the year 2014-2015. All HIV patients clinically suspected as TE were include in this study, then clinical parameter was collected from anamnesis, physical diagnostic, serology IgG anti Toxoplasma, and Head CT Scan. Level of CD4 was also taken into account.

Result: There were 8 patients diagnosed with TE in 2014 and 6 patients in 2015. Their age was vary between 24 – 44 years old. Male was more prevalent than female with ratio 9:5. The most prevalent clinical manifestations are headache (9 patients) and decreased consciousness (6 patients); meanwhile seizure, hemiparesis, and fever was found to be equal (each 2 patients). Level of CD4 was vary between 3– 122 cell/mm3. Serology test showed that IgG level was increased in 12 patients and normal in 2 patients. Head CT scan with contras was conducted in 7 patients, meanwhile the other 7 patients did not have head CT scan. Results of the head CT scan were 4 CT appropriate with TE, 2 CT normal, 1 CT showed infarct of the basal ganglia and 7 patient not performed CT Scan. After given standard treatment 7 patients recover from the disease and sent to outpatient department, the rest 7 patients were died.

Conclusion: The most prevalent clinical manifestations of TE in HIV/AIDS patients were headache and decrease of consciousness. All of those patients had CD4+ T cell count less than 200 /mm3.

Key Words: Toxoplasma Encephalitis, HIV/AIDS, CD4, Clinical Manifestation

829

PO 367Title: Clostridium difficile - retrospective study of 4 years in Internal Medicine Service

Authors: Pedro Lopes, José Mateus, João Gomes, Diana Ferreira, Hugo Clemente, João Fonseca, João Porto, Manuel Veríssimo, Armando de Carvalho

Background: Clostridium difficile is an anaerobic bacillus Gram +, spore producer, being the main agent responsible for infectious diarrhea in hospitalized patients. Diarrhea associated with Clostridium difficile (DACD) has registered an increase in developed countries and appears usually associated with some risk factors such as advanced age, multiple comorbidities, antibiotic (ATB) and previous hospitalizations and usually take proton-pump inhibitor (PPIs). The goal was the characterization of DACD in a hospital for a period of four years.

Methods: A retrospective study conducted between 2013 and 2015 about DACD diagnosed in an Internal Medicine Service. We analyzed the origin of the patients, the presence of hospitalization in the intensive care unit, the performance of ATB, PPIs and corticosteroid therapy (CT) prior, state of dependence, relapse, the treatment and the occurrence of death.

Results:344 cases were identified. There were in total 78 recurrences (22,7% of cases). The average age was 79 years (between 48 and 99). 77% were female, 37% lived at home and 46% were nursing homes. 54% had been hospitalized in the last month. 79% held ATB in the previous 6 months (59% beta-lactams and quinolones 25%), 11% have CT and 62% have IBP. 23% died.

Conclusion: The high incidence of the disease in the elderly, the poor population with multiple comorbidities who are living in nursing homes, as well as increased intake of antibiotics and PPIs are prognostic factors for infection with clostridium difficile. The data in Portugal are limited and will be needed more studies to better characterize the DACD. One solution would be the obligation of notification of DACD.

830

PO 368TUBERCULOSIS AMONG DISABLED

Maria Goretti AmetembunSt Damian Diasble Rehabilitation Centre, Labuan Bajo, Flores, Nusa Tenggara Timur - Indonesia

Background: Patients with disabled are particularly vulnerable to co-morbidities because of their disadvantages. Indonesia is one of the high-burden tuberculosis (TB) countries.

The Aim To describe tuberculosis problem among disable people.

Methods I was on vacation in Labuan Bajo near Komodo island and visited St Damian Rehabilitation Centre, Binongko, Labuan Bajo, West Manggarai Barat, Flores, Nusa Tenggara Timur, Indonesia on August 22-23, 2012. The principal asked me to check for the handicapped voluntarily. Informed consent were obtained from the managerial of rehabilitation center. Data were collected by one internal medicine specialist using (1) anamnesis for both constitutional symptoms and symptoms related to tuberculosis; (2) physical examination including general condition as well as doughy abdomen, “Dam-board’ phenomenon” and no “shifting dullness” according to peritoneal tuberculosis; and another organs involved. No laboratory, X ray nor ultrasound facilities were available in the rehabilitation center and in the Labuan Bajo at that time.

Results: Within the total 32 (12-34y, mean 19 y): 21 (66%) female and 11 (34%) male. All patients complained chronic recurrent cough more than 2 weeks with or without sputum as well as constitutional symptoms were general discomfort, fatique, loss of appetite, weigh loss, low-grade fever and night sweating; Symptoms related to the peritoneal tuberculosis were subacute/chronic recurrent colic abdomen, chronic diarrhoea or constipation and abdominal distention. 4 (12,5%) female with severe dyspeptic syndrome. Physical examination including general examination as well as abdominal examination associated with peritoneal tuberculosis were abdominal distention, doughy abdomen, “dam-board’ phenomenon”, without shifting dullness. The diagnosis were suspected pulmonary and peritonitis tuberculosis (dry type) . All patients had been referred to local public health centre.

Conclusion: Tuberculosis was prevalent among disabled.

831

PO 369EXTRAPULMONARY TUBERCULOSIS PATTERN AND ITS ULTRASOUND FINDINGS

Maria Goretti AmetembunStela Maris Hospital And Lukas Hilisimetano Government HospitalSouth Nias – North Sumatera - Indonesia

Background: Tuberculosis is a systemic disease that can affect both pulmonary and extra-pulmonary organs.

Aim: To describe the pattern of organs affected in extrapulmonary tuberculosis.

Method This descriptive study conducted at Stela Maris Hospital and Lukas Hilisimetano Government Hospital South Nias – North Sumatera from April - July 2015. Data were abstracted from medical records of all disseminated tuberculosis cases. All patients were diagnosed base on history, physical examination, laboratory, Thorax X-ray, ECG and ultrasound by one very skill certified ultrasound internal medicine specialist

Results There were 301 cases, including 269 new and 32 relaps cases. All patients with pulmonary TB (cough history more than 2-3 weeks with or without sputum, with and without haemoptoe, with and without secondary infection. Positive X-ray with minimal to advance lesion, nodular pattern to fibro-exudative lesions supporting the possibility of pulmonary tuberculosis. Microscopic smear sputum was not available at that time. The extra-pulmonary organs were involved were: all (100%) Peritoneal (dry type) and small bowel, 1 (0,3%) peritoneal wet type tuberculosis. Urinary track including 212 (70%) chronic process of kidney, 193 (64%) irregular thickening of the urinary bladder wall due to chronic cystitis. 6 (2%) pleural effucion. 6 (2%) neck lymph node enlargement. 3 (1%) cases of musculoskeletal. 2 (0,6%) miocarditis and 1 (0,3%) case scropuloderma with mandibula affected.

Conclusion: Peritoneal dry type and small bowel tuberculosis was found in all extrapulmonary tuberculosis, followed by urinary tract, pleural effusion, cervical lymph node enlargement, musculoskeletal, miocarditis, peritoneal wet type and scropuloderma.

832

PO 370EXTRAPULMONARY TUBERCULOSIS PATTERN AND ITS ULTRASOUND FINDINGS

Maria Goretti AmetembunStela Maris Hospital And Lukas Hilisimetano Government HospitalSouth Nias – North Sumatera - Indonesia

Background: Tuberculosis is a systemic disease that can affect both pulmonary and extra-pulmonary organs.

Aim: To describe the pattern of organs affected in extrapulmonary tuberculosis.

Method This descriptive study conducted at Stela Maris Hospital and Lukas Hilisimetano Government Hospital South Nias – North Sumatera from April - July 2015. Data were abstracted from medical records of all disseminated tuberculosis cases. All patients were diagnosed base on history, physical examination, laboratory, Thorax X-ray, ECG and ultrasound by one very skill certified ultrasound internal medicine specialist

Results: There were 301 cases, including 269 new and 32 relaps cases. All patients with pulmonary TB (cough history more than 2-3 weeks with or without sputum, with and without haemoptoe, with and without secondary infection. Positive X-ray with minimal to advance lesion, nodular pattern to fibro-exudative lesions supporting the possibility of pulmonary tuberculosis. Microscopic smear sputum was not available at that time. The extra-pulmonary organs were involved were: all (100%) Peritoneal (dry type) and small bowel, 1 (0,3%) peritoneal wet type tuberculosis. Urinary track including 212 (70%) chronic process of kidney, 193 (64%) irregular thickening of the urinary bladder wall due to chronic cystitis. 6 (2%) pleural effucion. 6 (2%) neck lymph node enlargement. 3 (1%) cases of musculoskeletal. 2 (0,6%) miocarditis and 1 (0,3%) case scropuloderma with mandibula affected.

Conclusion: Peritoneal dry type and small bowel tuberculosis was found in all extrapulmonary tuberculosis, followed by urinary tract, pleural effusion, cervical lymph node enlargement, musculoskeletal, miocarditis, peritoneal wet type and scropuloderma.

833

PO 371Fatal cases of Weil’s disease : A case report

LP Paramita1, EJ Nelwan2

1. Department of Internal Medicine. 2Division of Tropical and Infectious Disease. Faculty of Medicine University of Indonesia

Abstract

Leptospirosis is a zoonotic disease usually transmitted from rats to humans through contact with the contaminated urine. Diverse presentations of illness might lead to poor prognosis. We presented two cases of severe form of leptospirosis (Weil’s disease)

A 43 years old man came with diarrhea since 7 days ago. He also had low grade fever, abdominal discomfort and myalgia. He became yellowish and decrease of urin output. He sell food in traditional market. On initial examination pasien was alert and hypotension, takikardia, tachipneu, afebris. His sclera was icteric. His heart sound, breathing sound and abdomen was normal. There was a tenderness over his thigh. The laboratory investigation showed Hb 10 g/dL, leucocyte 18,600 u/L, trombocyte 21,800 u/L, glutamate pyruvat transaminase (GPT) 91 IU/L, bilirubin (BilT/D/I 17/16/1,26), albumin 3,01, ureum 205, creatinin 5,3. Chest x-ray showed hyperlucense on both lung. Abdominal ultrasound showed chronic kidney disease. Leptospirosis was confirm by IgM anti leptospira. The patient received meropenem 1 gram every 8 hours per day and methylpredinolon 250 mg twice daily. Fluid balance was strictly monitored and further assigned the patient for haemodialisis. However the condition was rapidly deteriorated and patient died before haemodialisis.

A female 51 years old admitted to ED with coma since 1 day prior to admission. She had high fever 4 days ago, no cough nor sign of bleeding, There were tenderness in both thigh and calf. Her skin became yellowish. Stool and urine were normal. History of flooding in her house about a week ago. On physical examination she is unconcious, blood pressure of 130/90, pulse of 110 beats/min, tachypnoea 24/min, her temperature was 380C. There was conjunctival suffusion with icterus. Her chest and abdominal examination was normal. Cranial nerves were intact and no motor deficit was present. Electrocardiogram showed inferior ischemia. On laboratory examination leukocyte 24,700, trombocyte 91,800, albumin 2.88. Bilirubin (Total 20,9/Direct 18,07 /indirect 2,83), ureum 329 mg/dL, creatinin 8,99 mg/dL, natrium 120. HbsAg and anti HCV was non reaktif. The chest x-ray revealed heterogen consolidasion with air bronchogram in parakardial, infiltrate in both lung. Leptospirosis was clinically suspected which was further confirmed by the positive serum IgM. The patient was initiated on intravenous ceftriaxone 3 gram per day and methylprednisolon 250 mg twice a day, also intravenous heparin 10.000/24 jam.

834

Haemodyalisis was initiated, unfortunately she passed away few hours after hemodyalisis.

Onset of disease in Leptospira infection is important, however in most of severe case could be difficult to determine. In addition to that the diverse presentations of illness make the diagnosis became late. Leptospirosis causes oliguric AKI and even acute tubular necrosis. The major burden of leptospirosis is due to Weil’s disease with mortality higher than 50% as presented here.

Keywords: Weil’s disease, onset of illness, mortality

835

PO 372Silencing of Sialyltransferase Increases Colorectal Cancer Metastasis by Releasing Cellular Metastases Suppression CD82 Via Exosome-Mediated Exportation, and Thereby Rescues Integrin Signaling

Yu Ri Jung, Eun Ju Kim, and Minyoung Lee

1. Division of Radiation Effect, Korea Institute of Radiological and Medical Sciences, Seoul, 01812, Republic of Korea

Abstract

Background/Rationale: Abnormal sialylation due to dysregulation of sialyltransferases or sialidases has long been connected with human cancer. ST6Gal I (-galactoside 2, 6 sialyltransferase) has been highly associated with tumor metastasis. We have extensive circumstantial data that sialylation is connected to colorectal cancer (CRC) metastasis, but we do not understand in detail how sialylation can switch on/off multiple steps in CRC metastasis.

Methods: Here, we used immunohistochemistry (IHC) to examine ST6Gal I expression in human tissue arrays (TMAs) containing CRC samples and uninvolved normal colon tissues. The human CRC cell lines, HCT116 and SW620, were subjected to RT-PCR (reverse transcription polymerase chain reaction) and immunoblotting to determine the expression levels of ST6Gal I and CD82. To examine of ST6Gal I knockdown on tumor growth and liver metastasis in mice, we subcutaneously injected SW620-shST6Gal I or SW620-shv cells (1 106) in the flanks of athymic nude mice and also injected into the spleen parenchyma of athymic nude mice.

Results: To investigate the molecular mechanism underlying the ST6Gal I-mediated metastasis of CRC, we silenced the ST6Gal I gene in a metastatic SW620 CRC cell line (SW620-shST6Gal I) and observed the metastatic behavior of the cells. We found that various hallmarks of metastatic ability were significantly enhanced in ST6Gal 1-depleted SW620 clones, as evaluated both in vitro and in vivo. In particular, the metastasis suppressor, CD82, was down-regulated in ST6Gal I-deficient SW620 clones. This revealed the increased exosome-mediated exportation of CD82, and was associated with a decrease in the CD82-mediated inhibition of integrins.

Conclusion: Our results suggest that gene silencing of ST6Gal I could enhance metastasis in CRC by down-regulating CD82 activity via exosome-mediated exportation and rescuing its negative effects on integrin signaling.

Correspondence to: Eun Ju Kim, e-mail:[email protected]

Minyoung Lee, e-mail:[email protected]

836

PO 373INFLUENCE OF EXPERIMENTAL HYPERTHYROIDISM ON RHEOLOGIC PROPERTIES OF BLOOD

S. Toplan1, N. Dariyerli2, M. C. Akyolcu1, S. Özdemir1

1. Department of Biophysics; 2 Department of Physiology; Istanbul University,Cerrahpasa Medical Faculty, Istanbul,Turkey

Background: The thyroid hormones play a critical role in growth, maturation, and metabolism needed for the normal function of almost all the tissues in the body. The present study has been planned with the purpose to determine the effects of experimental hyperthyroidsm on blood rheological parameters.

Methods: In this study Spraque–Dawley type albino female rats weighing 160–200 g were used in both control and experimental group animals. Both control (n = 8) and experimental group (n = 8) animals were kept in the same physical conditions during the experimental period and were fed with standard fodder and tap water. To constitute hyperthyroidism L-thyroxin (0.4mg/100 g fodder) was given to experimental group animals for 20 d. After the experimental period, blood samples were taken from the abdominal aorta under light ether anesthesia. Serum levels of triiodothyronine( T3), thyroxine(T4), and thyroid-stimulating hormone (TSH) were determined by the radioimmunoassay (RIA) method. Plasma and blood viscosity were measured in Harkness viscometer. The ability of RBCs to deform was represented as a RBC rigidity index. The plasma fibrinogen concentration was determined in spectrophotometer. Statistical analysis was done by the Mann–Whitney U test. The values were expressed as means ± standard deviation. Differences between groups were considered significant at the p < 0.05 level.

Results: In the experimental group, T3 and T4 levels were higher and TSH levels lower than that of the control rats (respectively, p < 0.01, p < 0.001, p < 0.001). Plasma viscosity and fibrinogen concentration of hyperthyroid group were found significantly higher than controls (p < 0.01). However there was no significant difference found in blood viscosity, hematocrit, and erythrocyte rigidity index between control and experimental groups.

Conclusions: Hyperthyroidism induced increased fibrinogen concentration can alter the rheological structure of blood by inducing increase in plasma viscosity.

837

PO 374ENGRAFTMENT PERIOD AND INFECTION INCIDENCE IN MULTIPLE MYELOMA PATIENTS UNDERWENT AUTOLOGUS PERIPHERAL BLOOD STEM CELL TRANSPLANTATION

Noor Diansyah Muhammad, Savitri M, Amrita PN, Bintoro UY, Sedana MP, Ashariati A,

Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Airlangga University – Dr. Soetomo Hospital, Surabaya, Indonesia

Background: High-dose chemotherapy followed by autologous peripheral blood stem cell transplantation (PBSCT) has been used widely for treatment of Multiple Myeloma (MM) resulting in higher complete response rates and improved long-term survival. High-dose myeloablative conditioning regiment directly associated with neutropenia condition and increase the risk of infection as one of the most life threatening complications during PBSCT. Engraftment (marrow recovery) is characterized by a stable growth of hematopoietic cells (without tranfusion), usually takes 3 weeks to 3 months period after PBSCT. Engraftment period and duration of neutropenia are the predominant risk factor for infection. This study was carried out to describe the engraftment period and the infection incidence in MM patients underwent autologus PBSCT.

Method: A retrospective study in Hematology and Medical Oncology Division, Department of Internal Medicine, Dr. Soetomo Teaching Hospital Surabaya. Secondary data collected from medical record of 8 MM patients underwent autologus PBSCT during the period of September 2014 to February 2016. All patients were given melphalan 200mg/m2 as myeloablative conditioning regiment, ciprofloxacin 800mg/day, fluconazole 300mg/day and acyclovir 600 mg/day as antimicrobial prophylaxys.

Results: Mean age was 49.87±7.01 years (ranged 37 to 59 years). Average length of stay was 48.12±4.18 days (ranged 40 to 52 days). The median engraftment period was 19 days (ranged 13 to 37 days) after stem cell reinfusion. The median duration of neutropenia (neutrophil count ≤1000/µL) was 11 days (ranged 7-24 days). Most infection came from the central venous catheter in 4 (50.0%) patients with Staphylococcus spp. strain in blood culture and diarrhea in 3 (37.50%) patients. No transplant related mortality in all patients.

Conclusion: Low infection incidence in this study can be affected by short engraftment period, duration of neutropenia and antimicrobial prophylaxys.

Keywords: Engraftment, infection, autologus PBSCT, multiple myeloma

838

PO 375CORRELATION BETWEEN VITAMIN D LEVEL, INTERLEUKIN-6 AND IRON STATUS WITH HEMOGLOBIN LEVEL IN SUBJECTS ANEMIA CHRONIC DISEASE YOUNG ADULT

Polii E*, Ongkowijaya J**, Rotty LWA*** *Division of Pulmonologi, University of Sam Ratulangi **Division of Rheumatology,University of Sam Ratulangi ***Division of Hemato-Oncology, University of Sam Ratulangi

Objectives: Vitamin D receptors (VDR) were found in many tissues other than bone and intestine such as T-helper type 1 cells, makrophage, prostate and other tissues. Vitamin D receptor activation inhibits the expression of inflammatory cytokines including IL-1, IL-6, TNF-α, IFN-γ. Inflammatory state is one of the causes of anemia. Several studies have shown that inflammatory cytokines such as IL-6 was positively related to the use of erythropoietin. The role of vitamin D as the regulator of immune system has been proven from various studies.

Methods: The method used in this research was analytic observational study with cross-sectional design performed in RSU Prof.dr.R.D. Kandou Manado started in December 2014 to February 2015. The sample data taken in sequence until the desired sample size is reached.

Results: The results showed 45 samples consisting of 19 women and 26 men. The distribution of the sample based on the level of vitamin D found 30 samples have low level of vitamin D and 15 samples of normal level. Hemoglobin level based on the degree of anemia was found 16 samples have mild anemia, 24 samples with moderate anemia and 5 samples have severe anemia. For interleukin-6, all subjects were above normal .

Conclusion: 1. there was no correlation between the level of 25(OH)D3 with IL-6; 2. There was no correlation between the level of 25(OH)D3 with hemoglobin levels; 3. There was no correlation between the level of IL-6 with hemoglobin level; 4. There was a highly significant correlation between the levels of IL-6 with SI; 5. There was a highly significant correlation between the level of IL-6 with TIBC; 6. There was no correlation between IL-6 with FS; 7. There was a significant correlation between SI with hemoglobin level; 8. There was a significant correlation between TIBC with hemoglobin level; 9. There was a significant correlation between FS with hemoglobin level.

839

PO 376A CASE REPORT OF PRIMARY LEIOMYOSARCOMA OF LIVER – A RARE PRESENTATION

Rahul Chowdary Kongara, K VengadakrishnanName of the presentor: Rahul Chowdary KongaraSri Ramachandra Medical College and Research Institute, Chennai, IndiaIntroduction

Primary hepatic leiomyosarcomas are rare. Most of the hepatic leiomyosarcomas are metastatic from other sites including gastrointertsinal tract, uterus, retroperitoneum and lung.

Case report

A 31 year male with no known comorbid illness presented with fever for 4 months more during the evening, right shoulder pain for 4 months, right hypochondrial pain for 10 days. Gives history of tobacco chewing since10 years. Physical examination revealed a pulse rate of 70 beats/min, BP 110/70 mm Hg and tender hepatomegaly. Other system examination was unremarkable. Labs revealed hemoglobin 8.2 gm%, total counts 7600 cc/mm3, platelet count 380000 cc/mm3, low serum iron and ferritin . Peripheral smear showed microcytic hypochromic anemia. Renal function was normal, liver function revealed an elevated alkaline phosphatise (319 IU). Abdomen ultrasound showed a large mass in the right lobe and a cyst in the left lobe and mild splenomegaly. CT abdomen revealed hepatomegaly, with a large well marginated rounded heterogenous lesion measuring 15.8 x 13 x 16.3 cm, with enhancement in arterial and venous phase, showing gradual centripetal contrast filling is seen in segment VII and VIII. Another small cystic lesion was seen in left lobe segment IV A 3.6 x 3.4 cm. Biopsy was done under sonographic guidance. Histoparthology revealed high grade sarcoma with extensive necrosis. Immunohistochemistry was positive for smooth muscle antigen (diagnosic of leiomyosarcoma high grade) with Ki67 labelling index of 70% PET SCAN showed nodular uptake in the liver with no uptake anywhere else in the body . He was diagnosed as primary leiomyosarcoma of the liver.

Conclusion

Primary hepatic leiomyosarcoma is very rare, usually arise from intravacular structures, bile ducts and ligamantum teres. So far around 67 cases have been reported.

840

PO 377Kaposi sarkoma existing during Chronic Lymphocytic Leukemia follow-up

Betul Erismis*,Hatice Kaya*, Mehmet Hursitoglu*, Yildiz Okuturlar*, Hakan Kocoglu*, Bahar Pehlivan*,Deniz Tural*, and Ozlem Harmankaya*

*Internal Medicine Department, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, Istanbul, Turkey.

Introduction: Chronic Lymphocytic Leukemia (CLL) is the most common adults leukemia types (25%). In Western community the annual incidence is at 4/100.000. Although the average age of diagnosis is increasing, it is about 65 years old. There are reports of co-existence of second malignancies with CLL. Here we report a rare second malignancy, Kaposi Sarkoma (KS), associated with CLL.

Case: A 88 years old female patient has been diagnosed with stage 1 CLL 5 years ago. At the 2nd year of follow-up, a chemotherapy protocol (Cyclophosphamid plus prednisolone) was started because of progress of her CLL to stage 3 (because of the associated anemia and thrombocytopenia of 9.8 mg/dL and 150000/mm3, respectively). After 9 months, she developed nodular lesions on plantar aspects of her feet and on her fingers (1st were red to purple and later changed to dark black color) but these lesions was ignored. After 6 months of her follow-up, she admitted to our internal medicine clinic because of febrile neutropenia. A punch biopsy was taken from these skin lesions. Histopathological result was consistent with Human Herpes virus type 8 positive KS. Although the disease progressed to stage 4 rituximab was added to the above chemotherapy. In addition to the above chemotherapies, radiotherapy was also started for KS.

Conclusion: Although it is rare, KS should be born in mind when investigating CLL associated skin manifestations.

Key words: CLL, Kaposi sarkoma, chemotherapy, radiotherapy.

841

PO 378Correlation Between IL-1　, Testosterone, Serum Erythropoietin and Hemoglobin in Young Adults Male Subjects with Anemia of Chronic Disease

Umboh O, Rotty LWA, Datau EA, Haroen H, Surachmanto E, Soekarno J

Department of Internal Medicine, Faculty of Medicine Sam Ratulangi University/RSU Prof. R. D. Kandou Manado

Background. Anemia of chronic disease is the second most commonly found in patients with infection or inflammation and malignancy. Chronic inflammation is a cause of anemia of chronic disease. Pro-inflammatory cytokines, such as IL-1 has a very important role in the occurrence of anemia of chronic disease. Testosterone is one of androgen hormones, which has an anti-inflammatory effect and physiologically will induce erythropoietin hormone to maintain normal hemoglobin level. Decrease in testosterone level is not followed by decrease in erythropoietin in anemia of chronic disease. Erythropoietin hormone is an anti-apoptosis agent mainly in erythroid colony. Increase in erythropoietin level may aid red blood cells formation by helping proliferation in burst-forming unit-erythroid as well as colony-forming unit-erythroid.

Aim. The aim of this study is to find out the correlation of IL-1, testosterone and serum erythropoietin with hemoglobin level in young adults male subjects with anemia of chronic disease.

Methods. This study is an analytic observational study with cross-sectional design performed in RSU Prof. Dr. R. D. Kandou Manado, RSI Siti Maryam Manado and RS GMIM Pancaran Kasih Manado. Sample of this study is anemia of chronic disease that is caused by infection within the period of January – April 2016.

Results. This study was done on 35 patients with anemia of chronic disease. There was a significant negative correlation between IL-1 with testosterone (p=0.000); there was no significant correlation between IL-1 level with erythropoietin level (p=0.339), IL-1 level with hemoglobin (p=0.264), testosterone with erythropoietin (p=0.318), testosterone with hemoglobin (p=0.053), and erythropoietin with hemoglobin (p=0.166).

Conclusion. There was a very significant negative correlation between IL-1 as a pro-inflammatory cytokines with testosterone as an anti inflammatory hormone in young adults male subjects with anemia of chronic disease.

Suggestion. More studies are needed on testosterone as an anti-inflammatory and propability for adjuvant treatment to reduce inflammation process in chronic disease including cardiovascular diseases.

Keywords. IL-1, testosterone, erythropoietin, hemoglobin, anemia of chronic disease.

842

PO 379AN INTERESTING CASE OF EXTRAMEDULLARY HEMATOPOIESIS IN A PATIENT WITH NEWLY DIAGNOSED HEMOGLOBIN H DISEASE

Introduction: Extramedullary hematopoiesis is a rare entity, which consists of the formation of hematopoietic tissue in various parts of the human body due to the existence of a hematological disorder. A–thalassemia is a great example of a disease that can result in extramedullary hematopoiesis.

Hemoglobin H disease is a type of a-thalassemia consisting of the loss of 3 genes (--/-a) and is often manifested as a mild anemia with thalassemic morphological changes and the existence of erythrocyte inclusions. Hemoglobin H is a tetramer composed of four beta globin chains and a great decrease in alpha chain availability. In this hemolytic disorder, splenomegaly may occur, as well as mandibular and bone marrow hyperplasia and pathological fractures.

Case description: The present study reports an unusual case of a 64-yr-old male, former blood donor, who, after undergoing a CT scan, was admitted to our clinic because of the recent occurrence of mild anemia, of splenomegaly and of the appearance of a paraspinal mass extending longitudinally between the T9 and T10 vertebral bodies. Eventually, hemoglobin H disease was diagnosed by the presence of erythrocyte inclusions in the Hb electrophoresis in conjunction with an MRI scan which had already suggested the possibility of the paraspinal mass being an example of extramedullary hematopoeisis.

Discussion: The question remains what is to be done in this kind of situations. Surely these patients should remain under observation. Whether or not they should receive a blood transfusion relays upon the better judgement of the physician in charge, who is after all responsible for weighing the advantages and disadvantages of multiple blood transfusions, especially since many of these patients will later on require chelation therapy in order to treat the iron overload.

843

PO 380A CASE OF RENAL CELL CARCINOMA, PRESENTED WITH PARANEOPLASTIC SYNDROME

T. KURT1, S.DEMIRBAS1, I. CETINDAGLI1, K. SAGLAM1

1. Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY

BACKGROUND: Renal cell carcinoma (RCC) is the most common primary kidney tumor. RCC present with a variety of non-specific symptoms and signs. Classic triad of RCC is hematuria, flank pain and palpable abdominal mass. Most of the patients present with systemic symptoms or paraneoplastic syndromes. Here we present a case of RCC presented with anemia and hypercalcemia.

CASE: 81-year-old male patient, admitted with the complaints of loss of appetite, weakness and fatigue. Patient had the diagnose of diabetes mellitus, coronary artery disease and hypertension in his history. In physical examination; patient’s tongue was slightly dry. In biochemistry study; Hb: 9,6gr/dL, urea: 60mg/dL , creatinine: 1,63mg/dL, LDH: 374U/L, calcium: 14,6mg/dL, PTH: 7,7pg/mL and sedimentation: 52mm/h were detected. In ultrasounographic examination; solid character, malignancy suspicious lesion was observed in the right kidney region. In CT scan; in the lower section of the right kidney, 11x10cm size, heterogeneous and calcific mass was observed. Some areas seen inside the right renal vein and vena cava inferior, thougt as tumor trombus. Nephrectomy operation was not considered because of the patient’s age, morbidities and tumor trombus. Imaging-guided renal biopsy was performed. The renal biopsy was reported as clear cell type renal cell carcinoma. Patient referred to the medical oncology unit for planning chemotherapy.

CONCLUSION: RCC patients; may present with wide spectrum of signs and symptoms due to the tumor itself, metastasis and paraneoplastic syndrome. Therefore, all RCC considered patients should be evaluated for renal masses.

844

PO 381THE RARE HEMOGLOBIN H DISEASE

S. DEMIRBAS1, H. SARLAK 2, T. KURT1, I. CETINDAGLI1, K. SAGLAM1

1. Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY2. Diyarbakir Military Hospital, Department of Internal Medicine, Diyarbakir , TURKEY

BACKGROUND: Thalassemias are the most common genetic disorders. Alpha thalassemias has four classical shape. Hemoglobin H disease occurs in three loci deletions in four loci of alpha globin. Moderate hemolytic anemia and ineffective erythropoiesis seen in hemoglobin H disease. Here, we present a case of hemoglobin H disease as rare cause of the thalassemias.

CASE: 20-year-old male patient was admitted with the complaint of yellow eyes. Physical examination showed icteric scleras, tenderness of left upper quadrant and epigastric region of the abdomen. The spleen was 2-3 cm palpable. In his assays hemoglobin:11.07g/dL, MCV:69fl, HCT:36.6%, LDH:460U/L, indirect bilirubin:4.14mg/dL were observed. In ultrasound spleen size was increased to 160mm. The count of reticulocytes 5.07%, corrected reticulocyte 4.36%, and reticulocyte production index was found to be 2.90 of the patient. There was no sign of nutritional anemia and acute bloodloss. Haptoglobulin was observed 1mg/dL. Direct Coombs resulted negative. In peripheral blood smear hypochromia, anisocytosis, macrocytosis, basophilic stippling, target cells and rare tear drop cells were seen. The patient was considered as non-immunohemolytic anemia. Hb H was found 7.1% in the hemoglobin electrophoresis. With these results, the patient was diagnosed as hemoglobin H disease.

CONCLUSION: In the management of thalassemias, thalassemia minor is often kept in the forefront and without further investigation premature diagnosis are made commonly. However, the CBC findings are similar, distinction is only possible with the assessment of hemoglobin electrophoresis between thalassemia minor and Hemoglobin H Disease.

845

PO 382A Case of DRESS syndrome with pathologically confirmed Dermatopathic Lymphadenopathy

Michito SADOHARA, Naoho TAKIZAWA, Takahiro KUMODE,Saburo KOJIMA, Hideyo NISHINOKishiwada Tokushukai Hospital, Osaka, Japan

Description of Case: 69 years-old man was undergone the thoracic aortic graft surgery for repair of aneurysm. The surgery was successful and after the 9 days of intensive and postoperative recovery care, he discharged from ICU. On the 41st day of admission, he developed generalized rash with facial desquamation. On the 50th day, the fever greater than 38.0 ℃ stated and liver enzyme and creatinine elevation to his base lines , and eosinophilia was observed. Scoring system for classifying DRESS syndrome by Kardaun et al. was 8 pointes and define. Vancomycin and mexiletine were considered as candidates of the drugs which were possible with Naranjo adverse drug reaction probability. FDG –PET/CT showed the multiple enlarged lymph nodes, up to 3 cm in diameter with FDG accumulations in supraclavicular, axillar, mediastinal. By the axillary lymph node biopsy, the histology revealed the dermatopathic Lymphadenopathy with pigment laden histiocytes accumulation from cortex to paracortex of the lymph node.Stopping the candidate drugs, antihistamines and occasional corticosteroids, and supportive measures, skin symptoms were diminished gradually, fever resolved, and eosinophils counts, liver enzymes and creatinine went back to the baseline, multiple lymph node swelling subsided spontaneously.By the titer of human herpes-6 IgG, reactivation was not obvious in this case.

Conclusion: The DRESS syndrome is a severe drug adverse reaction with acute rash, fever, lymphadenopathy, and internal organ involvement, occurring most commonly 2-6 weeks after initiation of medications. Dermatopathic lympadenopathy is a rare benign lymphatic hyperplasia with exfoliative or eczamatoid dermatitis.

Cases of these two syndrome and pathology had been reported and discussed separately. We experience the case of the DRESS syndrome with pathologically comfirmed dermatopathic lympandenopathy.

846

PO 383APLASTIC ANEMIA WITH PARTIAL RESPONSE TO RITUXIMAB TREATMENT: A CASE REPORT

I Made BaktaDivision of Hematology and Medical OncologyDepartment of Internal Medicine, Udayana UniversityDenpasar, Bali, Indonesia

Aplastic anemia is more prevalent in Southeast and East Asia compared to incidence in developed countries. One of the pathogenesis of aplastic anemia is abnormality of the immune system with immunosuppression to hematopoietic stem cells and microenvironment of the bone marrow. The main treatments are supportive treatments, immunosuppressive therapy with steroid and anti-thymocyte globuline and bone marrow transplantation. The prognosis is still not encouraging, especially in developing countries. Mabthera, anti-CD 20 chimeric antibody, is reported give good result to some aplastic anemia patients because of its effects on T-regulatory lymphocyte. Here is a report of one aplastic anemia case who had a partial response to mabthera treatment.

A 63-year-old Balinese male, a hotel employee, was referred in November 4, 2015 for pancytopenia. He had presented with fatigue and shortness of breath since 3 months. Seven months before he had hospitalized with the same symptoms in another hospital. He was given vitamins and methylpredinosolone maintenance. He was denied chemical exposure, smoking or alcohol use, or a family history of blood disorders. The other past medical history was unremarkable. On physical examination there was severe conjunctival pallor but no scleral icterus. No lymphadenopathy and hepatosplenomegaly was palpable. Widespread echymosis and petechie were noted on lower legs, arms , and abdomen.

The complete blood count (CBC) on April 11, 2015 were: WBC 3.04 x 109/L, ANC 1.10 x 109/L, lymphocyte 1.68 x 109/L (55.2%), Hb 3.9 g/dl, platelets 13 x 109/L. CBC on November 6, 2015 (recent admission) were: WBC 3.62 x 109/L, ANC 1.62 x 109/L, lymphocyte 2.19 x 109/L (60.5%), platelets 14 x 109/L, Hb 6.5 g/dl, with absolute reticulocyte count of 0.247 x 109/L (0.71%). Liver, renal and bilirubin were normal. Serum iron 194 µg/dl, TIBC 266 µg/dl, serum ferritin 884 µg/dl, and LDH 425 U/L. Serological test for HBs Ag and anti HCV were negative. Bone marrow biopsy showed an acellular marrow with less than 5% cellularity with marked reduction to absent of trilineage hematopoiesis. Flowcytometry and cytological examinations were not available. A diagnosis of idiopathic severe palstic anemia was made.

The patient was managed with transfusion support of packed red cells and thrombocyte concentrate and methyl predinolone 375 mg/day intravenously. Drug-induced hyperglycemia was occured and was managed with short-acting insulin. On day-20 of

847

hospitalization, patient was still pancytopenic with Hb 7.2 g/dl, platelets 11 x 109/L, 3.86 x 109/L, and blood sugar 216 mg/dl. Methyl prednisolone was tappering off, treatment with mabthera 600 mg (375 mg/sqm) every weeks for 4 weeks was started. There was no serious side effects of mabthera treatment. Patient was still pancytopenic with transfusion support. After 3 months of mabthera treatment, hemoglobin and platelets showed a steady improvement without transfusion (Hb 10.3 /dl, platelets 76 x 109/L and WBC 3.03 x 109/L). Bone marrow biopsy showed a marked increase of celluarity (cellularity = 10%). On seventh month of mabthera treatment patient had no symptoms, doing well his job. The CBC on last examination (2016-05-16) was: Hb 11.8 g/dl, platelets 81 x 109/L and WBC 3.67 x 109/L.

This case shows a partial response of aplastic anemia patient to mabthera treatement. The response is slow, but without serious side effects. The use of anti-CD 20 antibody in aplastic anemia is promising and warrants further investigation.

848

PO 384PANCYTOPENIA DUE TO MYCOBACTERIUM TUBERCULOSIS INFECTION IN BONE MARROW

I Made BaktaDivision of Hematology and Medical OncologyDepartment of Internal Medicine, Udayana UniversityDenpasar, Bali, Indonesia

Tuberculosis (TB) is a major health problem worldwide, partcularly in developing countries. Nearly 3 million cases of tuberculosis occur per year in South and Southeast Asia alone. Indonesia is one of country with high morbidity and mortality of tuberculosis. In developed countries the increase incidence of TB is closely related to epidemic of HIV/AIDS. Bone marrow tuberculosis is a rarely type of disseminated tuberculosis (TB that involves two or more non-contagious sites). The clinical presentations are not specific and the diagnosis is delayed. This is a case report of bone marrow tuberculosis manifest as pancytopenia.

A 37 years-old Balinese male was admitted with a two-months history of on and off moderate to high grade fever. It was associated with weight loss of 6 kilograms in one month, and generalized fatigability. No history of cough. The other medical history was unremarkable. On examination, the patient had a high grade fever (39.8oC), normal consciousness, blood pressure was 100 mmHg systolic and 70 mmHg diastolic, and tachycardia (104/min). There was no hepatosplenomegaly, no superficial lymphadenopathy and there was no signs of meningeal irritation.

A complete blood count revealed hemoglobin of 10.1 g/dl, white blood count (WBC) of 0.9 x 109/L, with absolute neutrophil count (ANC) of 0.41 x 109/L, with lymphopenia (lymphocyte of 0.17 x 109/L, platelet of 42 x 109/L. Peripheral blood smear showed leucopenia and thrombocytopenia, and no blast was found. Liver function test, blood urea & creatinin, were within normal range. Chest X-ray was within normat limit. A diagnosis of pancytopenia with febrile neutropenia and sepsis was made. The differential diagnosis of aplastic anemia was made. He was treated with antibiotics (meropenem 3 x 1 g), methyl prednisolone 3 x 125 mg, and supportive care. On day-3 patient was still fever and neutopenic (WBC 0.69 x 109/L and ANC 0.41 x 109/L), fluoconazol and G-CSF (leucogen) were added and the dose of mehtylprednisolone was increased to 3 x 250 mg. Bone marrow biopsy (histopathologic examination) showed normocellular marrow, with histiocytes and macrophage collection, constitute a ill defined granuloma. Acid-fast bacilli was found on Ziehl Nielsen stain. The final diagnosis was Mycobacterium tuberculosis infection in bone marrow. Treatment with rifampicin (600 mg), isoniazid (300 mg), ethambutol (1100 mg), and pyrazinamide (1600 mg) were started. Methylpredinolone was tappering off. Serologic tes for HIV/AIDS was negative. Three days after anti-TB treatment fever was resolved, the CBC results were: hemoglobin 9.7 g/dl, WBC 2.68

849

x 109/L, ANC 4.52 x 109/L, and platelet 127 x 109/L. On day-15 of hospitalization, the clinical condition became normal, with CBC Hb 9.6 g/dl, WBC 8.34 x 109/L and platelet 96 x 109/L. Patient was discharged for out patient care. On the last outpatient examination (3 months after hospitalization) the clinical condition was well with CBC: Hb 15.9 g/dl, WBC 6.23 x 109/L, and platelet 216 x 109/L.He was still used anti-TB traetment.

This case is a Mycobacterium tuberculosis infection without clinical signs of disseminated tuberculosis. Diagnosis is confirmed based on finding of granuloma and acid –fast bacilli in bone marrow and a good response to anti-tuberculosis treatment. This is a rare case.

Key words: pancytopenia, tuberculosis infection, bone marrow.

850

PO 385PLATELET TRANSFUSION FOR HEMATOLOGY ONCOLOGY PATIENTS IN SANGLAH HOSPITAL

Cokorda A Wahyu, Ketut Suega, I Made Bakta

Hematology and Medical Oncology Division of Internal Medicine Department Medical Faculty Udayana University

Background: Platelet transfusion has steadily increased throughout the past three decades. Several factors known to have risk on platelet recovery post transfusion. This study aim is to discover platelet recovery after transfusion. There has been very view study of the current transfusion practices.

Study Design and Methods: A study was conducted at Sanglah Hospital Denpasar, from December 2015 until April 2016. Inquiries were made relating to the extent of use of platelets, criteria used for transfusion of platelets and type, and dose of platelets used. Data were analyzed accordingly.

Results: This study involved 50 participants, consisting of 22 men (44%) and 28 women (56%) with a mean age of 45.02 ± 2.83 years. Most cases who received transfusion of platelets are aplastic anemia (26%), followed by AML (16%), ITP (8%) and MDS (8%). Fourteen patients (28%) had naïve transfusion and only 10 of them had increased their platelets. Eight patients (16%) had transfusion after chemotherapy. Twenty four patients (48%) received transfusion pool platelet, 16 patients (32%) received apheresis transfusion and 10 patients (20%) received combination of both transfusion. Eighty percent of patients showed increase their platelets after transfusion and 20% without response. An average increase of thrombocyte is 28.62 ± 5.91 X103 / dL. Six bag of platelet concentrate increased the average of thrombocyte 13.32 ± 2.79 X103 / dL, whereas 1 bag apheresis increased the average of thrombocyte 41.54 ± 4.41 X103 / dL.

Conclusion: This study showed that for some patients their platelets level decreased after platelets transfusion without clear explanation and platelet recovery rate after transfusion was higher with platelet apheresis compared to multiple pool donors.

KEY WORDS: Platelet, Platelet Transfusion, Platelet Apheresis

851

PO 386THORACOCENTESIS PROCEDURE IN A PATIENT WITH SEVERE THROMBOCYTOPENIA

Roza Kurniati1, Gurmeet Singh2

1. Division of Pulmonology, Department of Internal Medicine, Faculty of Medicine, University of Andalas

2. Division of Respirology and Critical Illness, Department of Internal Medicine, Faculty of Medicine, University of Indonesia / Cipto Mangunkusumo General Hospital

ABSTRACT

Introduction: Pleural effusion is the presence of abnormal fluid in the pleural cavity that can be caused by various diseases. Thoracocentesis is an invasive procedure to remove fluid in the pleural cavity. Severe thrombocytopenia is one of contraindication for performing thoracocentesis procedure, but in a state of massive pleural effusion, when considering life saving, thoracosintesis procedure in patients with severe thrombocytopenia can be done.

Case Presentation: A 76-year old woman was referred with a suspected case of mielodysplastic syndrome with gum bleeding and melena. Patient was already being treated previously at different hospital for approximately 25 days and had received PRC and platelet transfusions but did not show a good response, especially platelet counts. On presentation, from physical examination and clinical features of chest x-ray showed nosocomial pneumonia and bilateral pleural effusions, laboratory tests showed mild anemia and severe thrombocytopenia (platelet counts of 2000 /mm3). Currently, this patient had been given platelet transfusion , oral medications to increase platelet count and corticosteroid, but still did not show a good response, the platelet counts remained 1000-2000 /mm3. During the subsequent treatment, patient complained shortness of breath and worsening clinical condition . Thoracic ultrasound revealed massive right pleural effusion. Thoracocentesis was performed twice on different days and before the procedure, patient was given transfusion of platelet apheresis 1 unit. Thoracocentesis drained about 1000 cc serous hemorrhagic pleural fluid and after thoracocentesis no bleeding complication was observed. Post thoracocentesis the patient’s clinical condition improved.

Conclusion: This is a case report of a patient with severe thrombocytopenia who underwent thoracocentesis in a life saving condition and post procedure no bleeding complications occurred.

Keywords: thoracocentesis, severe thrombocytopenia.

852

PO 387INCIDENCE RATE OF AMYLOIDOSIS IN PATIENTS FROM A MEDICAL CARE PROGRAM IN BUENOS AIRES, ARGENTINA: A PROSPECTIVE COHORT

María Adela Aguirre2; Bruno Rafael Boietti1; Elsa Nucifora3, Patricia Beatriz Sorroche4; Soledad Saez; Paloma Rojas; Cristina Elizondo; Giulana Olmedo; Julieta Rocca; Ivan Ravenna; Isaac Morgunovsky; Gabriel Waisman; Fernán González Bernaldo de Quirós1; Diego H. Giunta1; María Lourdes Posadas-Martínez1.

Abstract

Background: There is limited data concerning the Incidence density (ID) of WTTTR, AL, and AA amyloidosis in the Argentinean population. Our aim was to estimate the ID of WTTTR, AL, and AA amyloidosis at the Hospital Italiano Medical Care Program in Buenos Aires, Argentina.

Methods: Population was all members of a hospital-based health maintenance organization who were affiliated since January 2006 to December 2014. Each person was followed contributing time at risk since January 2006 or enrolment date to the final date. Incident cases of Amyloidosis were captured from the institutional registry of Amyloidosis. Incidence rate was calculated with 95% confidence intervals.

Results: During the eight-year study period, there were 15; 12 and 2 cases of WTTTR, AL and AA Amyloidosis, respectively for 1105152 person-years of follow-up. The crude ID of AL amyloidosis was 11 (95% CI: 6 to 19) and 1.8 (95% CI: 0.5 to 7.2) for AA amyloidosis per 1000000 person-years. The highest ID was found in men (15.9 for AL and 2.27 for AA 1000000 person-years).

The ID adjusted to the population of the city of Buenos Aires was 6.13 (IC95% 2.57 - 9.7) for AL and 1.21 (IC95% -0.56 - 2.99) for AA.

Conclusions: This is the first paper to report the incidence density of WTTTR, AL and AA amyloidosis in Latin America. WTTTR, AL and AA amyloidosis is a rare but high morbid mortality health problem, especially in men

853

PO 388Comparison of Epidermal Growth Factor Receptor (EGFR) Expression level with response of neoajuvan chemotherapy and extensive level of tumor primer on advanced nasopharyngeal cancer patients

dr. Eifel Faheri, SpPDHematology-Onkology Medic Division of Dr.M.Djamil Hospital, Padang

Background: Neoadjuvan chemotherapy is one option of treatment for nasopharyngeal cancer (NPC). The response of chemotherapy influenced by EGFR expression. EGFR is important factor for the growth and tumors invasion. Purpose of the study is compare of the EGFR expression level with response of neoadjuvan chemotherapy and extensive level of the primary tumor.

Methods: Cross-sectional study that assessment of response to neoadjuvan chemotherapy and extensive level of the primary tumor. The NPC patients who have received neoadjuvan chemotherapy is examined for EGFR expression.

Result : The proportion of EGFR expression in NPC for negative, positive and strong expression is 10%, 70%, and 20% respectively.Patients whose responses to neoadjuvan chemotherapy are 23 patients(76.6%) and non-responses 7 patients (23.4%). The group patients whose responses to chemotherapy, 15 patients (50%) have EGFR weak intensity. Patients with T3-T4 tumors (56,6%) have EGFR expression is greater than T1-T2 tumors(44,4%).

Conclusion : The proportion of EGFR expression in NPC in Indonesia is 90 percent. Neoajuvan chemotherapy is more response in tumors with positive EGFR expression and weak intensity. Tumors with high extensive levels have higher EGFR expression.

Keywords: Epidermal growth factor receptor (EGFR), Extensive primary tumors level, Response chemotherapy

854

PO 389The Sieve’s Syndrome in Autoimun Immune Hemolitic Anemia (AIHA) patient with Alcoholism

Bobi Sewow*, Handono Kalim**

*Department of Internal Medicine **Rheumato-Immunology Division, Department of Internal Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia

ABSTRACT

Zieve’s syndrome is an acute metabolic condition that can occur during withdrawal from prolonged alcohol abuse. It is defined by hemolytic anemia, hyperlipoproteinaemia, jaundice, and abdominal pain.The underlying cause is liver delipidization. This is distinct from alcoholic hepatitis which, however, may present simultaneously or develop later. Haemolytic anaemia is anemia due to shortened survival of red cells in the circulation.

Case Report – A 29 year-old male with right upper abdominal pain since 3 weeks before admission, stabbed sensation, intermittently.The pain was spread from upperr abdominal to the ack side of his body. He had low grade fever since 3 weeks before and the last 3 days there was high grade fever. He seems yellowish in the last 2 weeks. Patient also suffered from nausea and vomiting since 3 days before, vomited 3 times, contain fluid and residual food, volume 1/2 glass each vomit. Patient consuming alcohol since about 10 years ago,ussualy 3 times per week , until he got drunk, at the same period, he was a smoker, with 1-2 packs per day. Since last year, he stopped consuming alcohol. Phisical examination: Jaundice. Laboratorium; Coomb test: +4, Hb 6,50 mg/dg,leukocite 26.650 /µL.Therapy: Omeprazole inj 2x 40 mg, Melhilprednisolone 3x 62,5 mg, Metoclopramide 3x 10 mg, Ceftriaxone ; 2 x 1 gr Per Oral : Paracetamol 3x500 mg, Asam Folat 1 x 3 tab, Vitamin B6 /B12 3x1 tab, Azathiporine 2 x 50 mg. Patient was hospitalized in 10 days,and than controled as out patient.

Conclusion – We report the case of a 29-year-old male who was admitted with The Sieve’s Syndrome in AIHA patient with Alcoholism.

855

PO 390

Presenter Name : Mujgan Gurler, Asst. Prof.Adress : Abant Izzet Baysal University, Faculty of Medicine, Department of Internal Medicine, 14820, Bolu, Turkey. Phone : +903742534656/3550 E-mail : [email protected]

Prilocaine Induced Methemoglobinemia in a Patient with Pancreas Carcinoma

Abstract

Introduction: Local anesthetics such as prilocaine is frequently used in several interventions. Although prilocaine is generally safe, here we present a case diagnosed with pancreas carcinoma who developed methemoglobinemia after administration of prilocaine while inserting a chemotherapy port catheter. To our knowledge, this is one of the rare cases of methemoglobinemia in a patient with carcinoma.

Case: A 63 years old female was admitted to emergency department with dyspnea and cyanosis. A right subclavian venous port catheter had been administered an hour ago and 3 ml of 2% Prilocaine had been used subcutaneously. She had no other chronic disease. Vital signs were tension arterial: 125/73 mmHg, pulse: 95/minute, body temperature: 37C, respiratory rate: 20/minute. Pulse oximeter saturation: 95% in room air. Physical examination was normal except perioral and bilateral acral cyanosis. ECG was normal. There was an image of a catheter on the apex of the lung in chest X-Ray. Methemoglobin was measured 27% in arterial blood gas test. The other venous blood laboratory tests were in normal range. The patient treated with supportive treatment such as nasal 100% oxygen inhalation and 0.9% saline intravenous hydration. The patient was discharged free of symptoms after 48 hours of observation. Methemoglobin level was 0.5% in control analysis. This case highlights one of the potentially severe complications associated with prilocaine administration in clinical practice. Although this illustrates an unusual toxicity of prilocaine, a high index of suspicion should be given to high risk patients due to ethnic heritage, anemia, or advanced age to increase awareness of interventional radiology and oncology practitioners of the risks of prilocaine-induced complications.

Conclusion: Rarely, as in our patient, the use of prilocaine may lead to acquired methemoglobinemia. In patients having dyspnea and central cyanosis after prilocaine administration, methemoglobinemia should be kept in mind by the physicians.

Key words: Methemoglobinemia, Prilocaine, Pancreas carcinoma.

856

PO 391COMPARISON OF NEUTROPHIL-LYMPHOCYTE RATIO AMONG HEALTHY ADULTS WITH DIFFERENT BMI STATUS IN ATMA JAYA HOSPITAL

Imelda Nita Saputri*, Luse**, Yunita Maslim*** General Practitioner in Atma Jaya Hospital, Jakarta, Indonesia** Department of Internal Medicine, Atma Jaya Faculty of Medicine / Atma Jaya Hospital, Jakarta, Indonesia

Objective: Increasing evidence supports the role of chronic inflammation in the pathophysiology of obesity and its associated comorbidities, such as diabetes mellitus and cardiovascular diseases. Subclinical inflammation has been documented in obesity even before the clinical manifestation of diseases. Measurement of leukocyte and its subtypes provide a simple and affordable objective marker of inflammatory conditions. One of these is the neutrophil-lymphocyte ratio (NLR), which has been proposed as a marker of systemic inflammation. This study aims in comparing the neutrophil-lymphocyte ratio between different BMI status in apparently healthy adults.

Method: This is a cross-sectional comparative study. The data were taken from medical record of adult patients presented for medical check-up in medical check-up unit of Atma Jaya Hospital, Jakarta, from January to May 2015. Patients with documented cardiovascular diseases, diabetes mellitus, acute infection, malignancy, immunodeficiency, receiving immunosuppressant therapy, and elderly were excluded. After normality testing, statistical analysis was performed with Kruskal-Wallis H test.

Result: Sixty-eight subjects were included in the study. Subjects were 28 (41.2%) male and 40 (58.8%) female aged 18-53 years (mean age 28.69±7.44). These patients were grouped according to WHO BMI classification for Asian adults: 7 (10.3%) subjects were underweight, 28 (41.2%) were normoweight, 8 (11.8%) were overweight, while 25 (36.8%) were obese. Kruskal-Wallis H test showed that there was no significant difference in NLR between the different BMI status (χ2(3) = 3.406, p = 0.333) with NLR mean rank of 21.93 for underweight, 36.70 for normoweight, 32.75 for overweight, and 36.12 for obese.

Conclusion: There was no difference in neutrophil-lymphocyte ratio between different BMI status in healthy adults.

Keyword: neutrophil-lymphocyte ratio, BMI status, obesity.

857

PO 392THE RELATIONSHIP OF MEAN PLATELET VOLUME (MPV) VALUES WITH THE DEGREE OF SEPSIS

Andi Raga Ginting, Endang Sembiring, Armon Rahimi

Division of Tropical Diseases and Infections – Department of Internal Medicine Faculty of Medicine Universitas Sumatera Utara

ABSTRACT

Background: Sepsis is a major disease that affects millions of people worldwide every year. Almost all organs and systems were affected by sepsis. Hemostatic system is also affected. Easily accessible, inexpensive and widely used laboratory test that shows sepsis and the severity is important

Purpose: To investigate the relationship of the MPV values with the degree of sepsis, correlation MPV with procalcitonin and the diagnostic value of MPV to diagnose sepsis

Method: A cross sectional study was conducted. The subject with infection was treated in ward or intensive care unit (ICU) in Adam Malik General Hospital, after fulfilling the inclusion criteria, full blood examination including MOV, procalcitonin, blood cultures was taken. The MPV values was compared between sepsis and non-sepsis, also between sepsis and severe sepsis. Then MPV value was correlated with procalcitonin. And also investigate the cut-off value to diagnose sepsis.

Result: Of the 50 patients with sepsis and 50 non sepsis, found significant difference in MPV levels of sepsis patients 10.97 (0.63) compared to the non-sepsis 9.17(0.75), (p<0.001). From the 17 sepsis and 33 severe sepsis patients also found a significant difference in MPV levels of severe sepsis patients 11.19 (0.64) compared with groups of sepsis patients 10.52 (0.27), (p<0.001). And there is a strong correlation between MPV with procalcitonin r=0.702. Also found the cut-off of MPV value 10.15 fL with sensitivity 94% and specificity 92%, PPV 92.2% and NPV 93.9%, AUC 0.979

Conclusion: The value of MPV is higher in sepsis and non-sepsis patients, and there is also a difference value of MPV in sepsis and severe sepsis patients. And also found there is correlation between MPV and procalcitonin

Keywords : sepsis, severe sepsis, mean platelet volume

858

PO 393ASSOCIATION BETWEEN ABSOLUTE NEUTROPHIL COUNT (ANC) AND MORTALITY IN POST CHEMOTHERAPY NEUTROPENIC FEBRILE PATIENTS IN RSUP DR. SARDJITO YOGYAKARTA FROM 2014 - 2015

ABSTRACT

Alamsyah1, Mardiah Suci Hardianti21 Resident of Internal Medicine 2 Hemato-Oncology Division of Internal Medicine Departement FK UGM/RSUP Dr. Sardjito Yogyakarta

Background. Neutropenic febrile is a common complication in patients receiving chemotherapy and this condition is associated to mortality in these patients. Mortality in neutropenic patients especially related to the high risk of infection. The severity and the duration of neuropenia are in linear relation to susceptibility and severity of infection, indicating that neutropenia can be used as a prognostic factor for mortality in post chemotherapy neutropenic febrile patients.

Methode. This is an observational study, aimed to findout the association between ANC and mortality in post chemotherapy neutropenic febrile patients. Data collected from medical record of patients with neutropenic febrile receiving chemotherapy from 2014-2015. Internal medicine ward inpatients from 2014 to 2015, aged 18 years and older, receiving chemotherapy, with neutropenic febrile were included in this study.

Results. There were 23 patients with post chemotherapy neutropenic febrile, in which 69.57 % were high risk. Mortality rate were 43.47%. The Absolute Neutrophil Count (ANC) were lower (158.6) in dead patients compared to survived patients (182,46) with p value 0.319.

Conclusion. ANC can be used as a prognostic factor for mortality in post chemotherapy neutropenic patients.

Keywords: Neutropenic febrile, absolute neutrophil count, mortality.

859

PO 394OVERVIEW OF DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PATIENT WITH FEBRILE NEUTROPENIA AFTER CHEMOTHERAPY IN DR. SARDJITO HOSPITAL 2014-2015

Iswandi Darwis1, Mardiah Suci Hardianti21. Resident in Department of Internal Medicine2. Hematology-Oncology Divisions, Department of Internal Medicine Faculty of Medicine

Universitas Gadjah Mada – Dr. Sardjito Hospital

Background. Febrile neutropenia is a frequent complication in patients with cancer who are undergoing chemotherapy and can lead to death if untreated. Dr. Sardjito hospital does chemotherapy in patients, but does not have data on the demographic and clinical picture of febrile neutropenic patients after chemotherapy. The purpose of this study is to describe the demographic and clinical patient with febrile neutropenia after chemotherapy in Dr. Sardjito Hospital in 2014-2015.

Methods. This study is a retrospective study, data is extracted from medical records of patients who experience febrile neutropenia receiving chemotherapy from the year 2014 to 2015. The population in this study were all patients aged over 18 years who are undergoing chemotherapy and has a febrile neutropenia treated in Dr. Sardjito Hospital in 2014-2015.

Result. Obtained 23 patients febrile neutropenia after chemotherapy with a high risk of 69.57%. The mean age is 55 years old male patient (52.17%) and 56.52% high school background. Mortality for patients as much as 43.48% with the cause of death was septic shock (55.56%). Length of stay of patients an average of 8 days. Most types of cancer are given chemotherapy is the NHL and also many causes febrile neutropenia is RCHOP 34.78%. On examination of blood cultures in patients on admission, obtained growth of germs as much as 13,04%, include Streptococcus viridans 66.67% that still sensitive to cephalosporins 3rd generation.

Conclusions. 23 cases of febrile neutropenia were found with a mortality rate of 43.48% with the cause of death was septic shock.

Keywords. Febrile neutropenia, demographic and clinical characteristics, mortality

860

PO 395Osler-Rendu-Weber disease: A cause of repeated haemorrhage

Authors: Inês Ferraz de Oliveira, Joana Urzal, Iuri Correia, Fernando Aldomiro

Introduction: Osler-Rendu-Weber disease (ORWD), also known as hereditary haemorrhagic telangiectasia, is a rare dominant autosomal disorder that leads to multiple angiodysplastic lesions, with a high risk of haemorrhagic disorders. The most common presentation is epistaxis followed by digestive tube haemorrhage.

Diagnosis is based on presence of three out of four criteria: epistaxis, telangiectasia, visceral lesion and family history of the first degree.

Case Report: The authors present the case of a 90-year-old female patient with previous history of multiple myeloma, hypothyroidism, cyanocobalamin allergy and previous episodes of lower digestive haemorrhage due to an angiodysplasa of the ascending colon. She presented to the emergency room with abundant epistaxis and hematemesis. At physical examination there were no significant alterations beyond pale skin and mucosa with telangiectasia on the ventral face of the tongue. Blood analysis showed haemoglobin of 4,8 g/dL and upper digestive endoscopy showed no signs of recent bleeding. Epistaxis was controlled with an anterior and posterior nasal tamponade and anaemia with multiple transfusions. In the presence of diagnosed colon angiodysplasia, epistaxis and tongue angiodysplasia, the diagnosis of ORWD was admitted. There was no history of ORWD or haemorrhagic episodes amongst first-degree family members. Due to the patient’s medical history and functional status, a possible colectomy was contraindicated, and so it was decided not to continue the diagnostic study, namely, genetic tests and digestive endoscopic exams, which would be important if surgical treatment was a possibility.

Conclusion: With this case the authors highlight the importance of Osler-Rendu-Weber disease as rare cause of multiple haemorrhagic episodes. Despite few therapeutic options this diagnosis may imply surgical procedures when there are multiple haemorrhagic angiodysplastic lesions.

861

PO 396RELATIONSHIP BETWEEN THE DEGREE OF SEVERITYWITH THE FORMATION OF INHIBITORS IN PATIENTS WITH HEMOPHILIA A IN HAJI ADAM MALIK GENERAL HOSPITAL MEDAN

Rehulina Br Tarigan, Savita Handayani, Dairion GatotHematology & Medical Oncology Division of Internal Medicine DepartmentMedical Faculty of University of Sumatera Utara Haji Adam Malik General Hospital Medan – Indonesia

Background: Hemophilia is a bleeding disorder caused by a deficiency of blood clotting factors who inherited X-linked recessive. Hemophilia patients with inhibitor potentially life-threatening because the treatment becomes more difficult and expensive. Incidence of inhibitor in hemophilia A, 5-15% in mild to moderate hemophilia, and 10-50% (generally 20-30%) in severe hemophilia. Examination conducted by the Bethesda inhibitor Inhibitor Assay (BIA).

Aim: To determine the relationship between the degree of severity with the formation of inhibitors in patients with hemophilia A.

Methods: The observational study with cross sectional design to the 22 subjects patients with hemophilia A who measured the levels of factor VIII to determine the severity of hemophilia and associated with the formed of inhibitors.

Results: 22 subjects of research showed a mean age average of 28.68 years, 13 subjects (59.1%) had a family history of hemophilia, 5 subjects (22.7%) had a family history of inhibitor. Based on the severity, 17 (77.3%) subjects were moderate with the level of inhibitors average 3.04 BU. There was a significant correlation between the degree of severity with the formation of inhibitors (p = 0.004; p <0.05). However, in this study did not find significant differences in titer inhibitors based on the degree of severity of hemophilia (p = 0.284) and the mean of level of inhibitor was not difference based on the degree of severity of hemophilia (p = 0.068) and was not found a significant correlation between the severity of hemophilia and the levels of inhibitor (r = 0.097).

Conclusion: There was a significant correlation between the degree of severity of the formation of inhibitors in patients with hemophilia A, but was not found a significant correlation between the severity of hemophilia and the levels of inhibitor.

Keywords : Hemophilia A, FVIII Inhibitors.

862

PO 397RET- HE AS AN EARLY MARKER FOR TREATMENT RESPON IN PATIENT WITH IRON DEFICIENCY ANEMIAKetut Suega, I Made Bakta, I Wayan Losen Adnyana, Arundina SanyotoHematology-Medical Oncology DivisionUdayana Medical School/Sanglah Hospital Denpasar Bali

Introduction: Iron therapy generally relieves fatigue and weakness within the first week, but reticulocytosis does not occur until 7–10 days after therapy begins. No elevation is seen in the HB until 3 weeks. Aim of this study is to compared several markers for iron treatment respon in patient with IDA.

Methode: Patient with anemia were consecutively recruited. In all patients, iron laboratoty evaluation were performed. Iron deficiency anemia were diagnosed and oral iron were given for 4 weeks and every week marker for treatment respon were evaluated. Incremental for each marker were analysed and p < 0.005 was accepted.

Results; There were 87 patient with anemia consisted of 41 male (47.1%) and 46 female (52.9%), where 26 IDA patients. Before treatment level of each marker such as Ret-He , reticulocyte, HB, HCT and MVC were 18.16 pg ( SD 4.43), 0.67 (SD 3.02), 7.94 g/dl (0.74), 26.5 % (SD 2.48), 64.9 fl (SD 0.51) respectively. On weekly evaluation of first week to fourth week all 5 markers were steadily increased except for absolut reticulocyte level. On repeated measured analysis showed that there were statistically significant differences (p < 0.05) within and between markers. However on visual graph can be seen that increament of Ret-He overwhelmed other markers.

Discussion: Marrow erythropoietic activity as a response of iron therapy by measuring mature erythrocyte indices are not very reliable indicator of early deficiency erythropoiesis because of long life-span of erythrocyte (+ 120 day). Area under curve of MCV, MCH, RDW and transferrin saturation were between 0.62-0.77 when compared to bone marrow iron indicator as golden standard. Ret-He is the test to determine iorn availability for hemoglobin production and in addition Ret-He is usefull tool for monitoring patient responses to iron replacement therapy. This reticulucyte indices have prove to be sensitive indicator for early iron defficiency erythropoiesis due to short life-span of 2-3 days. In this study Ret-He significantly evidence as an early marker in responding to iron therapy and showed steadily increased starting on first week through fourth week compared to reticulocyte level which was increased on first week but slowly downward week later due to reticolcyte maturation index would shortened when erythropoietic stresed is subside.

Conclusion: Ret-He can be used as an immediate marker for iron treatment response in patient with iron deficiency anemia.

Key words : iron therapy,Ret-He, respon markers

863

PO 398A 63 YEAR OLD WOMAN WITH PORTAL VEIN THROMBOSIS ET CAUSA MYELOPROLIFERATIVE NEOPLASMS

Budi Setiawan, Catharina Suharti Division of Hematology and Medical Oncology Department of Internal Medicine, Faculty of Medicine Diponegoro University/Kariadi Hospital Semarang Indonesia

INTRODUCTION: Portal vein thrombosis (PVT) is an important cause of non-cirrhotic portal hypertension throughout the globe. The aetiology of PVT is heterogeneous and both local and systemic risk factors can be involved.

CASE REPORT: A 63 year old woman who presented to hospital with complaints of abdominal distended since 6 month before presented to the hospital. She was stable haemodynamically with heart rate of 100x/minute, blood pressure 120/80 mmHg and normal core temperature. Abdominal examination showed a distended abdomen, spleen was palpable schuffner 2, there was a positive shifting dullness.

The initial laboratory investigation showed haemoglobin 10.9 gm/dl, white blood cell count 8000/ul, platelet count 315000/ul. Differential count showed basophils 0%, eosinophils 0%, bands neutrophils 0%, segmented neutrophils 90%, lymphocytes 6%, monocytes 2%, erytroblast 1%, myelocytes 2%. D Dimer was 7489 ng/ml. Platelet aggregation test showed hyperaggregation. JAK2 V617F mutation analysis found mutations in the gene JAK2 V617F.

Abdominal ultrasound examination showed hepatosplenomegaly with ascites and varices of the splenic vein. The MSCT scan examination of the abdomen showed hepatosplenomegaly with portal vein dilation and tortuousity splenic vein which ascites and portal hypertension. The MSCT portography findings were hepatosplenomegaly with portal vein dilation, dilation and tortuousity splenic vein and portal vein thrombus. Gastroscopy examination revealed grade 1-2 esophageal varices. She was started on therapeutic with enoxaparin 60 mg bid.

CONCLUSION: Myeloproliferative neoplasms (MPNs) and prothrombotic genetic defects are the major systemic risk factors for PVT. MPNs account for up to a quarter of cases and PVT is a common presenting manifestation of MPN. Therefore all PVT patients should be assessed for the JAK2 V617F mutation.

Keyword : Portal Vein Thrombosis, Myeloproliperative neoplasms

864

PO 399Follicular thyroid cancer presentation as a lumbar metastasis

The thyroid cancer is the most common endocrine malignancy, and the most common presentation is an asymptomatic thyroid mass or nodule that can be felt in the neck. Metastasis are still rare and are due to angioinvasion and hematogenous spread. At diagnosis, only 10-15% of patients have distant metastases to bone and lung and initially are evaluated for pulmonary or osteoarticular symptoms. A clear distinction between benign and malignant disease based solely on cytological examination of a needle biopsy specimen may be difficult, requiring surgical procedure. Pathological examination showing capsular or vascular invasion may be required for this determination. Usually, signs of hyperthyroidism or hypothyroidism are not observed.

We present a 66 years old white female, that came complaining of lumbar pain in the last 6 months, after a fall, without neurologic compression symptoms. X Ray showed D12 pathologic fracture. Extended investigation was performed and a follicular thyroid cancer was diagnosed by both vertebral and thyroid biopsy.

She had a thyroid nodule under investigation for 2 years, diagnosed by fine needle aspiration biopsy as an indeterminate follicular lesion.

Luckly, in contrast to other cancers, thyroid cancer is almost always curable. In fact, most follicular thyroid cancers are slow growing and are associated with a very favorable prognosis as in this particular case.

865

PO 400Acute Myocardial Infarct in Acute Myeloid Leukemia: a Case Report

Annisa Puspitasari Nachrowi1, Reza Yogaswara1, Aulia Rizka21Department of Internal Medicine, Faculty of Medicine, University of Indonesia2Geriatric Division, Department of Internal Medicine, Faculty of Medicine, University of Indonesia

Acute myocardial infarct (AMI) and acute myeloid leukemia (AML), rarely found concurrently. The treatment of AMI in AML patients is problematic because of the thrombositopenic nature of leukemia, along with platelet dysfunction and systemic coagulopathy that may increase bleeding risk with the admission of thrombolytic agents. However, extreme leukocytosis that can be seen in AML is known to increase the risk of AMI and may be the initial presentation of acute leukemia, although very rare. In our case, a 57 years old man came into practice with severe headache and was later found to have acute leukemia. His vital sign was stable but he was pale. His blood tests showed anemia, thrombocytopenia, and leukocytosis (324,000/uL) with elevated blasts percentage (86%). His bone marrow puncture was suggestive of AML. During hospitalization, he had a typical chest pain accompanied with depressed ST segment in lead V3-V6 and elevated cardiac enzymes. He was treated with cytoreduction agents and symptomatic agents for his chest pain. There were debates about whether antiplatelets and anticoagulation should be given in this patient. The ST depression was resolved on the next day.

Keywords: acute myocardial infarction, acute myeloid leukemia, acute leukemia, acute myelogenous leukemia

866

PO 401LYMPHOCYTE AND INCIDENT OF INFECTIONS IN GERIATRIC PATIENTS IN INTERNAL MEDICINE WARD AT UKI GENERAL HOSPITAL JAKARTA

Hildebrand Hanoch Victor, Welly Salutondok, Department of Internal Medicine, Faculty of Medicine, Universitas Kristen Indonesia

Background: Lymphopenia, is the condition of having an abnormally low level of lymphocytes in the blood. Lymphocytes are a white blood cell with important functions in the immune system. Age-related immune impairment may be one of the factors influencing successful and pathological aging, being strongly tied to nutritional status. Several long term cohort studies suggest that a lower total lymphocyte count is associated with higher mortality. Nevertheless, prevalence, incidence and impact of lymphopenia on frailty and prediction of pathological events have not been described extensively. The principal aim of this study was to reveal patients lymphocyte and incident of infections in geriatric patients at UKI hospital. To evaluate lymphocyte and incident of infections in geriatric patients in internal medicine ward at UKI general hospital Jakarta.

Methods: A retrospective study of geriatric patients hospitalized from January until December 2014 was carried out in UKI general hospital internal medicine ward. Clinical and laboratory data were collected. All patients aged 60 or older admitted in the unit about 1 year were eligible for inclusion. A lymphocyte count was obtained within 48 hours after admission. Patients were classified based on clinical diagnosis and treatment history.

Results: 594 patients were included and revealed 404 patients with lymphopenia about 68 %. Mean age (SD) was 67.04(5.50) years, 307(51.7%) patients were men. From our data revealed that infection had significantly the most lymphopenia patients about 26% (105 patients) from 157 geriatric patients with infection problems. The most common infection problems was pneumonia about 51.4% (54 patients); and followed by urinary tract infection 31.4% (33 patients), ulcus decubitus 12.4% (13 patients), and diabetic foot 4.8% (5 patients).

Conclusion: Our finding suggest that lymphopenia is very common in acutely admitted geriatric patients and is associated with aging and disease. Our study showed lymphopenia was 404 patients (about 68%) from 594 geriatric patients and found that our geriatric patients with lymphopenia had infection about 26 % (105 patients), with the most common infection problems was pneumonia about 51.4 % (54 patients).

Keywords: Lymphocyte, Geriatric, Infection, UKI General Hospital

867

PO 402INTERDISCIPLINARY APPROACH THROUGH COMPREHENSIVE GERIATRIC ASSESSMENT IN MANAGEMENT ELDERLY PATIENT WITH SYSTEMIC SCLEROSIS

Roza Mulyana1, Rose Dinda Martini2, Arya Govinda1 1 Division of Geriatrics, Department of Internal Medicine, University of Indonesia, 2 Division of Geriatrics, Department of Internal Medicine, Andalas University

Systemic sclerosis is a chronic multisystem disorder of unknown etiology, characterized by the presence of cutaneous sclerosis in more than one area and supported by the presence of internal organ involvement such as esophagus, gastrointestinal tract, lung, heart, and kidney.

A 60 years old female patient came to dr. M. Djamil Padang Hospital with shortness of breath increasing since 1 week before. Shortness of breath had been suffering since last several years. The patient had difficulty to open her mouth and suffered dysphagia that caused weight loss about 25 kg during 3 years. Body mass index was 17.6 k/m2 and mini nutritional assessment score was less than 17. There were difficulties in daily activities because of extremities stiffness. Thorax CT revealed pulmonary fibrosis. Modified Rodnan Skin Score (MRSS) was 40, and Anti-Scl-70 antibody was +++. Her diagnosis was systemic sclerosis include both pulmonary fibrosis and malnutrition.

This is a case about systemic sclerosis in elderly. Comprehensive geriatric assessment through interdisciplinary approach resulted in better condition. Improvement of breath and better functional status were achieved with breathing exercise, range of motion exercise and other type of exercise that suggested by physical medicine and rehabilitation specialist. Patient also had better nutrition status after hospitalization due to improvement of mouth opening and better swallowing condition under the supervision of nutritionist, in addition to pharmacologic therapy.

Key words: systemic sclerosis, elderly, comprehensive geriatric assessment

868

PO 403PREVALENCE AND CLINICAL PROFILE OF URINARY TRACT INFECTION IN HOSPITALIZED ELDERLY PATIENTS AT ACUTE GERIATRIC WARD

Rensa, Noto Dwimartutie

Geriatric Division, Department of Internal Medicine, Faculty of Medicine, University of Indonesia-Cipto Mangunkusumo Hospital

Background. Urinary tract infection (UTI) is one of the most burdensome infections in the older population. Diagnosis of UTI in elderly patients can be difficult because of the non-specificity and frequently misleading symptoms and signs. The aim of this study is to determine prevalence and clinical profile of urinary tract infection in hospitalized elderly patients at Acute Geriatric Ward.

Methods. A retrospective study in patients aged 60 years and over, admitted to Acute Geriatric Ward-Cipto Mangunkusumo Hospital during January 1st until December 31st, 2015, was conducted using medical records, which comprised clinical history taking, physical and laboratory examination of UTI patients.

Results. Of 544 elderly patients, 51 patients (9.4%) were diagnosed with UTI, mean of age was 73.8 years-old and predominantly women (58%). Most of the clinical signs and symptoms revealed loss of appetite (78.4%), delirium (60.8%), fever (58.8%), dysuria (35.3%), frequency (19.6%). Indwelling urinary catheter were inserted in 43 cases (86.3%). Sepsis was found in 28 cases (54.9%). Another clinical conditions which were related to UTI include renal impairment (76.5%), immobility (72.5%), urinary incontinence (70.6%), cognitive impairment/dementia (70.6%), cerebrovascular-disease/stroke (66.7%), malnutrition (64.7%), and depression (47.1%). Laboratory test showed positive results for urinary leucocyte-esterase (92.2%), leucocytosis (74.5%), bacteriuria (64.7%) and positive results for urinary nitrite (56.9%). Microorganisms isolated from urine cultures were Enterococcus faecalis (15.7%), Eschericia coli (11.8%) and Klebsiella pneumonia (7.8%) and the rest were Pseudomonas aeruginosa, Staphylococcus epidermidis, and Acinetobacter lwofii (3.9%, consecutively). These isolates mentioned sensitivity to Fosfomycin and Meropenem (33.3%, consecutively), Nitrofurantoin (25.4%), and Tigecycline (19.6%).

Conclusion. The prevalence of UTI in hospitalized elderly patients at Acute Geriatric Ward was 9.4%. Loss-of-appetite and renal impairment were the most common clinical condition signified UTI, with Enterococcus faecalis found to be the most prevalent microorganism in urinary culture isolates.

Keywords: Prevalence, clinical profile, urinary tract infection, hospitalized elderly patient

869

PO 404THE EFFORTS OF IMPROVEMENT HOLISTIC SERVICES UTILIZATION GERIATRIC UNIT OF INTEGRATED SERVICE SANGLAH HOSPITAL DENPASAR INDONESIA

Study Effect of Differentiation toward Public Patient Visits (Customer Demand)*RA Tuty Kuswardhani, *S Supriyanto, *Windhu Purnomo*Geriatric Division of Medical Faculty of Udayana University /Sanglah Hospital*Lecturer of Public Health Faculty of Airlangga University

Background:The increase of aging population has been anticipated in Bali by their health specialty elderly services. Geriatric Unit of Sanglah Hospital would require a learning process for growing health industry environment. A comprehensive marketing to all customers need to do a review of the differentiation as one of the essence in marketing. This study was to analyze the effect of content, context process and infrastructure differentiation in Geriatric Unit of Sanglah Hospital (outpatient) as the most dominant variable relationship with the patient visits (customer demand). All the Patient are without disorder of cognitive and mental.

Method: This is an analytic cross-sectional study. Elderly patients are aged 60 years and older. Samples were 120 people, is determined by the cluster random sampling. Examine tools is a validity and reliability questionnaire. Statistical analysis used form and discriminant analysis with SPSS 16. The examination of cognitive with MMSE and the mental test with Geriatric Depression Scale.

Result: The results of the discriminant analysis is known as value of Standardized Canonical Discriminant Function Coefficients of variable content differentiation, context process differentiation, infrastructure differentiation are 0,569; 0,128; and 0,818. The significance of the F test each variable is smaller than alpha of 0.05 (5%).

Conclusion: A significant difference between content, context process, and infrastructure differentiation in outpatient visits Sanglah Hospital (customer demand). Variable differentiation that provides contribution and most dominant influence in relation to the general patient visits is infrastructure differentiation followed by the variable content differentiation and context process differentiation.

870

PO 405CORRELATION BETWEEN INSOMNIA AND DEPRESSION IN ELDERLY PATIENTS IN SANGLAH HOSPITAL, BALI: A CROSS-SECTIONAL STUDY

N Astika, R PurnamiGeriatric Division of Internal Medicine Department,Udayana School of Medicine/ Sanglah HospitalBali, Indonesia

Abstract

Background: Depression is less prevalent among older adults than among younger adults but can have serious consequences. Insomnia is an often overlooked risk factor for late life depression.

The aim of this study is to evaluate whether insomnia has correlation with depression in elderly patient at Sanglah Hospital on July 2015 until December 2015.

Methods: A cross sectional study was carried out from July 2015 to December 2015 at Sanglah hospital, with primary data from 139 medical records consecutively included in the study. Screening data of insomnia and depression was collect by using data from medical record.

Results: As basic characteristics from geriatric patients (age ≥60 yo) that hospitalized in Sanglah hospital during July 2015 until December 2015, we found that: there are 64 males (46%) and 75 females (54%) included in this study. Based on age, we divided into 3 groups: 60-70 yo (44,6%), 71-80 yo (33,1%), only 22,3% samples more than 80 yo. We found that there are 42 patients (30,2%) with depression, and 97 (69,8%) without depression. In screening of insomnia, we found 38 patients (27,3%) with insomnia, and 101 (72,7%) patients without insomnia. We analyzed data using Lambda correlation test and found that there are significant correlation (p = 0,000) between insomnia and depression in elderly patients with r = 0,619.

Conclusions: There are significant correlation between insomnia and depression in elderly patients. Insomnia is one of modifiable factor that increases the risk of depression in elderly patients. We should perform next study to know others factors that also give a great impact to depression in elderly patient.

Keywords: Insomnia, Depression, Elderly.

871

PO 406CORRELATION BETWEEN INSOMNIA AND DEPRESSION IN ELDERLY PATIENTS IN SANGLAH HOSPITAL, BALI: A CROSS-SECTIONAL STUDY

N Astika, R PurnamiGeriatric Division of Internal Medicine Department,Udayana School of Medicine/ Sanglah HospitalBali, Indonesia

Background: Depression is less prevalent among older adults than among younger adults but can have serious consequences. Insomnia is an often overlooked risk factor for late life depression.

The aim of this study is to evaluate whether insomnia has correlation with depression in elderly patient at Sanglah Hospital on July 2015 until December 2015.

Methods: A cross sectional study was carried out from July 2015 to December 2015 at Sanglah hospital, with primary data from 139 medical records consecutively included in the study. Screening data of insomnia and depression was collect by using data from medical record.

Results: As basic characteristics from geriatric patients (age ≥60 yo) that hospitalized in Sanglah hospital during July 2015 until December 2015, we found that: there are 64 males (46%) and 75 females (54%) included in this study. Based on age, we divided into 3 groups: 60-70 yo (44,6%), 71-80 yo (33,1%), only 22,3% samples more than 80 yo. We found that there are 42 patients (30,2%) with depression, and 97 (69,8%) without depression. In screening of insomnia, we found 38 patients (27,3%) with insomnia, and 101 (72,7%) patients without insomnia. We analyzed data using Lambda correlation test and found that there are significant correlation (p = 0,000) between insomnia and depression in elderly patients with r = 0,619.

Conclusions: There are significant correlation between insomnia and depression in elderly patients. Insomnia is one of modifiable factor that increases the risk of depression in elderly patients. We should perform next study to know others factors that also give a great impact to depression in elderly patient.

Keywords: Insomnia, Depression, Elderly.

872

PO 407ALBUMIN LEVEL AS INDEPENDENT PREDICTOR FACTOR IN DETERMINE LENGTH OF HOSPITALIZATION IN GERIATRIC PATIENTS

Ni Wayan Meindra Wirtayani, IGP Suka Aryana, RA Tuty Kuswardhani

Department of Internal Medicine, Faculty of Medicine, University of Udayana/Sanglah General Hospital, Denpasar

ABSTRACT

Background: There is a high prevalence of malnutrition in geriatric patients who are hospitalization. Albumin as a part of marker for malnutrition condition, said to increase morbidity and mortality in geriatric patients. This study aimed to determine the relationship between albumin levels with lenght of hospitalization in geriatric patients.

Method: The subjects in this study is 60 years old patients or older who are hospitalization because of a variety of medical ilness. Albumin levels checked when the patient admitted to hospital then followed and recorded about the length of hospitalization.

Results: A total of 64 samples were included in this study. There is a significant strong negative correlation between albumin levels and length of hospitalization (r = -0.676, p<0.001). By entering the age, sex, haemoglobin, hematocrit, thrombocyte, sodium, potassium, and creatinin level in the multivariate linear regression analysis, albumin levels still significantly correlated with length of hospitalization (r = -0.609, p <0.001).

Conclusion: The conclusion of this study was the albumin level are independently correlated with lenght of hospitalization in geriatric patients

Keywords: albumin levels, length of hospitalization, independent predictor factor, geriatric patients.

873

PO 408CORRELATION OF ALBUMIN SERUM AND FUNCTIONAL STATUS AMONG ELDERLY PATIENTS IN SANGLAH HOSPITAL DENPASAR BALI INDONESIA

ABSTRACT

Background and Objective: Functional status is the ability to perform daily activities and a key aspect of the quality of life and also a strong predictor of survival. In the other hand low albumin level is the result of the combined effects of inflammation and malnutrition in elderly. This study aims to determine whether there is a correlation between serum albumin levels with functional status in elderly patient in hospital.

Method: This study was designed with cross-sectional method using the analytical observational was conducted with purposive sampling. Subject is elderly patients (≥60 years) admitted to Sanglah hospital Denpasar, Bali, Indonesia, between November 2014-February 2015 (n=72). Serum albumin level was examined in the laboratory used bromcresol green method and functional status was measured with activities of daily living (ADL) Barthel questionnaire. Nonparametric spearmen’s test was used to analyze the correlation between serum albumin with functional status and data were presented with 95% confidence interval.

Result: 72 samples were obtained in the study with a mean albumin level of 2.99 ± 0.72 g/dl. The prevalence of hypoalbuminemia (<3.5 g/dl) was 75% and 46.2% with total dependency. Positive correlation Spearmen’s test was statistically significant between albumin serum and functional status (r=-0.254; p=0.031).

Conclusion: Albumin has positive correlation with functional status among elderly patients.

Keywords: albumin, functional status, ADL, elderly patients.

874

PO 409CORRELATIONS OF BODY MASS INDEX AND PLASMA ALBUMIN WITH INFECTION IN GERIATRIC POPULATION

I Made Wisnu Wardhana1, R.A. Tuty Kuswardhani2

1. Department of Internal Medicine of Sanglah Hospital, Udayana University Denpasar

2. Department of Internal Medicine of Sanglah Hospital, Geriatric and gerontology division, Udayana University Denpasar

Abstract

Background: Geriatric population more prone to infection. There still unclear about the correlation of body mass index (BMI) and hypoalbuminemia in geriatric patient as a risk factor for infectious disease. This research aimed to resolve this problem by finding correlation between BMI and plasma albumin level with infection in geriatric patient.

Methods: An analysis of 36 cases of geriatric patient was done in Sanglah general hospital Denpasar.. Low and normal BMIs were defined as <18.5 kg/m2and ≥18.5 kg/m2, respectively. Hypoalbuminemia was defined as plasma albumin < 3.5 g/dL. Correlations coefficient were calculated to compare between this groups.

Results: Among this 36 eligible geriatric patients, there is 20 patient with infection ranging from urinary tract infection to pulmonary infection and 16 patient without infection. 22 of this population are male, and 14 of them is female. There is 23 geriatric patient with hypoalbuminemia and 13 patient with normal plasma albumin level, also 23 patient with normal BMI and 13 patients with low BMI. From analyses we find that there is a correlation between BMI and infection with Lambda correlation coefficient 0.43, we also find that hypoalbuminemia correlated with infection with Lambda correlation coefficient 0.43, among that we also find that BMI correlated with plasma albumin albumin level with Lambda Correlation coefficient 0.23.

Conclusion: Low BMI have moderate significant correlation with infection, hypoalbuminemia also have moderate significant correlation with infection, also there a weak correlation between BMI with plasma albumin level. Correcting these problem may reduced the risk of infection.

875

PO 410CORRELATION OF ALBUMIN SERUM AND INTERLEUKIN-6 (IL-6) SERUM AMONG ELDERLY PATIENTS IN RSUP SANGLAH DENPASAR BALI INDONESIA

Ni Made Darma Patni Sri Rejeki1, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

ABSTRACT

Background and Objective: Albumin is a protein in the blood that is necessary for wound healing and if the lack of protein can inhibit wound healing. In addition, increased demand for protein when the injury required for the process of inflammation, immunity, and the development of granulation tissue. During inflammation, cytokines will increase, especially IL-6 is responsible for the production of acute phase proteins. This resulted in increased cytokine, drawn albumin from the intravascular to the liver and circulates until the inflammatory process is completed. The objective of this study was to study the correlations of albumin and IL-6 among elderly patients.

Method: Cross-sectional design using the analytical observational was conducted with purposive sampling. Subject is elderly patients (≥60 years) admitted to RSUP Sanglah Denpasar, Bali, Indonesia, between November 2014-February 2015 (n=72). Serum albumin level was examined in the laboratory using bromcresol green method and serum IL-6 assessed using Human Interleukin 6 Immunoassay (Quantikine) kit. Statistical test using nonparametric spearmen’s test (SPSS 16.0).

Result: There was significant correlation between albumin serum and IL-6 serum (r=-0.305; p=0.009).

Conclusion: Albumin has negative correlation with IL-6 among elderly patients.

Keywords: albumin, IL-6, inflamation, elderly patients.

876

PO 411CORRELATION BETWEEN DELERIUM WITH ALBUMIN SERUM AMONG ELDERLEY IN SANGLAH HOSPITAL DENPASAR 2015

Putu Dhenny Wahyu W1, RA TutyKuswardhani,2 2Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

Backgraund : Delirium is a serius and severe condition that occurs in elderly patients who have hospitalized. Delirium is often not recognized, where the doctor in the emergency department estimated missed diagnosis of delirium in 76% of cases. Chronic conditions such as chronic inflammation or infection is a common trigers of delerium in elderly. Cronik inflamation increased use of amino acids to create pro-inflammatory cytokines, and suppression of albumin synthesis. This condition also exacerbated by the decline in appetite, so the intake of proteins as raw materials albumin is also reduced. Based on this, we estimated delirium have associated with levels of albumin serum in elderly

Objective : this study is objected to evaluate the albumin serum and their correlation with delirium status of the elderly people that stay in health care unit in Sanglah Hospital using the instrument of Memorial Delirium Assesment Scale (MADS). and examination of the level albumin standarized

Method : this study use cross sectional analytic design. The sample are taken from Sanglah Hospital from november 2014 until february 2015. The sample are structurally interviewed (demographic and MADS quisioner), and the examination of the level of albumin serum (by Bromcresol Green method). Statistical test using spearman correlation test (SPSS 16.0).

Result : Seventy two elderly in Sanglah Hospital Denpasar Bali Indonesia (age [60-85]) year were included, with a score of Delirium by MADS criteria varies between 13 to 24 and albumin levels between 1.74 to 5.44. The association between delirium and albumin level was found significant (r= - 0,248 p=0.036).

Conclusion : Delirium is correlated with albumin level in elderly in Sanglah Hospital Denpasar

Key word : elderly, delirium, albumin, MADS

877

PO 412ASSOCIATION BETWEEN DELIRIUM STATUS AND ANEMIA IN ELDERLY PATIENTS HOSPITALIZED AT GERIATRIC WARD SANGLAH GENERAL HOSPITAL

Shelvy Florence Gousario1, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

Background: Delirium is common, occurs in 20% to 79% of hospitalized older patients. It has been associated with increased health care costs, long-term cognition deficits, and increase mortality. Anemia has been noted as one of predisposing factors for delirium. Elderly patients with many risk factors will be vulnerable to a low level precipitating insult, whereas those without risk factors may only become delirious after a high level insult. The objective of this study was to find association between delirium status and anemia among elderly patients.

Method: cross-sectional design using analytic observational was conducted with purposive sampling. Total subject of this study was one hundred and sixteen elderly patients, taken at geriatric ward Sanglah general hospital from January to May 2016. Delirium status was screened using Confusion Assessment Method (CAM), and anemia was defined as level of serum hemoglobin < 10 g/dL. Statistical analysis used was chi square comparative test .

Result: One hundred and sixteen elderly patients age 60 to 95 years old with mean 72.16 + 8.179 were included. The prevalence of delirium and anemia were 28 (24.1%) and 40 (34.5%) respectively. We found significant association between delirium status and anemia (p= 0.034).

Conclusion: there was significant association between delirium status and anemia among elderly patients at geriatric ward Sanglah general hospital.

Keywords: Delirium, anemia, elderly

878

PO 413INCREASING LEVELS OF S100β and INTERLEUKIN-6 SERUM CORRELATE WITH DELIRIUM SEVERITY IN GERIATRIC PATIENTS THAT ADMITTED IN SANGLAH HOSPITAL, BALI

Yosef S Sugi1, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

Background: Delirium is a complex neuropsychiatric syndrome with acute onset and fluctuating. Patients who experienced delirium, when compared with patients who did not experience delirium, have longer hospital stay. S100β is a calcium-binding protein secreted by astrocytes under the influence of metabolic stress conditions and a biomarker that indicates damage of the central nervous system. While increased levels of IL-6 (a marker of neuroinflamasi) associated with risk of delirium.

Methods: The study design was cross-sectional analytical study on the correlation between levels of S100β and levels of interleukin-6 with severity of delirium. Delirium severity was measured using a Memorial Delirium Assesment Scale (MDAS) questionnaire. Levels of S100β and IL-6 will be measured using the ELISA.

Results: The study involved 72 study subjects, 38 males (52.8%) and 34 women (47.25%). The mean age of subjects was 68 ± 6.96. Median S100B 5520 pg / ml (950.87 to 7741.89 pg / ml). Median IL-6 63.58 pg / ml (1.03 to 376.80 pg / ml). Median MDAS 17 (13-24). In this study, there is no correlation between levels of S100B with severity of delirium (r = -0.051, p = 0.673). However, there is correlation between levels of IL-6 and Charlson’s age-comorbidity index (CACI) with the severity of delirium (r = 0.162, p = 0.173; r = 0,473, p = 0,000).

Conclusions: In this study, there is no correlation between levels of S100B with severity of delirium. But levels of IL-6 and CACI have correlation with the severity of delirium.

Key word: S100β, IL-6, Delirium, Geriatric

879

PO 414MicroRNA profile analysis in patients who later suffered a stroke versus controls in an elderly Mediterranean populationOrtega-Azorín C1,2, Sorlí JV1,2, Godoy D3, Carrasco P1,2, Barragán R1,2, Férriz E1,2, Portolés O1,2, Corella D1,2

1Department of Preventive Medicine and Public Health. School of Medicine. University of Valencia. Spain2CIBER-OBN (Center of Biomedical Research Network Obesity and Nutrition). Carlos III Health Institute, Spain3Department of Internal Medicine, University General Hospital of Valencia. Spain

Background: Cardiovascular diseases are a leading cause of death, stroke being the second most common cause of mortality world¬wide. Stroke can affect an individual’s physical and mental capacity and is most common in post 55-year-olds, its risk increasing with age. Recent studies show the important role played by microRNAs (miRNA) in regulating gene expression in the cardiovascular system. The aim of our pilot study was to determine differences between microRNA expression with participants who later suffered a stroke versus controls in an elderly Mediterranean population.

Methods: We studied subjects with high cardiovascular risk (average age: 67±6 years) from the PREDIMED (PREvención Dieta MEDiterránea) study, recruited in Valencia. Anthropometric and clinical data were obtained and plasma microRNAs were isolated in a subsample for the pilot study of microRNA analysis. Initial miRNA screening was performed using the TaqMan Low Density Array (TLDA) on 10 participants (5 later stroke-sufferers and 5 controls). Later, we individually analyzed miRNA by RT-qPCR in 52 participants (26 later stroke-sufferers) to validate TLDA results.

Results: TLDA results showed that miR-891 was constantly expressed in patients and controls, so serving as an endogenous control for individual trials. We also detected that miR-150, miR-451 and miR-222, were upregulated in patients who had later suffered a stroke compared with controls, remained at the limit of statistical significance (p=0.062;p=0.067;p=0.094, respectively). Individual analyses of these miRNAs, however, presented no statistical significance. Moreover, we detected an inverse correlation between age and two microRNAs, miR-150 (p=0.015) and miR-410 (p=0.011). After segmentation, we observed in later stroke sufferers these inverse correlations with age for miR-150 (p=0.031) and miR-410 (p=0.025), this correlation being undetected in controls.

Conclusion: This pilot study reveals changes in several microRNAs between patients who later suffered a stroke and controls in an elderly Mediterranean population, further studies being required to confirm these results.

880

PO 415PROFILE OF GERIATRIC PATIENTS HOSPITALIZED IN ACUTE GERIATRIC WARD BASED ON CIPTO MANGUNKUSUMO HOSPITAL PALLIATIVE CARE SCREENING TOOL

Shanti Pricillia, Noto DwimartutieDivision of Geriatric, Department of Internal Medicine, Faculty of MedicineUniversitas Indonesia, Cipto Mangunkusumo Hospital

Background: Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing serious illness. The profile of geriatric patients those meet the score of Cipto Mangunkusumo Hospital palliative care screening tool has not been well known. The aim of this study was to describe the proportion and the characteristic of patients hospitalized in acute geriatric ward based on Cipto Mangunkusumo Hospital palliative care screening tool.

Methods: This observational study used medical record data of hospitalized patients (age≥60 yr) from January to December 2015. The variables recorded were age, gender, education, nutritional status (Mini Nutritional Assessment), functional status, comorbidities (Charlson Comorbidity Index) and total score from the components of Cipto Mangunkusumo Hospital palliative care screening tool.

Results: There were 143 (47%) patients met criteria for palliative care. Majority of the patients were female (60%) with the most group of age was 60-65 years (53%). Most patients had cancer (56%), followed by end stage renal disease (18%) and stroke with decreased function by at least 50% (15%). Fifty one patients (36%) were having diabetes mellitus as a concomitant disease processes, followed by hypertension, liver disease and moderate renal disease (11.3%, 9.6% and 8.6%), consecutively. There were 102 (71%) subjects had grade 2 ECOG (Eastern Cooperative Oncology Group) performance status and most of patients were at risk of malnutrition (64%).

Conclusion: There were 47% patients hospitalized in geriatric acute care ward required consultation for the palliative care. Most of them were 60-65 years old and female, with the basic disease process was cancer, had moderate ECOG performance status, and at risk of malnutrition.

Keywords: palliative care, screening tool, geriatric patients

881

PO 416THE IMPACT OF ANEMIA ON COGNITIVE FUNCTION IN HOSPITALIZED ELDERLY PATIENTS

Made Nopriantha1, S Aryana2, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

Background: Anemia is a common problem with serious consequences in elderly patients but the impact of anemia on cognitive function has not been extensively studied.

Aim: To evaluate the association between anemia and cognitive impairment in hospitalized elderly patients with medical illness.

Method: This is a hospital-based analytic cross-sectional study. The data were derived from the medical records of elderly patients (age ≥60 years) admitted to Internal Medicine Department of Sanglah General Hospital between February 2013 and May 2014. A total of 134 elderly patients were enrolled in this study. Anemic status and cognitive function were defined by using WHO criteria and Mini-Mental State Examination (MMSE) questionnaires, respectively. Chi-square or Fisher-Exact test was used to test for significance between 2 proportions. The risk was estimated by using Odd Ratio (OR) and 95% Confidence Interval (CI).

Results: The overall-prevalence of anemia and cognitive impairment among hospitalized elderly patients was 66.4% and 48.5%, respectively. The prevalence of anemia did not differ significantly between male and female patients, as well as between younger (age <75 years) and older patients (age ≥75 years). Cognitive impairment was more prevalent among female (60.0% vs. 40.5%, p-value=0.026) and older patients (59.6% vs. 41.5%, p-value=0.040). After stratified for age and sex, we found no significant association between anemia and cognitive impairment.

Conclusion: There is no significant association between anemia and cognitive impairment in hospitalized elderly patients with medical illness.

Keywords: anemia, cognitive impairment, elderly

882

PO 417THE IMPACT OF DEPRESSION ON COGNITIVE FUNCTION AND FUNCTIONAL STATUS IN HOSPITALIZED ELDERLY PATIENTS: A CROSS-SECTIONAL STUDY

Godfried EY Saragih1, S Aryana2, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

Background: Depression is a common psychiatric disorder in elderly but the impact of depression on cognitive function and functional status has not been extensively studied, especially in hospitalized elderly patients with medical illnesses.

Aim: To evaluate the association between depression, cognitive function, and functional status in hospitalized elderly patients.

Method: This is a hospital-based analytic cross-sectional study. Data were derived from the medical records of elderly patients (age >60 years) admitted to Internal Medicine Department of Sanglah General Hospital between February 2013 to May 2014. A total of 152 consecutive patients were enrolled in this study. Depression status, functional status, and cognitive function were assessed using Geriatric Depression Scale (GDS), Barthel Index for Activity of Daily Living (ADL), and Mini-Mental State Examination (MMSE), respectively.

Result: The overall prevalence of depression and cognitive impairment in hospitalized elderly patients was 21.1% and 46.1%, respectively. However, the prevalence of depression did not differ significantly between male and female patients, as well as between younger (age <75 years) and older patients (age ≥75 years). The prevalence of cognitive impairment was significantly higher in female patients (59.3% vs. 37.6%, p=0.009) but the prevalence did not differ significantly between younger and older patients. After stratified for age and sex, there was a significant association between depression and cognitive impairment, but only in female patients younger than 75 years (OR 2.417, 95% CI 1.567-3.727). We did not found a significant association between depression and poorer functional status.

Conclusion: Depression is associated with cognitive impairment in hospitalized female patients younger than 75 years.

Keywords: depression, functional status, cognitive impairment, elderly.

883

PO 418The Risk Profile and Prophylaxis Use for Deep Vein Thrombosis in Elderly Patients Admitted to Internal Medicine Department of Sanglah General Hospital

I Made Bayu Indratama1, S Aryana2, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

Background: Venous thromboembolism (VTE) is a relevant complication of medical illnesses among hospitalized elderly patients. There is a compelling need to identify those at risk and administer appropriate prophylaxis to reduce the incidence of VTE.

Aim: To describe the risk profile of DVT and the use of thromboprophylaxis among elderly patients admitted to Internal Medicine Department of Sanglah General Hospital

Methods: This is a retrospective, descriptive epidemiologic study of 191 consecutive elderly patients (age ≥60 years) admitted to Internal Medicine Department of Sanglah General Hospital between February 2013 and May 2014.

Results: The prevalence of DVT was 1.04%. After excluding those with newly diagnosed DVT at admission, a substantial proportion of patients (56.6%) were at increased risk of having DVT based on individual risks assessment (IRA) on exposing and predisposing factors for DVT. By using Wells clinical prediction score for DVT probability, 10.1% patients had a high risk of having DVT. Older age (age >65 years) is the most prevalent risk factor for DVT (79.9%), followed by infection (50.8%), sepsis (13.8%), COPD (11.6%), CHF (7.4%), cancer and thrombocytosis (4.8%), and acute MI (1.1%). Only 7.5% of those who had increased risk of DVT based on IRA that also had a low risk of major bleeding (i.e., eligible for antithrombotic prophylaxis) based on RIETE Registry Bleeding Score. However, antithrombotic prophylaxis was only administered in 1.6% patients.

Conclusions: Hospitalized elderly patients with medical illnesses are at increased risk of having DVT but recommended thromboprophylaxis is still under-used. Further efforts are required to better define their risk profile and optimize the use of antithrombotic prophylaxis.

Keywords: DVT, elderly, risk, prophylaxis, Sanglah General Hospital.

884

PO 419RELATIONSHIP BETWEEN CALCITONIN SERUM LEVEL AND INCIDENCE OF FRAGILITY FRACTURES IN ELDERLY

Fandy Santoso Budiardjo*, Suyanto Hadi**, Bantar Suntoko**, Heri Nugroho**, Redjeki Andayani***Residenship in Departemen of Internal Medicine, Faculty of Medicine Diponegoro University – dr. Kariadi Hospital, Semarang, Indonesia** Departemen of Internal Medicine, Faculty of Medicine Diponegoro University – dr. Kariadi Hospital, Semarang, Indonesia

Abstract

Background. Osteoporosis is a systemic bone disease characterized by compromised bone strength which causes bones vulnerability to fracture. The diagnosis of osteoporosis is primarily based on the measurement of bone mass densitometry, but clinical diagnosis can be made in someone with several risk factors experiencing a fragility fracture. Fragility fractures are defined as fractures resulting from a fall from a standing height or less, or presenting in the absence of obvious trauma, spontaneous or low-energy trauma fracture. Fragility fractures in the elderly is a major problem in many countries including Indonesia, that cause of health and socioeconomic problems. The etiology of fragility fracture due to osteoporosis is not fully established. The role of calcitonin, whose biological and pharmacological effects include inhibition of bone resorption with diminished osteoclastic activity, remains uncertain and controversial. Reduced basal levels of calcitonin have been found in fragility fracture related osteoporosis by some investigators but not others.

Methods. The study was conducted in elderly patient who had to be over 60 years of age suffered new cases of fragility fractures within 3 month in one of location at column femoris / vertebrae / wrist / proximal humerus and radiologically confirmed ( n = 26 ). Healthy elderly without fragility fracture from same age range served as a control group ( n = 26 ).

Results. Calcitonin serum level in the elderly with fragility fractures (15,95 ± 6,66 pg / ml ) was lower when compared with elderly without fracture (18,93 ± 7,50 pg/ ml ) but no significantly difference between 2 groups (p = 0.137).

Conclution. Serum calcitonin levels in this study were not significantly depressed in a elderly with fragility fracture suggesting that calcitonin deficiency is not involved in the pathogenesis of fragility fracture related osteoporosis.

885

PO 420ELDERLY IN EMERGENCY DEPARTMENT OF INDONESIAN HOSPITAL: CHARACTERISTICS AND OUTCOME

Aulia Rizka, CH SoejonoDivision of Geriatrics, Department of Internal MedicineFaculty of Medicine Universitas Indonesia, Cipto Mangunkusumo NationalGeneral Hospitalcorrespondency to [email protected]

Background: In European and Western countries, elderly patients represent up to 12% of the overall emergency department population. Elderly patients typically present with complex medical condition leads to difficulty in diagnosis and experience increase in adverse outcomes with mortality rate reported around 7% in other countries. Currently there is no data about elderly visit to ED in Indonesian hospital.

Methods: a retrospective analysis of data extracted from ED visit database in Cipto Mangunkusumo General hospital, a national referral academic hospital in Jakarta, Indonesia was done to describe the characteristics and outcome of elderly patients visit from January to December 2015.

Results: During 2015, 3211 elderly (15% of overall patients) visited ED with mean age of 68,2 6,7 years. Of those, 1713 (53%) patients are male. The three most common diagnosis were Cerebrovascular Disease (CVD), cancer and pneumonia, followed by diabetic acute complications. In-hospital mortality rate was 23% and 28% among these group of patient died within the first 3 days since admission. Mean length of stay was 11,2 12,4 days. Sub group (n=232) with highest mortality within first three days ( 32%) was composed by those aged > 80 years.

Findings: Proportion of elderly patients visiting Indonesian ED is slightly higher than in European and Western countries. However, in hospital mortality rate is much higher due to late and severe stage of the illness at initial presentation. Our result predates the need of a more elder-friendly ED system to address special issue of care concerning this population.

886

PO 421ANTHROPOMETRY, BODY COMPOSITION AND MUSCLE FUNCTION AMONG NON-DIABETIC PRE-FRAIL GERIATRIC OUTPATIENTS

Purwita Wijaya Laksmi,* Siti Setiati*, Rahmi Istanti*

*Geriatric Division Department of Internal Medicine – Dr. Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia

Background: Aging process leads to sarcopenia that may affect physical performance and have an increased risk of disability. The objective of this study is to determine muscle function and their correlation with anthropometry and body composition.

Method: This was a cross-sectional study at tertiary hospital of non-diabetic pre-frail geriatric outpatients based on CHS and FI 40 items criteria whose age 60 years or older enrolled in RCT of effects of metformin in pre-frail elderly project from March 2015 till March 2016. Sex, age and measurement of body composition using BIA TANITA SC 330, handgrip strength (HGS) using JAMAR hydraulic hand dynamometer model J00105, 15 feet gait speed and anthropometry (BMI, triceps skin fold thickness, mid-arm, calf and waist circumference) were evaluated. Data were analyzed using Spearman correlation test.

Results: This study was conducted among 103 elderly with mean age 68.9 (5.2) years old. Almost half of the subjects (41.7%) were overweight with mean BMI 25.7 (3.8) kg/m2. In all subjects analysis, there were correlation between HGS with calf circumference (r=0.232; p=0.018), waist circumference (r=0.204; p=0.039) and gait speed (r= - 0.346; p=0.000). Among female subjects, significant correlation were found between gait speed and calf circumference (r=0.25; p=0.04) as well as between HGS and triceps skin fold thickness (r=0.29; p=0.02). No significant correlation was found between gait speed, HGS and anthropometry parameters among elderly men. In both gender, skeletal muscle mass index (SMI) and fat mass have significant correlation with all anthropometry measurements, but did not correlate with HGS and gait speed, although in all subjects analysis SMI had correlation with HGS (r=0.605; p=0.000) and gait speed (r= -0.228; p=0.021), while fat mass with HGS (r= -0,267; p=0.006).

Conclusion: This study indicates influence of gender in the correlation between gait speed and handgrip strength with anthropometry measurements and body composition.

887

PO 422DIFFERENTIATION OF VITAMIN D {25 (OH)D3} LEVELS ON FRAGILITY FRACTURES AND NON FRAGILITY FRACTURES ELDERLY

Fience Regina Dorkas*, Suyanto Hadi**, Bantar Suntoko**, Rejeki Andayani R**, Tjokorda GD Pemayun**

*Internship in Department of Internal Medicine Faculty of Medicine, Diponegoro University, Dr. Kariadi Hospital, semarang, Indonesia**Department of Internal Medicine Faculty of Medicine, diponegoro University, Dr. Kariadi Hospital, Semarang, Indonesia

ABSTRACT

Background: Vitamin D (25(OH)D3) levels deficiency in the elderly was more common due to the lack of exposure to UVB light, low food intake so easy occurrence of osteopenia and osteoporosis will increase risk of fragility fractures. The impact of this fragility fractures will cause other problems such as immobility, incontinence, decubitus ulcers, chronic pain, and recurrent fractures which will cause independence of the elderly to be reduced and ultimately lead to death.

Methods: Cross-sectional study, research subjects by 52 people consisting of 26 cases (fracture) and 26 controls (non fractures). Statistical test using differentiation test unpaired independent t-test and Man Whitney. Furthermore, the cut off point specified of vitamin D {25(OH)D3} levels in elderly fragility fractures with ROC curve.

Results: The number of patients in this study 52 people, 22 men, 30 women, with the characteristics of most age over 70 years, normoweight, and no history of immobilization. Fractures location consists of 34% femoral neck, 31% vertebral, 23% wrist, 8% multiple and 4% humerus. There was no significant association between calcium levels with fragility fractures (p = 0.352) and the glomerular filtration rate in the fractures (p = 0.898). There was a significant association between vitamin D (25(OH)D3) levels on fragility fractures and non fragility fractures elderly ( p = 0,0001). Vitamin D (25(OH)D3) levels deficiency was found in the fractures 54%, insufficiency 27% and suffisiensi 19% were non fractures deficiencies 0%, insufficiency 19%, and suffisiency 81%, with mean of 22.10 ± 12.29 ng / ml in a fractures and 43, 76 ± 14.26 ng / ml in the non-fractures . The cut off point obtained vitamin D (25(OH)D3) levels on fragility fractures elderly was 25.135 ng / ml.

Conclusion: There was a significant negative association between vitamin D (25(OH)D3) levels of fragility fractures in the elderly. There was a cut off point vitamin D (25(OH)D3) levels suffer in the fragility fractures.

Keywords: Vitamin D (25(OH)D3) levels, fragility fractures, elderly.

888

PO 423Attributes Of Geriatric Patient Admitted To The Emergency Department In 7 Days Before Eid Al-Fitr

Anita Sanjaya1, Probosuseno21 Resident of Internal Medicine at the University of Gadjah Mada/dr. Sardjito, Yogyakarta2 Consultant Geriatric Medicine, Section of Internal Medicine dr. Sardjito, Yogyakarta

Abstract

Background: Geriatrics is the branch of medicine relating to diagnosis and treatment, or sometimes just the management of conditions and disorders that occur in old age. Geriatrics is important because older adults may react to diseases and conditions differently than younger adults. Given the many problems in a geriatric then need to be handled a team of experts from various disciplines who work in interdisciplinary. In health care during the holidays Hospital with care in the emergency room to be very important which became a major milestone due to the cessation of activities of non-emergency services. Eid celebration is an important moment in a person’s bersilahturahmi so that mobility becomes very high, and it is not separated by a group of geriatrics where many who suffer from chronic diseases. So with this high mobility, enables the recurrence rate or acuteness of the disease. The second thing is then a basis for improvement of geriatric patients in the emergency department.

Objective: Provide an overview of the characteristics of geriatric patients who visit the ER dr. Sardjito for 7 days before Eid.

Methods: This study is descriptive-retrospective. Where data are taken from the book registers the hospital and later in referred or consulted the disease unit within 7 days before Eid. The data presented in the form of a percentage.

Results: There were 118 patients who consulted the Internal Medicine Unit 7 days before Eid, 5 people were excluded because of incomplete data register, so that the remaining 113 people and among them there were 46 patients (40.7%) is a geriatric patient, which further will be analyzed further in this study. From this study, patients who consulted to the Internal Medicine consists of 46 cases of geriatrics. With the distribution of pulmonary cases were 11 cases (23.91%), 7 cases of hemato-oncology (15.21%), 6 cases of endocrine (13.04%), 5 cases each with problems in the field cardiologi, gastrologi and trophic-infection (10.86%) and 1 case of psychosomatic (2.17%). A total of 40 cases (86.95%) needed further treatment with hospitalization, 4 patients (8.69%) return, and 1 patient (2.17%) died in the ER to cause respiratory failure.

889

Limitations: Recording incomplete registry book that caused kereksklusi sample and the sample size is small study.

Conclusions: Most cases of geriatric patients who come to the ER dr. Sardjito with the distribution of three consecutive clinical cases are cases of pulmonary, hemoato-oncology and endocrine systems, with as many as 86.95% of patients require inpatient treatment.

Keywords: Eid, geriatrics, emergency room, epidemiology.

890

PO 424DETERMINANT FACTOR OF CHRONIC KIDNEY DISEASE (CKD) ON ADULTS IN TENGGER BROMO MOUNTAIN AND SURABAYA COMMUNITY

Widati Fatmaningrum, Djoko Santoso, Djohar Nuswantoro, Sidarti SoehitaAirlangga University

In 2002, US National Kidney Foundation Kidney disease Outcomes Quality Initiative clinical practice guidelines, defines Chronic Kidney Disease (CKD) as kidney damage, or glomerularfiltration level is lower than 60 mL / minute per 1 • 73 m² in 3 months or more. Public health approach to do early identification CKD is needed to prevent the disease progression and diminish the risk of morbidity and cardiovascular mortality. CKD increases along with modern life style which can be found in urban areas. Hypertension, Diabetes Mellitus and obesity proven as the result of modern life style and is the important risk factor of chronic kidney disease.

This research aims to analyze the determinants of CKD such as gender, elderly, abdominal obesity, Body Mass Index (BMI), smoking habits, Diabetes Mellitus (DM), and hypertension.

The type of this research is Analytic Observational with the draft of Cross sectional to observe the association between CKD with the determinants. The population is all residents which are >18 years old in Tengger mountain area and in Surabaya. The formula to calculatethe kidney’s function is determined using the CG-BSA (Cockcroft-Gault) formula and be corrected based on the body surface area and MDRD (modification of diet in renal diseases) formula.

The amount of CKD cases discovered using CG-BSA formula is more than using the MDRD formula. There is a positive correlation between CKD using CG-BSA formula with the risk of elderly factor and Diabetes Mellitus (DM), and negative correlation with the Body Mass Index (BMI). The most dominant risk factors are elderly, followed by Diabetes Mellitus and BMI.

Key Word: Chronic Kidney Disease, determinant factor, CG-BSA and MDRD formula

891

PO 425CORRELATION BETWEEN DELIVERED KT/V WITH ALBUMIN LEVELS AND NEUTROPHILS/LYMPHOCYTES RATIO IN HEMODIALYSIS PATIENTS IN DR AGOESDJAM HOSPITAL KETAPANG WEST KALIMANTANSony Yusuf Wibisono, Bambang Djarwoto Iri Kuswadi, Heru Prasanto. Sub Division of Nephrology, Dept Of Internal Medicine Sardjito Hospital/ FK UGM

Abstract

Background. Delivered Kt/V is a marker of hemodialysis efficiency. Efficient hemodialysis will obtain good nutritional status and decrease the inflammatory process. The purpose of this study is assessing the relationship of hemodialysis efficiency with albumin as a marker of nutritional status and the neutrophil/lymphocyte (N/L) ratio as a simple marker for inflammation. Method. The Study design was cross sectional conducted in regional public hospital involving 58 regular hemodialysis patients consist of 32 (55.2%) men and 26 (44.8%) women. Chi-square test used to analyzed. Results. The results showed that 36 (62,1%) patients have delivered Kt/V <1.2. Albumin levels < 3.5 gr/dL involved 42 (72.41%) patients, and 45 (77.5%) patients had N/L ratio > 3. Chi-square test showed significant correlation between the delivered Kt/V with albumin levels (p <0.05) and N/L ratio (p <0.05). Conclusion. This study shows a correlation between the hemodialysis efficiency with nutritional status and inflammation.

Keywords: Delivered Kt/V; Nutritional status; Inflammation.

KORELASI ANTARA DELIVERED KT/V DENGAN KADAR ALBUMIN DAN RASIO NETROFIL/LIMFOSIT PADA PASIEN HEMODIALISIS DI RSUD DR AGOESDJAM KETAPANG KALIMANTAN BARATSony Yusuf Wibisono, Bambang Djarwoto Iri Kuswadi, Heru Prasanto.

Sub Bagian Nefrologi RSUP DR Sardjito / FK UGM Yogyakarta

Abstrak

Latar Belakang. Delivered Kt/V merupakan marker untuk menilai efisiensi hemodialisis. Hemodialisis yang efisien akan memperbaiki status nutrisi dan menurunkan proses inflamasi. Tujuan penelitian ini menilai hubungan efisiensi hemodialisis dengan kadar albumin sebagai marker status nutrisi dan rasio jumlah netrofl/limfosit (N/L) sebagai marker sederhana untuk inflamasi. Metode. Penelitian dilakukan di rumah sakit umum daerah terhadap pasien hemodialisis rutin. Disain penelitian cross sectional, melibatkan 58 pasien hemodialisis rutin. Analisis korelasi dengan menggunakan Chi-square. Hasil. Subyek terdiri dari 32 (55,2%) laki-laki dan 26 (44,8%) wanita. Hasilnya menunjukkan delivered Kt/V < 1.2 terdapat pada 36 (62,1%) pasien, 42 (72,41%) pasien kadar albumin < 3,5% dan 45 (77,5%) pasien nilai rasio N/L > 3. Hasil uji chi-square menunjukkan ada

892

korelasi yang bermakna antara delivered Kt/V dengan kadar albumin (p < 0,05) dan rasio N/L (p< 0,05). Kesimpulan. Penelitian ini menunjukkan adanya korelasi antara efisiensi hemodialisis dengan status nutrisi dan inflamasi.

Kata kunci : Delivered Kt/V; Status nutrisi ; Inflamasi.

893

PO 426A RARE CASE - ACUTE KIDNEY INJURY ASSOCIATED WITH SYNTHETIC CANNABINOID USE

I. CETINDAGLI1, V. OZALPER2, Y. HANCERLI3, Y. ONEM3, M. SALMANOGLU3, M. EROGLU41 Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY2 Hakkari Military Hospital, Department of Internal Medicine, Hakkari , TURKEY3 Gulhane Military Medical Faculty, Haydarpasa Training Hospital, Department of Internal Medicine, Istanbul, TURKEY4 Gulhane Military Medical Faculty, Haydarpasa Training Hospital, Department of Emergency Medicine, Istanbul, TURKEY

BACKGROUND: Spice products are recent abuse form of psychostimulants. Inspite of many psychogenic and other effects, possible nephrotoxic effects have recently been reported. We report a case of acute kidney injury (AKI) associated with the use of a synthetic cannabinoid product.

CASE: A previously healthy 21-year-old male presented to the emergency department with unresponsivenes after smoking a “bonsai”, local form of “Spice”. His vital signs was normal except bradycardia(56 bpm). His physical exam was unremarkable. His neurological status resolved within a few hours after admission. He admitted to use 4 years of heroine history and , also stated that he used this product for the first time. Admission serum chemistry panel showed the following results: bicarbonate,17.9mEq/L; urea,77mg/dl; creatinine,3.4mg/dl; creatinine kinase,2901U/L. Urinalysis showed proteinuria(+++),erythrocyturia(+++)., and leukocyturia(+++). Urine toxicology screen was negative. The renal ultrasound was unremarkable. Due to the lack of patient consent, renal biopsy couldn’t be performed. On the second day in the hospital, his creatinine and BUN peaked at 3.84mg/dL and 39mg/dL, respectively. On the fifth day, serum creatinine reduced to 1mg/dl and discharged with recommendation of following visit control.

CONCLUSION: Synthetic cannabinoids are new on the market, but also they are newer for the medical community. Due to production form variations, these product’s composition or concentration of ingredients and exposure technique may differ. The mechanism for AKI is not all clear, but acute tubular necrosis by rabdomyolisis seems most probable way for nephrotoxicity. To understand the occurrence of injury, further studies examining are needed.

894

PO 427Association of Low Birth Weight with Microalbuminuria and Hypertension in Adults

Adam Iskandar, Rully MA Roesli, Ria Bandiara, Lilik SukesiInternal Medicine Department, Faculty of Medicine, Padjadjaran University, dr. Hasan Sadikin General Hospital

ABSTRACT

Some studies indicate that there is a relationship between low birth weight (LBW) with chronic diseases in adulthood such as stroke, coronary heart disease (CHD), hypertension, microalbuminuria and type 2 diabetes mellitus. Microalbuminuria is known as an important predictor of vascular disease and renal disease in patients without diabetes. Albuminuria serves as a marker of endothelial damage and it is present in conjunction with hypertension can be used a a marker of cardiovascular risk. This study aims to analyze the relation between LBW with microalbuminuria and hypertension in young adulthood.

This study using cross sectional method. Subject of the research is the data from babies born in Tanjungsari, Sumedang starting in 1998-1990 that are currently aged 24-26 years. Blood pressure measurement and inspection of albumin creatinine ratio (ACR) were perfomed on the subject. Data were analyzed using chi square test.

This Study involved 39 subjects with low birth weight and 32 subjects with normal birth weight (NBW). The result showed that the incidence of prehypertension on LBW group (11,1%) was higher compared with NBW group (0) (p=0,083).The incidence of hypertension on NBW group (17,1 %) was higher compared with LBW group (8,3%), but the difference not statistically significant (p=0.083). The incidence of microalbuminuria on NBW group (9,38 %)also show higher result compared with the group of LBW (5,88 %)(p=0,674). The results of the study conveniently indicates that there is no significant relationship between the incidence of LBW with microalbuminuria and hypertension (p = 0.493 (p-value> 0.05).

The study concluded there was no correlation between LBW with microalbuminuria and hypertension in young adults in Tanjungsari, Sumedang, West Java.

Key Word : Low Birth Weight, Microalbuminuria, Hypertension

895

PO 428THE USE OF NICOTINAMIDE IN THE MANAGEMENT OF HYPERPHOSPHATEMIA IN PATIENTS ON HEMODIALYSISMeivina Ramadhani Pane, Abdurrahim Rasyid Lubis

Department of Internal MedicineFaculty of Medicine, University of Sumatera Utara

ABSTRACT

Background: Hyperphosphatemia remains a significant problem for patient undergoing dialysis and is an important modifiable risk factor for death. Current treatment options include dietary restriction, dialysis and phosphate binders. Nicotinamide has been shown to reduce hyperphosphatemia by inhibition of sodium-dependent phosphate co-transport in renal tubule and small intestine.

Objective: To evaluate the use of nicotinamide in reducing hyperphosphatemia in patients undergoing hemodialysis.

Methods: The clinical study was conducted in 17 undergoing regular hemodialysis patients at Adam Malik Hospital Medan. Patients on other phosphate binders were given 2-week wash-out period. Nicotinamide 250 mg capsule were given twice daily immediately after meal for 8 weeks. Serum phosphate, calsium, calsium-phosphate product, alanine amino transferase and aspartate amino transferase were estimated at the beginning, 4th week and 8th week. Patients were regularly monitor for side effects.

Result: There were significant decrease in the serum phosphate (8.15±1.5 mg/dl at the baseline to 7.54±1.69 mg/dl at 4th week to 6.67±2.09 mg/dl at 8th week), and serum calsium-phosphate product (78.82 ± 13.77 mg2/dl2 at the baseline to 68.43 ± 14.64 mg2/dl2 at 4th week to 60.34±18.95 mg2/dl2at 8th week). Serum calcium were also significant decrease but still in normal range (mean 9.19 ± 0.99 mg/dl at 8th week). Other parameters remained unchanged. Watery stools reported by one patient and resolved when the drug was stopped.

Conclusion: The use of nicotinamide 250 mg twice daily is effective in controlling serum phosphate in regular hemodialysis patient.

Keywords: Nicotinamide, hyperphosphatemia, hemodialysis.

896

PO 429The association between elevated levels of erythropoietin and Improvement of cardiac function on renal failure who underwent kidney transplantation

Harnavi H*, Maruhum BM**, Endang S**, Hamzah S**,Marulam MP*****Kidney and Hypertension Divison of Internal MedicineFaculty Medicine of Andalas University Padang**Kidney and Hypertension Divison of Internal MedicineFaculty Medicine of Indonesia University***Psychosomatic Divison of Internal MedicineFaculty Medicine of Indonesia University****Cardiology Division on Internal MedicineFaculty Medicine of Indonesia University

Background. Kidney transplantation improved cardiac function. Based on animal trials, elevated levels of erythropoietin hormone can improved cardiac function, but in clinically still debate.

Aim. To determine association between elevated levels of erythropoietin and improvement cardiac function on renal failure who underwent transplantation.

Methods. Prospective cohort study on renal failure who underwent kidney transplantation at Cipto Mangunkusumo Hospital. The study include 21 subjects who collected it from Marct to September 2013. Data of echocardiography and erythropoietin level were collected at time prior to kidney transplantation and repeat 3 months there after. The association between elevated levels of erythropoietin and cardiac function was analyzed using Pearson correlation and Spearman test.

Result. The study showed a significantly elevated levels of erythropoietin from 7,58 (2,56) to 18,1 (6,4) ml U/ml. There was statistically significant association between elevated levels of erythropoietin and LVEDD (r=-0,56 p<0,05), LVMI (r=-0,45 p<0.05) post transplantation. There was no association erythropoietin level and LVEF (r=0,06 p>0,05).

Conclusions. There was association elevated levels of erythropoietin and improvement of LVH, LVEDD on renal failure who underwent transplantation, however, there was no association of elevated levels of erythropoietin level and improvement of LVEF.

Keywords: kidney transplantation, erythropoietin, cardiac function.

897

PO 430EFFECT OF LOSARTAN IN INTERLEUKIN-6 (IL-6) SERUM LEVEL IN HYPERTENSIVE PATIENTS WITH ASYMPTOMATIC HYPERURICEMIA AT DR. MOHAMMAD HOESIN HOSPITAL PALEMBANG

SUPRAPTI1, YULIANTI2, NOVADIAN3, ZULKHAIR A4, IAN E 5

1-5 : STAFF OF DIVISION OF NEPHROLOGY AND HYPERTENSION DEPARTEMENT OF INTERNAL MEDICINE FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ MOHAMMAD HOESIN HOSPITAL PALEMBANG, INDONESIA

Aim: Knowing the effect of losartan on serum levels of IL-6 in hypertensive patients with asymptomatic hyperuricemia in Hospital Dr. Mohammad Hoesin (RSMH) Palembang.

Background : Hypertension and hyperuricemia are factors related to cardiovascular disease risk. Hyperuricemia is found in approximately 25% patients with hypertension while hypertension is found in 30% patients with hyperuricemia or gout. The link between hypertension and hyperuricemia theoretically explained by the effect of uric acid on renal and vascular smooth muscle cells. Hyperuricemia leads to inflammation and endothelial dysfunction. Losartan is an angiotensin renin blocker that has other effects as an anti-inflammatory and uricosuric agent.

Methods: This study is a clinical trial with before and after study design. This research was conducted in the Internal Medicine ward at Dr. Mohammad Hoesin (RSMH) Hospital Palembang, Indonesia from March to August 2014. The purpose of this study is to determine the effect of losartan on IL-6 serum level in hypertensive stage 1 patients with asymptomatic hyperuricemia. Subjects were given 50 mg of losartan once daily for 8 weeks.

Results: We were cruited 30 patients 53.3% men and 46.7% women. Effect of losartan on reduction in systolic and diastolic blood pressure (146.004.98/88.673.45 to 126.67 7.39/79.004.02 mmHg, p=0.000), uric acid serum (8.571.26 to 5.941.57 mg/dl, p=0.000), 24-hour urinary uric acid (369.03146.49 to 510, 67 231.70 mg/24 hours, p=0.001), IL-6 serum levels is 3.27(0.48-19.8) to 2.66(0.3-17.83) pg/ ml (p=0.015) by administration losartan potassium tablet 50 mg once daily for eight weeks.

Conclusions: Losartan decreased interleukin-6, blood pressure, serum uric acid levels and increased urinary excretion of uric acid 24 hours in hypertensive patients with asymptomatic hyperuricemia significantly.

Keyword : hypertension, hyperuricemia, losartan, IL-6

NB: pasien hipertensi stage 1 yg baru terdiagnosis dan menghentikan obat antihipertensi selama 3-4 kali masa paruh obat (1 minggu)

898

PO 431A CASE OF SPINOCEREBELLAR DEGENERATION COMPLICATED WITH SEVERE RENAL FAILURE

AUTHOR : Masayuki Kitagawa, Yoshihiro Yamanaka, Toru Adachi, Junitsu Ito, Jiro Akiba, Kazutoshi Fukase, Ikuro Ohta

AFFILIATION : Department of Internal Medicine, Yamagata Prefectural Kahoku Hospital

Introduction: Spinocerebellar degeneration may exhibit a severe clinical course. We report the spinocerebellar degeneration complicated with pneumonia, heart failure and renal failure.

Case Presentation: The case is 62-year-old. She had both sides of visual impairment than childhood. She was led to the gait disturbance from the 44-year-old. When she was 47-year-old, she was diagnosed with spinocerebellar degeneration. From dominant inheritance type, calcification of the basal ganglia and macular degeneration, she was diagnosed with a special type of spinocerebellar degeneration and attending to our hospital neurology. When she was 62-year-old, at the end of May 2016, she became difficult breathing and visited our hospital emergency room. She was pointed out pneumonia, heart failure and renal failure and became our department admitted. She was treated by diuretics, antibiotics and catecholamines. By treatment, infiltration shadows of both lung fields were reduced and C-reactive protein also decreased. However, creatinine went increased. On the admission day 16, she died.

Discussion: Spinocerebellar degeneration is complicated by difficulty walking, swallowing disorders and lead to severe clinical course. As in the present case, spinocerebellar degeneration exhibiting merger severe pneumonia, heart failure and renal failure is present. In the hospital course, renal failure has been worse but the consent of the family for the dialysis treatment was not obtained. Cause of death in this case was estimated to be worsening of renal failure. Spinocerebellar degeneration was considered to be necessary to pay attention to complications such as pneumonia, heart failure and renal failure.

899

PO 432Case Report: Rhabdomyolysis and Acute renal failure due to Hypothyroidism

İrem KIRAÇ UTKU, Ayhan LEVENT, Ali BAKAN, Hanişe ÖZKAN, Ömür TABAK, Abdulbaki KUMBASAR

Hypothyroidism is one of the most common endocrinopathy that can cause rhabdomyolysis at long term nondiagnosed cases. We will present a young hypothyroidic patient with rhabdomyolysis and acute renal failure.

23 year old male patient was admitted to hospital with fatigue, muscle pain and slow talking. Blood pressure: 100/70mmHg, pulse:76/min. There was no other pathological findings in physical examination. Laboratory analyses ; urea: 23 mg/dl, creatine: 1.9 mg/dl, CK: 1633 U/L, TSH: 258 Uuı/ml fT4: 0.07 ng/dl. There was no trauma, exercise, infection or drug history. We accepted this patient as rhabdomyolysis and acute renal failure due to hypothyroidism. We started the treatment with hydration and levothyroxin sodium. We discharged the patient after his clinical condition got better.

Hypothyroidism can affect all organs and systems in the body. This effect increases by the decrease of thyroid hormones. Neuromuscular symptoms can exist at the ratio of 30-80%. Muscle weakness, cramps, hypertrophy or atrophy in muscles and high serum creatine kinase levels can be detectable at myopathy of hypothyroidism. Rhabdomyolysis can rarely occur in severe hypothyroidism. Rhabdomyolysis is a syndrome that develops with acute necrosis of the skeleton muscles and transition of cell contents into the blood. The most frightening effect is acute renal failure. Acute renal failure occurs with the toxic effect of myoglobin and the obstruction of tubules with myoglobin. Hydration therapy and also thyroid hormone replacement therapy must be started at the initial treatment. Therefore hypothyroidism should be considered while doing rhabdomyolysis etiological research.

900

PO 433CASE REPORT HYPOPHOSPHATEMIA AND RHABDOMYOLYSIS AFTER FERRIC CARBOXYMALTOSE TREATMENT

İrem KIRAC UTKU¹, Hanişe OZKAN¹, Esra DEMİR¹, Omur TABAK¹, Abdulbaki KUMBASAR¹

Kanuni Sultan Suleyman Training and Research Hospital. / Department of Internal Medicine / Istanbul

AİM: We present a patient with hypophosphatemia and rhabdomyolysis one day after ferric carboxymaltose treatment.

INTRODUCTION: Ferric carboxymaltose is a new iron preparation which can be used with a much higher infusion speed than iron sucrose as a high single dose. Its most commonly reported side effect is headache. Because it is a newly used preparation, studies done on it is increasing day by day. According to the research, it causes temporary decrease in serum phosphorus levels as a side effect commonly seen. Developing hypophosphatemia can lead to delirium, coma, focal neurological signs, rhabdomyolysis, acute hemolysis, leukocyte dysfunction, platelet dysfunction.

CASE: A 36-year-old female patient with iron deficiency anemia was given 1000 mg of ferric carboxymaltose. The patient was discharged the same day without complication. One day after the patient admitted because of muscle pain and inability to walk. Her physical examination was normal. She had difficulty in walking due to severe pain. In the laboratory tests these results were obtained: aspartate aminotransferase: 66 U/L, alanine aminotransferase: 33 U/L, CPK: 3361 U/L, phosphorus 1.9 mmol / dL. The patient was considered as hypophosphatemia and rhabdomyolysis related to IV ferric carboxymaltose replacement. We started rhabdomyolysis treatment. On the 3rd day of the patient’s hospitalization CPK level started to decrease, serum phosphorus level started to rise. The patient’s muscle pains decreased and she started to walk. On the 5th day she discharged.

DISCUSSION: Hypophosphatemia is a common side effect of ferric carboxymaltose. The risk of developing rhabdomyolysis increases in hypophosphatemia longer than 1-2 days. In our case also, after IV ferric carboxymaltose application, severe muscle pains developed. It was detected that serum CPK was high and serum phosphorus was low. We haven’t come across with published case about rhabdomyolysis after ferric carboxymaltose up to now. So we want to submit this case.

901

PO 434The difference between visit to visit blood pressure before hemodialysis and interdialytric home blood pressure monitoring.TRIHARNOTO1,., WIDIANA, IGR2., SUWITRA IK3., WAYAN IS4., LOEKMAN JS.5, KANDARINI Y6., 1,2,3,4,5,6 Nephrology and Hyperternsion Division Department of Internal Medicine, Medical School of Udayana University, Denpasar Bali, Indonesia

Aim: To study the difference between visit to visit blood pressure mean taken at the clinic before hemodialysis and interdialytric home blood pressure monitoring mean on chronic hemodialysis patients.

Background: Blood pressure (BP) measurement may be taken as visit to visit at the clinic , ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM). The literature showed that ABPM or HBPM may be better measurement to monitor blood pressure, however they are not practical. Blood pressure of chronic hemodialysis (HD) patients taken the clinic before HD session have been regularly and more practical. It is important to know how the difference between visit to visit BP mean at the clinic and interdialytic HBPM mean on chronic HD patients.

Method: A cohort observational study was done among 81 hemodialysis patients at the HD centre of Sanglah Hospital. The patients had two session HD, blood pressure was measured at the clinic before HD of each session. Home blood pressure was taken at home every six hours in between of HD with the standardized automatic BP device. Blood samples was drawn with standard protocols to measure the URR, albumin, natrium and hemoglobin levels.

Results: Patients characteristic: age (47.23 +13.10) years, HD length ( 26.25 + 2.85) months, BMI (21.99 +3.19), Hemoglobin (9.90 + 1.88) g/dL, albumin (4.10 + 0.39) g/dL, natrium (138. + 3.30) meq/L, URR (0.675 +0.32). Systolic BP mean at the clinic before hemodialysis was 141.54 +20.09 mmHg, systolic HBPM mean was 126.02 + 20.51 mmHg (p=0.000). Diastolic mean of BP at the clinic before hemodialysis was 83,74 + 11,55 mmHg, Diastolic

HBPM mean was 82.85 + 14.07 mmHg (p=0.381). The mean of systolic interdialytic HBPM was significant lower than systolic BP monitoring at the clinic before hemodialysis. However there is no significance difference of HBPM diastolic interdialytic mean compared to diastolic mean of clinic measurement before HD.

Conclusions: Among chronic HD patients the systolic mean of visit to visit BP monitoring at the clinic before hemodialysis was significant higher than the systolic mean of interdialytic HBPM.

902

PO 435The Correlations Between Adequacy Hemodialysis With Quality of Life of Chronic Kidney Disease Patients in Hemodialysis Unit of Prof. W. Z. Johannes Hospital Kupang 2016

Paulus Pradatama Raga Come1, Herman P. L. Wungouw2, Stefany Adi Wahyuningrum31. Faculty of Medicine University of Nusa Cendana2. medical education Department of Faculty of Medicine Radiology of Nusa Cendana3. Department of Internal Medicine Prof. W. Z. Johannes Hospital Kupang

Background: End Stage Renal Disease patient suffered from uremic syndrome because the kidney didn’t work normally. The systemic manifestation of uremic syndrome causes decline of quality of life. Hemodialysis is one of the therapy for end stage renal disease patient. Effectiveness of hemodialysis is required. Measuring adequacy hemodialysis used to asses the effectiveness of hemodialysis.

Objective: This study aims to determine the correlation of adequacy hemodialysis with the quality of life of end stage renal disesase patient in hemodialysis unit of Prof. W. Z. Johannes Hospital Kupang in 2016.

Methods: This is an analytical observasional study with cross-sectional design. Subjects are the end stage renal disease patient who undergoing hemodialysis in Prof. W. Z. Johannes Hospital Kupang. The subjects were 52. Urea reduction ratio was used to measure adequacy hemodialysis and WHOQoL questionare was used to asses quality of life. Chi square test was used to analyse.

Results: Results of adequacy hemodialysis showed 18 subjects (34.6%) were adequate and 34 subject (65.4%) were inadequate. The quality of life assesment showed 30 subjects (57.7%) were good quality of life and 22 subjects (42.3%) were not good or poor quality of life. Statistical analysis showed p value =0.006 (p <0.05), that means there was significant correlation between adequacy hemodialysis and quality of life end stage renal disease.

Conclusion: Adequat hemodialysis relates with good quality of life. hemodialysis units have to improve adequacy hemodialysis to adequate and then the quality of life will be improved.

Keywords: Adequacy hemodialysis, quality of life, chronic kidney diseases

903

PO 436PERCUTANEUS TRANSLUMINAL ANGIOPLASTY FOR THROMBOSIS AT VASCULAR ACCES HAEMODIALYSIS ARTERIOVENOUS FISTULAS : A CASE REPORT

Heru Dento MD, Dono Antono MD

Division of Cardiovascular Departement of Internal Medicine, Faculty of Medicine University of Indonesia, Cipto Mangunkusumo National Hospital Jakarta Indonesia

Abstract

Background :Vascular acces for hemodialysis is the mainstay of adequate dialysis delivery. Its complication account for significant morbidity and mortality, increased financial cost in end stage renal disease (ESRD) patient. Catheter based interventions are the succesful in restoring flow in more than 80% of hemodialysis acces that undergo thrombosis and have replaced surgical revision, improved the quality of life, prolonged survival time and saving venous segment for future acces creation.

Case report :A 62 years old man came to our division diagnosed with thrombosis in left arteriovenous (AV) fistulae cephalica. He has did ESRD and haemodialysis since 2 year ago. Physical examination revealed evidence of a non-functioning dialysis fistula. His past medical history was significant for hypertension since 30 year ago, CAD post PTCA and PAD post PTA. An immediate Doppler examination revealed left cephalic vein thrombosis with partial obstruction. The Angiography examination revealed stenosis 95% at left cephalic vein. The Percutaneous Transluminal Angioplasty (PTA) were performed. Predilatation with ballon ATB 4.0 x 40 mm and stenting with stent Absolute 6.0 x 40 mm restored the patency of the fistula and the hand vascularity. Five month after PTA, we found re-oclusion at the below site. Venography revealed stenosis 70% at left cephalic vein and in stent restenosis (ISR) 30%. An second PTA was undertaken with ballon ATB 6.0 x 4.0 mm at ISR and cephalic vein. The fistula patency and the hand vascularity remained normal. After the treatment, we give double antiplatelet for several month.

Conclusion :A 62 years old man diagnosed thrombosis AV fistula cephalica sinistra. PTA were performed as the treatment for him. Five month after PTA, venography revealed stenosis 70% at vena cephalica and ISR 30%. The second PTA was undertaken. The fistula patency and the hand vascularity remained normal.

Keywords :Vascular acces, arteriovenous fistula, thrombosis, PTA.

904

PO 437PRESCRIPTION PATTERNS OF ANTIHYPERTENSIVE DRUGS AT POLYCLINIC OF INTERNAL MEDICINE IN MOHAMMAD HOESIN GENERAL HOSPITAL SOUTH SUMATERA

Erwin Azmar1 , Erwin Sukandi1, Ivan Alexander Liando2 1Cardiology Division Department of Internal Medicine, Faculty of Medicine, University of Sriwijaya, South Sumatera, Indonesia 2Faculty of Medicine University of Sriwijaya, South Sumatera, Indonesia

ABSTRACT

Background: The usage patterns of antihypertensive drugs is important to be noted in giving medication for hypertension. This study examined the pattern of physicians’ prescription of antihypertensive drugs and its possible effects on blood pressure control, combination of antihypertensive drugs, compelling indication and the conformance of antihypertensive medication according to literature as well as physicians’ compliance with recommended guidelines.

Methods: This research was a descriptive observational research with cross sectional design. Record of 300 patients data during January- June 2015 has been collected which is met the criteria of the research, the patterns of blood pressure, usage of the medication, combination of the medication, and conformance of antihypertensive medication from literature.

Result: Calcium Channel Blocker (Amlodipine Besylate) was used widely 50,7% (133) . ARB with distribution of Candesartan Cilexetile 137,3% (112) and Valsartan 29% (87). ARB and CCB is the most combination that has been used with distribution of Candesartan Cilexetile and Amlodipine Besylate 9% (27) patients, Valsartan and Amlodipine Besylate 6% (18). The conformance of drugs utilization is bigger (99,4%) compared to the unconformance utilization (0,6%). The conformance of the antihypertensive drugs utilization in patient with compelling indication is bigger (73,1%) compared to unconformance utilization (26,9%).

Conclusion: Based on the research that has been done, it can be concluded that the combination of drugs that consumed by patients in MH General Hospital Palembang is appropriate according to the literature.

Keywords: antihypertensive, combination of antihypertensive drugs, MH General Hospital

905

PO 438CALCIUM-PHOSPHATE PRODUCT LEVEL DOES NOT AFFECT THE NUMBER OF HOSPITALIZATION AMONG REGULAR HEMODIALYSIS PATIENTS IN 1 YEAR AT HOSPITAL SANGLAH DENPASAR

I Nyoman Adi Suparta, Gde Raka Widiana, Ketut Suwitra, Wayan Sudhana, Jodi S Loekman, Yenni Kandarini, Paramita Ayu, TrihartonoDivision Nephrology and Hypertension Departement of Internal Medicine Faculty ofMedicine Udayana University Bali Indonesia

ABSTRACT

Background : Hemodialysis is still the main choice of renal replacement therapy, while bone and mineral metabolism disorders are closely related to chronic kidney disease in patients undergoing regular hemodialysis. Morbidity was significantly and independently associated with higher levels of phosphate, calcium and calcium-phosphate product.

Objective : To determine the correlation between the calcium-phosphate product and the number of hospitalizations in the last 1 year of patients undergoing chronic hemodialysis.

Method : The study was conducted by cross sectional method. Subjects were patients undergoing chronic hemodialysis more than three months in Sanglah Hospital in Denpasar. The recording was made of the calcium-phosphate product value of each subject of study as well as a history of hospitalization in the last 1 year. Data were analyzed with SPSS wear bivariate hypothesis test with Spearman test.

Result : A total of 81 subjects, characteristic of data obtained by 56 men (69%) and women by 25 (31%), mean age 47.2 ± 13.1, HD length 35.8 (3-180) months. The number of subjects with calcium-phosphate product normal are 45 subjects and 36 subjects below normal. The mean calcium-phosphate product 58.7 (16-108). Subjects with a history of hospitalization within the last one year as many as 36 subjects and subjects who have never been hospitalized within the last one year as many as 45 subjects. Spearman analysis, no significant correlation was found between calcium-phosphate product with hospitalization in the last 1 year (r = -0.28, p = 0.806, n = 81).

Conclusion : There is no correlation between the levels of calcium-phosphate product with a history of hospitalization in the last 1 year.

Keywords: hospitalization, calcium-phosphate product, regular Hemodialysis

Results: The study revealed that the risk assessment of hypertension within 4 years of community around RTCU Buaran was predicted 41.8% at high risk, 15.7% at moderate risk, and 7.5% at low risk respectively. Using Chi-square test, there was significant difference between the risk assessment of hypertension and respondents’ age, blood

906

pressure and total cholesterol (p<0.05).

Conclusions: The present study showed that the risk assessment of hypertension within 4 years of community around RTCU Buaran was dominantly at high risk (41.8%). Factors that significantly related to risk of hypertension were age, blood pressure and total cholesterol.

Keywords: hypertension, risk assessment, Framingham Risk Score for Hypertension

907

PO 439The Risk Assessment of Hypertension in Community Setting: Preliminary Study

Marita Fadhilah1, Aliefa Syifa2 Zulhafdy3, Sayid Ridho4, Fika Ekayanti11. Community Medicine Department, Faculty of Medicine and Health Sciences, Syarif

Hidayatullah State. Islamic University, Jakarta, Indonesia2. Medical Student of Faculty of Medicine and Health Sciences, Syarif Hidayatullah

State Islamic University, Jakarta, Indonesia3. Ophthalmology Department, Faculty of Medicine and Health Sciences, Syarif

Hidayatullah State Islamic. University, Jakarta, Indonesia4. Internal Medicine Department, Faculty of Medicine and Health Sciences, Syarif

Hidayatullah State Islamic University, Jakarta, Indonesia

Background: Nowadays, hypertension is the highest global burden disease around the world with high morbidity and mortality, especially in low-income countries, including Indonesia. Many studies had been conducted to decrease hypertension morbidity and mortality. Risk assessment of hypertension using Framingham Risk Score for Hypertension was reported by some studies as primary prevention can reduce mortality.

Objective: This study aimed to identify risk assessment of hypertension in the community around Research, Teaching, and Clinical Unit (RTCU) Buaran, South Tangerang.

Methods: This study was cross sectional design and involved 134 respondents who live around RTCU Buaran, using two stages cluster sampling. During April to June 2015, respondents were asked to fill the questionnaire that developed from Framingham Study. Then respondents were registered some physical examinations, such as body weight, body height, blood pressure and total cholesterol examination. Those data were calculated using Framingham Risk Score for Hypertension tool.

Results: The study revealed that the risk assessment of hypertension within 4 years of community around RTCU Buaran was predicted 41.8% at high risk, 15.7% at moderate risk, and 7.5% at low risk respectively. Using Chi-square test, there was significant difference between the risk assessment of hypertension and respondents’ age, blood pressure and total cholesterol (p<0.05).

Conclusions: The present study showed that the risk assessment of hypertension within 4 years of community around RTCU Buaran was dominantly at high risk (41.8%). Factors that significantly related to risk of hypertension were age, blood pressure and total cholesterol.

Keywords: hypertension, risk assessment, Framingham Risk Score for Hypertension.

908

PO 440INSULIN RESISTANCE AND INFLAMMATION AS CARDIOVASCULAR RISK FACTOR AMONG NONDIABETIC CHRONIC KIDNEY DISEASE PATIENTS

Dede SIT1, Hasan KAYABASI2, Emel S. GOKMEN3, Bennur ESEN4, Mustafa H. DINCKAL5

1. Istinye University Medicalpark Hospital, Internal Medicine and Nephrology, Istanbul, Turkey

2. Bagcilar Education and Research Hospital, Internal Medicine and Nephrology, Istanbul, Turkey

3. Eyup State Hospital, Internal Medicine, Istanbul, Turkey4. Acibadem Taksim Hospital, Internal Medicine and Nephrology, Istanbul, Turkey5. Bakırkoy Dr. S. Konuk Education and Research Hospital, Cardiology, Istanbul,

Turkey

INTRODUCTION: Recent studies have shown that CVD, existed in all stages CKD. Insulin resistance (IR), commonly companied by compensatory hyperinsulinemia, has been demonstrated to exist in patients with CKD and play an important role in the development of CVD. The aim of this study was to investigate whether IR exists and its relationship with CVD in nondiabetic predialysis CKD patients.

MATERIALS-METHODS: In total 70 non-diabetic stage 1-4 CKD patients who were undergone coronary angiography for CAD enroled into the study. GFR of all patients were calculated using MDRD formula, and according to eGFR, the patients were divided into stage 1-4 CKD via K/DOQI guidelines. Demographic, biochemical, hemathological (CBC) parameters were recorded. Plasma insulin levels were measured, and IR were calculated using HOMA-IR. Spot urine protein kreatinin ratio was calculated. CRP, Ferritin, MPV/Plt, N/L, Plt/L was studied as inflammatory parameters. The patients were divided into two groups as angiography positive and negative for coronary artery disease, group 1 and group 2 respectively, and the parameters were compared.

RESULTS: The mean age of patients were 63.7±11.84 years and 56 (80%) were male, 14 (20%) were female. 55 (78.6%) of patients had CAD and 15(21.4%) had normal angiography. CAD was more frequent in stage 2 and 3 pateints (p<0.01). Among stages of CKD only CRP was significantly higher in advanced disease. HOMA-IR was not different between stages of disease. Inflamattory markers and HOMA-IR according to CKD stages was detailed in table 2. In comparing of the patients according to CAD there was statistically significant in levels of creatinine, albumin, and LDL-cholesterol. Biochemical parameters, HOMA-IR and inflammattory parameters of patients were detailed in table 1. There was no difference in HOMA-IR and inflammattory parameters between patients with and without CAD.

DISCUSSION: CVD morbidity and mortality is importan for CKD patients. In this study we failed to show the relationship between insulin resistance, inflammation and CAD in stage 1-4 CKD patients contrary to literature, although inflammation is elevated with the stage

909

disease. Thus further large scale studies are needed to show the value of inflammatory markers to predict cardiovascular mortality among early stage CKD patients.

Keywords: Insulin Resistance, Cardiovascular Risk Factor, Chronic Kidney Dısease

Table 1: HOMA-IR and inflammattory parameters of patients acoording to CADCAD

p(-) (+)

Hemoglobin 11,49±2,09 12,18±2,18 0,282

HOMA-IR 2,99±2,31 4,15±5,41 0,491

Ferritin 132,58±107,64 226,09±369,74 0,632

CRP 22,71±32,74 25,75±29,13 0,732

Middle Platelet Wolum/Platelets

0,03±0,01 0,04±0,02 0,937

Platelet/Lymphocyte 181,37±89,78 163,57±111,58 0,584

Neutrophil/ Lymphocyte 4,12±3,05 3,93±3,69 0,239

*CRP: C-reactive protein

910

PO 441Rhabdomyolysis, Acute Renal Failure and Myocarditis after Bonzai ( synthetic cannabinoid)

İrem Kıraç Utku, Hanişe Özkan, Esra Demir, Ömür Tabak, Abdulbaki Kumbasar

Aim: We present a case which has rhabdomyolysis, acute renal failure and myocarditis due to synthetic cannabinoid use.

Case: 26 year old male patient was admitted to the hospital with severe chest pain and anuria after synthetic cannabinoid use. His physical examination revealed that BP: 110/80mmHg, pulse: 110/dk, temperature: 36,5°C . There was no other pathological finding. Laboratory results showed that urea: 167 mg/dl, creatine: 5.8 mg/dl, uric acid: 16 mg/dl, CK:76800 U/L, phosphorus: 17.8 mg/dl . There was no pathology in urinary and renal doppler ultrasonography. We diagnosed as acute renal failure due to rhabdomyolysis. Although 12 hour follow-up with hydration and alkalization therapy, the patient didn’t have any urine. In arterial blood gas, pH was 7.0 so he had hemodialysis. Because of chest pain electrocardiography and echocardiography were done. As a result, there were negative T waves in all derivations, left ventricle global hypokinesia, EF:40% and myocarditis. Laboratory results showed that CK-MB :349.3 U/L, troponine T: 0,725 ng/ml which were higher than normal levels. Viral markers related with myocarditis were negative and cultures were sterile. Due to cardiology consultation, the patient was given carvedilol, heparine and tramadol for pain. He had hemodialysis for 2 times and urine output occured. Close follow-up continued with hydration and creatine levels became normal in following days. His chest pain regressed, control echocardiography showed that EF:60% and there was no hypokinesia. Therefore the patient was discharged with recommendations.

Discussion: Unfortunately, synthetic cannabinoid use has been common in recent years in our country. The most frequent side effects are nausea, vomitting, agitation, anxiety and psychosis. However there are also various effects on many organs. The most frightening effect is cardiac effect. Our case had rhabdomyolysis and as a result of this acute renal failure, besides he developed myocarditis. Because of common use of these drugs among young people in Turkey, addiction must be kept in mind in case of doubt.

911

PO 442COMPARISON BETWEEN SERUM LIPID PROFILE AND LEPTIN ON FAT MASS LEVEL OF MAINTENANCE HEMODIALYSIS PATIENTS IN INDONESIA

Rudi Supriyadi

Background: Malnutrition and inflammation complex syndrome is a problem in patients with maintenance hemodialysis. Various nutritional measurement have been used for maintenance hemodialysis (MHD) patients such as fat mass. Fat mass does not influenced by hydration status of HD patients and it is metabolically active and produce various inflammatory cytokines such as leptin. Leptin also regulate fat mass through central and local effect. Serum lipid profile in MHD patients showed different characteristics than normal people. Leptin and serum lipid profile could be the determining factors for nutritional status and inflammation in MHD.

Methods: This is an observational analytic with cross sectional study. Fat mass measured by bioelectric impedance analysis from Lifemax Quadscan 4000 UK. Levels of leptin was measured by Elisa technique. The results were statically analyzed.

Results: A total of 79 male subjects participated in this study. The mean age is 49.1±12.2 years, length of hemodialysis: 36 (6-126) months. Average fat mass is 12.8 ± 4 kg. Fat mass category by percentage for less, normal, and over found in 20(25%), 25(32%), 34(43%) subjects. Total cholesterol in less fat mass is 160.5(133-196), normal 125(99-169), and over fat mass is 143.5(70-244)mg/dL. LDL revealed 100.5(81-139), 77(46.8-103.2), 82.5(41-181)mg/dL respectively. Level of leptin respectively is 1350 (507.4-41956), 1224.8 (200.1-10379.9), and 2930.2(377.6-38880.4). There is significance difference with Bonferroni in leptin level between normal and over fat mass (mean difference=-1.12;p=0.001), less fat and over fat mass (mean difference=-1.73;p=0.000). Significance difference also found in triglyceride level between less normal fat mass with over fat mass (mean difference=-49.72;p=0.017).

Conclusions: This study showed significance difference of leptin level between less and normal fat mass with over fat mass and also triglyceride level between less normal fat mass and over fat mass. Fat mass suggested to play role determining leptin level and triglyceride in MHD patients.

Keywords: Maintenance HD, fat mass, leptin level, lipid profile

912

PO 443A WOMAN WITH DIABETES MELLITUS AND CHRONIC KIDNEY DISEASE ON HAEMODIALYSIS, AND WITH A WIRE JAMMING AND LEFT INSIDE THE RIGHT COMMON ILIAC VEIN

YUSUF HUNINGKOR, DONO ANTONODepartment of Internal Medicine, Cardiology Division, University of Indonesia andDr. Cipto Mangunkusumo National General Hospital, Jakarta, IndonesiaCorresponding author: Yusuf Huningkor: [email protected]

Subjective : A woman 33year with Diabetes and CKD on HD, was sent to our Division with complain that a Wire was jamming and left inside the right Femoral vein during insertion of double lumen catheter (CDL).

Objective : In Physical examination: the patient was in moderate illness, consciousness, BP 123/72 mmHg, pulse 114/min, temperature 37 oC, RR: 18/min. JVP 5-2 CmH20, slightly pitting edema at the left and right legs, and ex-puncture at the right inguinal site, painless. Another physics were in normal range.

Laboratory examination: Hb 7,3 g/dL, Ht 22%, leucocyte 22.170, Plt 605.000, BBS 48 mm/h, ureum 102 mg/dL, creatinin 4,96 mg/dL, glucose 281 mg/dL, BT 3’, CT 30’, HBsAg negative, anti HCV negative, HIV negative.

ECG: sinus tachycardia; chest x-ray : normal range; Fluoroscopy: Corpus Alienum as a short Wire was seen from right common Iliac vein to right Atrial.

Assesment : Type 2 Diabetes, Anemia, CKD on HD, and a Wire in the right common Iliac vein to the right Atrial.

Planning : Extraction of the Wire. We made PTA in local anesthesia through the left Femoral vein and snaring the wire with snar lift tech (ET SG 10). Guiding with catheter JR 3,5/6 Fr, tail of the wire was snared, and the wire was extracted entirely from the body. Then, we did insertion of CDL at the right Jugular vein and made tunneling.

There were only minimal bleeding at the puncture sites and no complication occurred. The patient was discharged in the next day.

Keywords: chronic kidney disease, catheter double lumen, snar lift tech, Percutaneus Trans Angiography

913

PO 444A TEENAGE GIRL WITH ARTERIOVENOUS MALFORMATION AND ANTIPHOSPHOLIPID SYNDROMEJuspeni K, Yenny DA

Hematology and Medical Oncology Division, Department of Internal Medicine Sriwijaya University,

Mohammad Hoesin Teaching Hospital Palembang

Arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, by passing capillary system. It was formed congenitally and causes high arterial shunting flow. Brain AVM may create aneurysms. Antiphospholipid syndrome is a constellation of symptoms of vascular thrombosis in arteries or veins. Antiphospholipid syndrome in pregnancy is related to high level of antibodies to plasma protein, which binds to anionic phospholipid.

A 16-year-old teenage girl presented with pain and redness at the left index and thumb, which associated with double vision, decreased visual acuity, severe headache and vascular dilatation on the left arm. Physical examination revealed right ophthalmoplegia, right facial hemihypesthesia, and hidrotic right face. There were angiomas from forehead to left superior eyelid, angioma at left thoracic area, uneven surface of left index and thumb, dilated veins of the left forearm and bruit on the index and thumb.

On laboratory tests, routine blood tests were within normal limits. Other tests revealed fibrinogen of 477 g/dL, D-Dimer of 0.22, ACA IgG of 12.96 MPL, ACA IgM of 15.28 MPL, protein C of 72.90%, protein S of 41.10%, C3 of 129 mg/dL, C3 of 129 mg/dL, C4 of 32 mg/dL, ANA titer of 1/320. CT angiogram of the left upper extremity showed AVM with nidus from deep/superficial arch artery, palmar digital artery of thumb and index from proximal portion to the distal with multiple aneurisms which were fed by radial artery and ulnar artery with draining veins to distal part of median antebrachial vein. CT angiogram of the Circle of Willis revealed fusiform aneurysm of basilar artery near the bifurcation. Vascular malformation was fed by left temporal artery, which was branch of left external carotid artery.

After getting anticoagulant for 1 month, the patient ‘s clinical condition was improving. She had less pain and redness. Embolization was planned for the AVM.

Conclusion: AVM is a congenital abnormality, which needs to be recognized and corrected early before its severe complications or death occur. Treatment with anticoagulant for hypercoagulable state should be done with close clinical and laboratory coagulation parameters monitoring.

Key words : AVM, antiphospholipid syndrome

914

PO 445A RARE CAUSE OF OSTEOPOROSIS: LYSINURIC PROTEIN INTOLERANCE

I. CETINDAGLI1, S.A.AY2, K. BASKOY2, F. DENIZ2, A. YONEM2

1. Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY2. Gulhane Military Medical Faculty, Haydarpasa Training Hospital, Department of

Endocrinology and Metabolism, Istanbul, TURKEY

BACKGROUND: Lysinuric protein intolerance (LPI) is a very rare autosomal recessive metabolic disorder associated with SLC7A7 mutations affecting amino acid transport. In the World, about 140 patients with LPI have been reported until now. Here we aimed to report a LPI patient with severe osteoporosis in long term follow-up.

CASE: A 20-year-old male patient presented with a history of growth retardation, reduction in oral feeding, nausea and vomiting at the age of 7, and examination showed that he had hepatosplenomegaly, elevated ferritin and lactate dehydrogenase levels. Plasma lysine, arginine, and ornithine levels were increased and urine levels were reduced. DNA mutation analysis for lysinuric protein intolerance was found to be consistent with LPI. With proper diet, the patient’s symptoms gradually decreased. Later, in spite of ongoing treatment, the patient was presented with fatigue and widespread pain. Because of increased risk of osteoporosis due to primary disease, a bone mineral density measurement was performed and revealed osteoporosis. Calcium and vitamin D were added to the treatment and a routine periodic follow up was started.

CONCLUSION: In LPI, due to poorly absorption from the intestine and increased urinary excretion of ornithine, arginine and lysine, their plasma concentrations are usually low. Skeletal and immunological abnormalities are linked to the lysine defiency.Gastrointestinal symptoms and growth problems associated with LPI are usually treatable with proper diet, but problems in bone metabolism depending on long-term lysine deficiency may be overlooked. Here we present a case of LPI with osteoporosis which is known to be very rare.

915

PO 446Title : IDIOPATHIC INFLAMMATORY MYOPATHY ASSOCIATED

MALIGNANCY: A CASE SERIES

Authors : Maria Eizelle M. Fernandez, MD, Sheila Reyes MD, Sandra V. Navarra MD

University of Santo Tomas Hospital, Manila, Philippines

Background/Rationale: This study aims to describe the clinical and laboratory features and types of malignancy associated with idiopathic inflammatory myopathy (IIM), namely dermatomyositis (DM) and polymyositis (PM).

Methods: This case series is a retrospective chart review of 9 patients diagnosed with idiopathic inflammatory myopathy in 2 private tertiary hospitals. Data on demographic, type of cancer, clinical and laboratory features were collected and analysed.

Results: In five patients, malignancy developed within one year of DM diagnosis. Malignancy preceded the diagnosis of DM in only one patient. Three of the malignancies were detected more than 2 years after the diagnosis of IIM. The malignancies associated with the 7 patients who had DM were: 2 nasopharyngeal, 2 breast, 1 endometrial and 1 cervical cancer. One patient with amyopathic dermatomyositis had adenocarcinoma of the ovary while the patient with polymyositis developed adenocarcinoma of the rectum. One patient died of malignancy while two was lost to follow-up.

Findings or Conclusion: DM is more commonly associated with malignancy. Malignancy was detected within the first year of DM diagnosis in majority of patients suggesting a paraneoplastic nature for IIM. However, malignancy also developed after more than 2 years in 3 patients which suggests that true association with malignancy exists. Nasopharyngeal cancer is associated with DM which is endemic in Southeast Asia.

916

PO 447A CASE OF SEVERE SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) WITH PREGNANCY IN CYCLOPHOSPAMIDE THERAPY

Kurniari P K, Kambayana G, Putra T R

Rheumatology Division, Internal Department, Faculty of Medicine Udayana University, Sanglah General Hospital

Abstract

Background: SLE is a chronic autoimmune disease. It mostly affect woman on their childbearing year. Pregnancy in SLE increase risk of morbidity and mortality to the mother and child. Disease activity, organ involvement, the limitations and the side effects of drugs also affect the outcome of pregnancy. Cyclophospamide is one of the drugs that are teratogenic. Cyclophospamide use in severe SLE with pregnancy requires close monitoring. It needs multidisciplinary collaboration to minimize the risk of mother and child complication.

Case presentation: A woman 34 years, Balinese Hindu, a housewife. SLE was diagnosed since 2014 with fullfill ARA criteria of arthritis, severe thrombocytopenia, malar rash and ANA positive. She was treated by pulse dose (500 mg) metyl prednisolone for 3 days, followed by 500 mg cyclophospamide infusion every month for 6 months and methylprednisolon 1 kg/kgbw/day dose titration. She was reported of pregnant when the first phase of three months of cyclophospamide infusion. Obstetric ultrasound was performed at the 20-21weeks of pregnancy and no congenital abnormalities found. They continue the pregnancy. She was treated by giving 500 mg cyclophospamide infusion every month combination with metyl predisolon 1 mg / kgbw / day dose titration because of severe lupus. At the 32 weeks of pregnancy, she gave spontaneus birth, male, 1800 gram and 41 cm, with no abnormalities. Day 6 of treatment she is discharged.

Conclusions: It has been reported a SLE woman with severe thrombocytopenia who become pregnant during cyclophospamide therapy. Cyclophospamide was continued during pregnancy. She was spontaneus birth at age of 32 with no abnormalities

Keywords: Severe SLE, Pregnancy, Cyclophospamide

917

PO 448DYSLIPIDEMIA AND ITS ASSOCIATED WITH SUBCLINICAL ATHEROSCLEROSIS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Kurniari P K, Kambayana G, Putra TR

Rheumatology Division, Internal Department, Faculty of Medicine Udayana University, Sanglah General Hospital

Abstract

Background: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease that is progressive. High mortality in SLE are caused by cardiovascular disease based on the premature atherosclerosis. Dyslipidemia is one of the traditional factors that increase the risk of atherosclerosis in lupus patients. The purpose of this study was to determine the prevalence of dyslipidemia and its associated to subclinical atherosclerosis in lupus patients.

Methods: This study is a cross sectional analytic study. A total of 54 women who diagnosed with SLE based on ARA criteria at Policlinic Care Sanglah General Hospital that meet the criteria for inclusion. Exclusion criteria in this study were diabetes mellitus, hypertension, smoking, malignant disease. Atherosclerosis is known to measure the value of the intima-media thickness of the carotid artery (CIMT) via ultrasound. Dyslipidemia is known to measure total cholesterol, HDL, LDL and triglycerides. Spearman’s correlation test is done to determine the relationship between variables.

Results: In this study, among the SLE patiens, the prevalence of dyslipidemia is 61.1%. Mean of total cholesterol 209.59 ± 53.59 mg / dL, mean of HDL levels mean 57.07 ± 15.69 mg/dL, mean of LDL levels 114.69 ± 42.63 mg/dL and mean of triglyceride levels 168.46 ± 128.53 mg/dL. The mean levels of CIMT in patients 0.48 ± 0.12 mm. The Spearman’s correlation test obtained only triglyceride level are associated with high levels of CIMT with r=0.34;p=0,01.

Conclusions: High prevalence of dyslipidemia in patients with lupus. High levels of triglycerides associated with subclinical atherosclerosis in lupus patients.

Keywords: Dyslipidemia, atherosclerosis, SLE

918

PO 449SYSTEMIC LUPUS ERYTHEMATOSUS IN THE ELDERLY : A CASE REPORT

Ali Mudiarnis, Noto Dwimartutie

Division of Geriatric Department of Internal Medicine, Faculty of Medicine, University of Indonesia ,Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

Introduction : Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease considered to affect predominantly woman of reproductive age. The age of diagnosis of most SLE patient is between 10 and 50 years old. Late-onset SLE has been defined as the disease onset occurring at age older than 50 years. In elderly patients SLE are rarely seen.

Case report : A 83-years-old woman was referred to our hospital because of severe anemia and artralgia. There were no skin rashes, photosensitivity nor neurologic deficit noted. Imunological tests showed positive Anti-Nuclear Antibodies (ANA) (titer of 1:100), elevated anti-ds DNA (titer of 1156 IU/ml), low complement C3 (70 mg/dl) and low complement C4 (4 mg/dl). Renal function test and urinalysis gave normal results. The patient was diagnosed using the 1997 American Collage of Rheumatology revised criteria for classification of SLE, with the bases of artralgia, Auto Immune Hemolytic Anemia (AIHA), positive ANA test and elevated anti-dsDNA level. Patient was started on oral prednisolon (1mg/kg/day) and gave good response. After 1 month there was reccurent anemia and arthralgia hence mycophenolic acid 1 x 180 mg tab was added, and showed sustained clinical and hematological improvement.

Conclusion : We reported a case of a 83-years-old woman with SLE. Patients with “late onset SLE” presents with more insidious disease onset, and less likely to have major organ involvement. This may give rise to diagnosis delay due to atypical clinical manifestation.

Key words : Systemic Lupus Erythematosus, late-onset, elderly

919

PO 450Name : dr. HerikurniawanStudy Program : Internal MedicineTitle : Correlation of Body Fat Distribution with Medial Tibiofemoral Joint Space Width in Knee Osteoarthritis with Obesity

Background: Obesity is a major risk factor for knee osteoarthritis. The relationship between obesity and OA may not simply due to mechanical factor. Evidence suggests that metabolic factors related to body fat play important roles, but the specific type of fat that contributes to OA is unclear. The objective of this study was to examine the possible correlation between body fat distributions with knee OA

Method: This study was a cross sectional study in OA patients with obesity visiting Rheumatology, Geriatric, Internal Medicine clinics in Cipto Mangunkusumo Hospital between January-March 2016. Samples were collected using consecutive sampling method. Knee OA was diagnosed from clinical and radiologic evaluation based on American College of Rheumatology 1986 criteria. Body fat distribution was measured by bioelectrical impedance analysis (BIA). Radiographs of the knee was measured by conventional radiography to evaluate joint space narrowing (JSN). The correlation between body fat distributions with joint space width was analyzed by bivariate analysis

Result: A total of 56 subjects were recruited, with majority of subjects were women (73.2%). Median of visceral fat was 12% (7.5-16.5), median of subcutaneous fat was 30.2% (16.5-37.9) and median of visceral to subcutaneous fat ratio was 0.40 (0.26-0.80). Mean of medial tibiofemoral joint space width was 2.34 mm (SB 0.78). In bivariate analysis we found correlation between visceral fat and medial tibiofemoral joint space width (r: -0.474 p: < 0.001). There is no correlation between subcutaneous fat and medial tibiofemoral joint space width (r: -0.187 p: 0.169) and also visceral to subcutaneous fat ratio and medial tibiofemoral joint space width (r: -0.225 p: 0.09).

Conclusion: Visceral fat is correlated with medial tibiofemoral joint space width (r: -0,474 p: < 0,001). There is no correlation between neither subcutaneous fat nor visceral to subcutaneous fat ratio and medial tibiofemoral joint space width.

Keyword: Osteoarthritis, obesity, visceral fat, subcutaneous fat, visceral to subcutaneous fat ratio, medial tibiofemoral joint space width

920

PO 451Correlation Between Serum Concentration of Nerve Growth Factor with Disease Activity in Patient with Rheumatoid Arhtritis

Ariska Sinaga1, Harry Isbagio2, Bambang Susetyo2, Sukamto Kusno31Departement of Internal Medicine Medical Faculty University of Indonesia. 2Rheumatology Division Departement of Internal Medicine Medical Faculty University of Indonesia 3 Clinical Epidemilogy Unit of Medical Faculty University of Indonesia – Cipto Mangunkusumo General Hospital

Background: Rheumatoid Arthritis (RA) is a chronic systemic inflammatory disease that attacks synovial tissue. Disease acticity of RA is an expression of the inflammatory cascade. Disease activity is a variable that can be used as a substitute for the RA marker of the inflammatory process. Disease activity of a given joint is correlated with the synovial vascularization. Synovial tissue inflammation accompanied by pannus formation requires intake of nutrients and oxygen via angiogenesis. Angiogenesis in an integral part of the development of the pannus formation. Increased angiogenic markers shows increase in progressivity of inflammation and disease activity. NGF is a signaling protein and growth factor that play a role in angiogenesis. Several previous studies reported NGF concentrations were increased in both the serum and synovial fluid of AR. NGF induce proangiogenic factors and other growth factors that play a role in AR. Currently, there are no studies of NGF serum concentration toward AR disease activity found.

Objective: To determine the serum concentration of NGF and compare them with indices of disease activity in RA.

Methods: This is a cross-sectional study conducted on outpatient of the rheumatology clinic at Cipto Mangunkusumo General Hospital from October to December 2015. NGF concentrations were evaluated with a two site immunoenzymatic assay (ELISA) in 50 RA patients. Disease activity in this study was assessed using DAS28 ESR and DAS28 CRP score using a calculator program accessible from the internet on http://www.das-score.nl/

Results: We recruted 50 subjects, consisting of 47 women (94%) and three men (6%). The mean age of the study subjects was 43.44 years. Median serum NGF was 4.33 pg / mL (2.35 to 20.83). The datas revealed correlation between serum NGF with 28 DAS28 ESR score (r = +0.427; p = 0.002) and DAS28 CRP score (r = + 0407; p = 0.003).

Conclusion: There was significant correlation between serum concentration of NGF with diesease activity in patient with RA.

Keywords: rheumatoid arthritis-nerve growth factor-disease activity-DAS28

921

PO 452The Prevalence and Risk Factors of Gouty Arthritis in Malang, Indonesia

Diyah Saraswati* Fajar Sariningsih* Camelia Qusnul C* Mohammad Ananto* Muhammad Anshory* Achmad Zainudin* Lia Sasmithae* Harun Alrasyid**, C. Singgih Wahono***, Handono Kalim***

*Departement of Internal Medicine, **Departement of Public Health, ***Rheumato-Immunology Division, Departement of Internal Medicine, Faculty of Medicine, Universitas Brawijaya Malang, Indonesia

Background : Gout is a leading form of inflammatory arthritis, characterized by severe joint pain and can lead to irreversible joint damage if untreated. Until recently, gout has been regarded as a minor medical problem, in part because the associated economic burden has not been appreciated

Objectives : To asses the prevalence and risk factors of gouty arthritis in the community of Malang, East Java, Indonesia.

Methods : A crosssectional study, using multistage randomized method in 2067 population over the age of 15 years old. Data collection was direct observation with interview and questionnaire, using the Modified COPCORD screening methodology. Chi Square describes factors that associated with gouty arthritis. Adjusted Odds Ratio (OR) and 95% confidence Interval (CI) were estimated by using logistic regression

Results: Respondents completed 2067 questionnaires. Of these 15 (0,73 %) respondents had gouty arthritis. Age, gender, and body mass index were associate with gouty arthritis (p<0.05). Age ≥ 45 y.o has higher risk for gouty arthritis than < 45 y.o OR 5.252 (95%CI 1,182-23,331). Man was higher risk for gouty arthritis than woman OR 3,614 (95% CI 1.231-10,614). Body mass index ≥ 23kg/m2 was higher risk than < 23 kg/m2 OR 3,888 (95%CI 0,875-17,275). Multivariate logistic regression for risk factors of gouty arthritis were age (OR4,479 95% CI 1.004-19,993 p 0.049), sex (OR 4,265 95% CI 1.436-12,664 p 0.049), and BMI (OR 4,539 95% CI 1.006-20,476 p 0.049) .

Conclusion: In this study, we found that prevalence of gouty arthritis is 0,73 %. The risk factors of gouty arthritis in our population were increasing by age, gender, and body mass index. The most dominant risk factor that associated with gouty arthritis was marital BMI.

922

PO 453THE CORRELATION BETWEEN BODY MASS INDEX, HISTORY OF PHYSICAL ACTIVITY, SMOKING HABITS WITH SEVERITY DEGREE OF KNEE OSTEOARTHRITIS PATIENTS AT PROF. DR. W. Z. JOHANNES GENERAL HOSPITAL IN 2016

Deodatus Theodorus Suriasa1, Ika Febianti Buntoro2, Stefany Adi Wahyuningrum31Medical Faculty of Nusa Cendana University 2Medical Education Department of Medical Faculty of Nusa Cendana University3Internal Medicine Department of Prof. W.Z. Johannes General Hospital

Background : Osteoarthritis (OA) is a most common arthritis in the elderly, and most occur in the fourth and fifth decades. OA is a chronic disease that causes pain and disability in the elderly. Disabilities that occur very closely related to the magnitude of OA severity. There are some risk factors that can lead to increased severity of OA. In this research will be discussed three factors that being trigger to increase severity of OA, there are body mass index (BMI), history of physical activity and smoking habits.

Purpose : This study was made to see the correlation between body mass index, history of physical activity, smoking habits and severity of knee OA were assessed by questionnaire Lequesne index.

Methods : The study design was cross-sectional. With 67 people respondents, then the data will be analyzed statistically with Spearman test and Chi-Square test.

Results : Statistical analysis between IMT with the severity of knee OA showed a significant correlation (p = <0.000, r = 0.630), and the results of statistical analysis between smoking history with the severity of knee OA also showed a significant correlation (p = <0.000 and r = 0591). However, the different results obtained from statistical analysis between smoking and severity of knee OA that did not show any correlation (p => 0.532 and r = 2.201).

Conclusion : Based on study, most of the respondents were experiencing OA is a man. Factors that can increase the severity of knee OA are the body mass index and fat strenuous physical activity. Smoking habits proved not affect the severity of knee OA.

Keywords: Body Mass Index (BMI), history of physical activity, smoking habits, knee osteoarthritis, the severity

923

PO 454Validity of Modified COPCORD Questionnaire Translated to Bahasa Indonesia as a Screening Tool for Rheumatic Disease

Muhammad Anshory*, Camelia Qusnul C.*, Fajar Sariningsih*, Mohammad Ananto*, Diyah Saraswati*, Achmad Zainuddin*, Lia Sasmithae*, Harun Alrasyid**, C.Singgih Wahono***, Handono Kalim****Departement of Internal Medicine, **Departement of Public Health, ***Rheumato-Immunology Division, Departement of Internal Medicine, Faculty of Medicine, Universitas Brawijaya Malang, Indonesia

Background: WHO-ILAR COPCORD is a program that intended as an early screening tool for rheumatic disease, especially in people with limited health facilities.

Objective: (1) To adapt the COPCORD questionnaire for use as a screening instrument among Indonesian, including translation, back-translation, assessment of cross cultural equivalence and (2) to evaluate the performance of the COPCORD questionnaire as a diagnostic tool for rheumatic diseases.

Method: Translation to Indonesian and assessment of cross cultural equivalence were undertaken by bilingual rheumatologist and the back translation was done by a certified english lecturer. We interviewed 100 samples and included in the analysis to evaluate sensitivity, specificity, receiver operating characteristics curve (ROC), and positive likelihood ratio (LR+) of the modified COPCORD questionnaire as a case-detection tool for rheumatic diagnosis. Forward logistic regression was performed to identify the strength of association (OR) for each question.

Results: Translation, cross cultural equivalence and back translation of the translated questionnaire were satisfactory and interviewer agreement was achieved. All questions were significant to establish the diagnosis, but pain in more than 7 days, high pain score in more than 7 days and history of drug consumption came with LR+ >1 for diagnosis and AUC > 0.8. We did a forward logistic regression for these three variables and the most significant question was about the drug consumption (OR 180,167;95%CI 38,196-849,834), and based on model these questions together can diagnose up to 84%.

Conclusion: The Modified Indonesian version of the COPCORD questionnaire has been adapted and appears to be a good case-detection tool for screening of rheumatic diseases in Indonesia.

924

PO 455THE CORRELATION BETWEEN THE JOINT SPACE WIDTH (JSW) WITH THE LEVELS OF SYNOVIAL FLUID CARTILAGE OLIGOMERIC MATRIX PROTEIN (COMP) IN THE KNEE OSTEOARTHRITIS SUBJECTS

‘Alima Susilawati Sadrina, Halima Sa’diyah, Faridin HP, A. Makbul Aman, Haerani Rasyid, Harun Iskandar,Sudirman Katu, Syakib Bakri

Department of Internal MedicineFaculty of Medicine of Hasanuddin University, Makassar, Indonesia

Background : Radiology examination has limitations that it can not show changes in knee Osteoarthritis (OA) at early stage. The alternative method that detect changes in the joints at early stage of disease is measurement of the tissue synthesis and degradation markers. Cartilage oligomeric matrix protein (COMP) is a marker of cartilage destruction found in cartilage and other tissue. This study aimed to assess the correlation between JSW with the synovial fluid COMP level in knee OA subjects.

Patients and Methods : The research was conducted in outpatients with primary knee OA based on American College of Rheumatology (ACR) criteria at the Rheumatology Clinic of Dr. Wahidin Sudirohusodo General Hospital, Makassar, South Sulawesi, Indonesia from March through June 2015. The research was an observational study with the cross sectional design. Patients were assessed for synovial fluid COMP level by using ELISA method and determined their JSW into 4 groups. The correlation between the severities of knee OA and serum COMP was analyzed by Spearman correlation and Kruskal-Wallis test. Level of statistical significance used was p < 0.05.

Results : Sixty-nine patients were included in the study, with a mean of age of 61.9 ± 9.1 years. Results of correlation analysis of JSW with synovial fluid COMP level showed a significant negative correlation (p <0.001), that level of synovial fluid COMP were higher in subjects with more severe narrowing of the joint space width. The closeness of the correlation between the JSW with the level of synovial fluid COMP is categorized as very close (r> 0.75).

Conclution : There is a correlation between the joints space width with the synovial fluid COMP level.

Keywords: OA, JSW, synovial fluid COMP level.

925

PO 456KUALITAS HIDUP LANSIA DENGAN OSTEOARTRITIS GENU DI RSU BETHESDA YOGYAKARTAMeryones Br. Tobing*, The Maria Meiwati Widagdo, Lisa Kurnia Sari, Mitra Andini Sigilipoe

Fakultas Kedokteran Universitas Kristen Duta Wacana/Rumah Sakit Bethesda

Latar Belakang: Populasi usia lanjut yang semakin bertambah memberikan tantangan baru dalam pelayanan kesehatan. Osteoartritis merupakan penyakit arthritis yang paling umum terjadi dan salah satu penyebab utama terjadinya rasa nyeri dan kecacatan di dunia pada lansia. Timbulnya rasa nyeri mempengaruhi kualitas hidup.

Tujuan: Mengetahui hubungan nyeri terhadap kualitas hidup lansia dengan osteoartritis lutut.

Metode Penelitian: Metode cross-sectional, menggunakan kuesioner WHOQOL-BREF dan pengukuran derajat nyeri dengan VAS (Visual Analogue Scale), WOMAC dan Indeks Lequesne serta wawancara singkat untuk mengetahui karakteristik responden. Subyek penelitian adalah pasien osteoartritis lutut rawat jalan di Poliklinik Penyakit Dalam Rumah Sakit Umum Bethesda Yogyakarta periode Februari 2016 – Mei 2016. Analisis data dilakukan dengan uji korelasi spearman.

Hasil: Subyek penelitian terdiri dari 41 lansia dengan osteoarthritis lutut. Terdapat 22 pasien perempuan dan 19 pasien laki-laki. Usia berkisar antara 60 sampai 80 tahun, dan proporsi tertinggi dari rentang usia berusia 60-70 tahun. Hasil uji analisis Spearman menunjukkan bahwa terdapat hubungan yang signifikan antara tingkat rasa sakit dan tingkat keparahan osteoarthritis dengan kualitas hidup lansia dengan osteoarthritis lutut dalam domain kesehatan fisik WHOQOL-BREF kuesioner, tapi tidak ada korelasi yang signifikan dalam psikologi , hubungan sosial, dan domain lingkungan WHOQOL-BREF kuesioner.

Kesimpulan: Terdapat hubungan nyeri atau keparahan penyakit terhadap kualitas hidup lansia dengan osteoartritis lutut.

Kata Kunci: lansia, osteoartritis lutut, kualitas hidup, nyeri

926

PO 457Atypical presentation of Henoch Schonlein Purpura in an adult.

Henoch Schonlein Purpura (HSP) is a rare non-thrombocytopenic lgA mediated small-vessel vasculitis of autoimmune hypersensitivity, more common in children than in adults.

The authors present the case of an 83 year old male patient who visited the Emergency Department due to persistent diffuse abdominal pain over the previous 2 months. His primary care physician had prescribed oral diclofenac sodium (with a history of allergy to this drug). With respect to his medical history, the only significant finding was benign prostatic hyperplasia.

A day after admission he developed palpable purple-red papules (various dimensions and configurations), initially of the lower limbs, but with a cephalic progression. Concomitantly he presented with hyperalgesia and mechanical allodynia accompanied by fever (38.5ºC) and generalized oedema, as well as dysuria, a sensation of bladder fullness and lower abdominal discomfort. During his stay in the ward he developed nausea, vomiting, macroscopic haematuria and blood in his stools.

Biopsy of the skin lesions was consistent with leukocytoclastic vasculitis. Laboratory tests showed leukocytosis (WBC: 20 900/microL); Hb - 12 g/dL; BUN - 80 mg/dL; serum creatinine - 2.5 mg/dL and urinalysis with hematuria and proteinuria. Antinuclear antibodies, antineutrophil cytoplasmic antibodies and anti-double stranded DNA were negative.

Colonoscopy was consistent with non-ischemic colitis.

Renal biopsy documented IgA deposits in the capillaries but not in the mesangium.

A cycle of 3 days of intravenous methylprednisolone was completed, but the patient developed steroid psychosis. For this reason, the treatment was altered to oral prednisone (40 mg) plus oral cyclophosphamide (1 gr) with complete regression his symptoms.

HSP is an IgA mediated small-vessel vasculitis, more common in children than in adults. This clinical entity should always be considered in adults presenting with vasculitic skin rashes and abdominal complaints.

927

PO 458ADULT-ONSET STILL’S DISEASE

Adult-onset Still’s disease is a rare inflammatory disorder that has been classified as a polygenic auto-inflammatory disorder. It is characterized by the classic triad of persistent high grade spiking fever, joint pain and distinctive salmon-colored rash. This disease is considered a diagnosis of exclusion and for a definitive diagnosis the Yamaguchi Criteria are utilized – these include major criteria (high grade spiking fever, arthralgia or arthritis, typical rash and leukocytosis), minor criteria (odynophagia, lymphadenopathies, hepatomegaly or splenomegaly, abnormal hepatic function, and negative antinuclear antibodies and rheumatoid factor) and exclusion criteria (exclusion of infections, malignant disease and other rheumatologic diseases). For a definitive diagnosis the presence of at least five criteria is mandatory (2 of which must be major).

The authors present a series of 3 cases of Adult-onset Still’s disease.

A 47 year old male patient with a history of diabetes mellitus and arterial hypertension who presented with high grade spiking fever (superior to 39ºC), poly-arthralgia and rash. Further study revealed leukocytosis with neutrophilia, hypoalbuminemia and high ferritin levels.

A 31 year old female patient with a history of a pancreatic paraganglyoma with surgical resection in 2004 who presented with high grade spiking fever, arthralgia and laboratory tests with leukocytosis and neutrophilia. All further tests, including auto-immune tests were negative.

A 47 year old male patient who presented with myocarditis, and later developed fever, odynophagia, polyarthralgia, hepatomegaly, typical rash and high ferritin levels. Further study and test were all negative, leading to a diagnosis of adult-onset Still’s disease.

Adult-onset Still’s disease is a rare, complex disease with a polymorphic clinical presentation. Here we present three different cases with completely different clinical presentations. The possibility of this clinical entity should always be present as a high level of clinical suspicion is necessary for a correct diagnosis.

928

PO 459A case of multiple autoimmune syndrome of Systemic Lupus Erythematous, Graves disease and autoimmune pancreatitisMuhammad Ikhsan Mokoagow, * Surya Wijaya, and **Aryan Yohanes**

*Dept of Internal Medicine, Fatmawati General Hospital**Dept of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr Cipto Mangunkusumo National Referral Hospital

Abstract

Several autoimmune diseases may occur in one individual and when three or more conditions coexists are termed multiple autoimmune syndrome. We present a 34-year-old female who presented to Fatmawati General Hospital with swollen legs with a suspicion of vascular occlusion. Further investigation revealed the presence of non scarring frank alopecia, urinary cast, leukopenia with lymphopenia, thrombocytopenia, positive Antinuclear Antibody (ANA) with positive for SS-A native and nucleosomes, and positive anti Ds-DNA that consistent with Systemic Lupus Erythematosus. She also suffered from lower limb weakness accompanied by weight loss, tremor, palpitation, excitable, heat intolerance and change of bowel frequency –later diarrhea. In addition, exophthalmos and palpable diffuse goiter was found. Further workup demonstrated low TSHs level with an increased in fT4 level, diffuse goiter with increased vascularization from ultrasound examination, and positive for Thyroid Receptor Antibody (TRAb) that consistent with Graves disease. During hospitalization, she suffered from nausea vomiting with greenish liquids. Increased levels of Amilase and Lipase suggested an acute pancreatitis. Unfortunately, pancreas imaging, elevated serum IgG4 levels and autoantibodies directed against carbonic anhydrase and lactoferrin were not documented in this patient, partly due to limited resources. Nevertheless, the inflammation of pancreas responded well to glucocorticoid therapy, suggesting an autoimmune pancreatitis in this patient. She was finally discharged from the hospital in a clinically improved condition having been treated with pulse dose steroid that was subsequently tapered down and also treatment with methimazole along with propranolol to alleviate her thyroid problems.

Keywords: Systemic Lupus erythematosus, Graves diseases and autoimmune pancreatitis

929

PO 460ASSOCIATION OF LYMPHOPENIA WITH DISEASE ACTIVITY, DAMAGE INDEX, AND QUALITY OF LIFE IN SLE

Hidayat, II; Hamijoyo, L

Background. Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by production of array of antibody and multisystem involvement, including hematologic system. Lymphopenia was observed in 62-75% of adult SLE patients. It was observed to be associated with disease activity and organ damage. Interestingly, clinical usefulness of lymphopenia has been limited mainly to aid in diagnosis of SLE. The aim of this study was to determine the association of lymphopenia with disease activity, damage index, and quality of life.

Methods. This study was a cross sectional study conducted on SLE patients fulfilling the ACR revised criteria or the SLICC Criteria for SLE in Rheumatology Clinics Hasan Sadikin Hospital, Bandung, Indonesia, from December 2013 to March 2015. All patients were participant of Lupus Low Disease Activity State (LLDAS) study. Disease activity was assessed using SLEDAI-2k. The quality of life was measured with SF-36 version2. SLICC/ACR-damage index(DI) was used to evaluate non reversible organ damage associated with SLE activity. The statistical analysis was performed using independent-samples T Test.

Results. Total participant of this study were 88 patients. Ninety five percent patients were women. Mean of age was 35 years with median duration of disease was 7 years. There were 44 patients with lymphocytes <1500/mm3 and the others were normal. Mean of SLEDAI-2k, SLICC-DI, PCS, and MCS in patients with lymphopenia were 4.82, 0.68, 44.68, and 40.77, meanwhile they were 3.18, 0.66, 44.48, and 43.93 in patients with normal lymphocyte count. The differences were not statistically significant with p-value 0.202, 0.915, 0.909, and 0.183, respectively. Correlation of lymphocyte count and SLEDAI had r -0.132 (p-value 0.22)

Conclusion. There was no association between lymphopenia and disease activity, damage index, and quality of life of SLE patients.

Keyword: Lymphopenia, lupus, disease activity

930

PO 461AMONG ELDERLY WITH KNEE OSTEOARTHRITIS, PAIN AND SEVERITY WERE ONLY CORRELATED WITH QUALITY OF LIFE IN PHYSICAL HEALTH DOMAINMeryones Br. Tobing*, The Maria Meiwati Widagdo**, Lisa Kurnia Sari***

*Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia**Department of Public Health, Duta Wacana Christian University,Yogyakarta, Indonesia***Internal Medicine Department, Bethesda Lempuyangwangi Hospital – Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia

ABSTRACT

Background: The increasing aging population provided new challenges in health care. Osteoarthritis is the most common arthritis and one of the main causes of pain and disability in elderly which can affect quality of life.

Objective: To assess the correlation of knee osteoarthritis severity and degree of pain with quality of life of elderly with knee osteoarthritis.

Methods: A cross sectional research was conducted from February 2016 to May 2016. Respondents were elderly outpatients with knee osteoarthritis, aged 60 or older, in Internal Medicine Clinic, Bethesda Lempuyangwangi Hospital, Yogyakarta. Visual Analogue Scale (VAS) was used to assess knee osteoarthritis degree of pain. Composite index of Western Ontario and McMaster Universities (WOMAC) and Lequesne index, as well as a brief interview, were conducted to determine osteoarthritis severity and characteristics of respondents. Quality of life was assessed using The Indonesian version of World Health Organization Quality of Life (WHOQOL)- BREF questionnaire. Data were analysed with Spearman correlations test.

Results: Respondents consisted of 41 elderly (22 females and 19 males) with knee osteoarthritis. There were significant correlations between VAS (r=- 0.313; p=0.047), WOMAC index (r=-0.341; p=0.029), and Lequesne index (r=- 0.441; p=0.04) with quality of life in the physical health domain of WHOQOLBREF questionnaire. There were no significant correlations in the psychological, social relations, and environmental domains of WHOQOLBREF questionnaire.

Conclusion: There were significant correlations between pain or severity of disease and quality of life among elderly with knee osteoarthritis in physical health domain.

Keywords: elderly, knee osteoarthritis, quality of life, pain.

931

PO 462A. Kotulska1, P. Wiland2, E. J. Kucharz1, M. Olesinska3, A. Felis-Giemza3, M. Kopec-Medrek3, A. Zon-Giebel3, W. Romanowski3, L. Szymczak-Bartz3, M. Tlustochowicz3, J. Lewandowicz3, J. Kowalska-Majka3, J. Bucka3, M. Majdan3, Z. Kielbik3, M. Korkosz3, A. Bielinska3, P. Leszczynski3, K. Pawlak-Bus3, M. Puszczewicz3, M. Majewski3, K. Smolik3, T. Migas-Kukla3, M. Sochocka-Bykowska3, M. Szarecka3, B. Luberda3, M. Falenta-Hitnarowicz3, J. Swikszcz-Gniadek3, W. Lepiarz-Rusek3, G. Rozwadowski3, B. Chara3, J. Zajdel3, Z. Zdrojewski3, I. Rosmus-Kuczia3Satisfaction and Dissatisfaction of Patients with Rheumatic Diseases Receiving Biologics

1. Department of Internal Medicine and Rheumatology, Medical university of Silesia, Katowice, Poland

2. Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Wroclaw, Poland

3. Research Group of the Polish Society of Rheumatology

Objectives. Biologics are medication widely applied in management of inflammatory rheumatic diseases. The drugs were found to be effective but their application is associated with some disadvantages. Medication with biologics is relatively expensive, and in Poland, it is carried out in specialized centers. The study was designed to evaluate various aspects of satisfaction and dissatisfaction of the Polish patients treated with biologics.

Methods. Anonymous questionnaires were distributed in 23 Polish rheumatological centers involved in the treatment, 1231 questionnaires were used for analysis. Responses were received from 606 patients with rheumatoid arthritis (RA), 427 with ankylosing spondylitis (SA), 117 psoriatic arthritis (PS), and 62 adult patients with juvenile idiopathic arthritis (JIA) (in whom administration of the drugs had been introduced before they were 18-year-old), as well as 19 ones receiving the drugs due to other musculoskeletal disorders. The investigated group constituted about one-fifth of all rheumatic patients on biologics in Poland.

Results. The main reasons for satisfaction were positive influence of the treatment on family life (41% RA, 41% SA, 41% PS), general physical status (51% RA, 51% SA, very positive 43% PS), mental well-being (46% RA, 47% SA, 48% JIA, very positive 43% PS), sexual life (39% SA, 38% PS, 31% RA), sleep (39% RA, 41% SA, 36% PS, 40% JIA), in smaller part of the patients it had effect on working and financial situation. In general, satisfaction of the treatment was evaluated as positive or very positive in 84% patients with RA, 72% with SA, 87% with PS and 81% with JIA.

In almost half of the patients, transportation to the medical center was a disadvantage of the treatment. 79% did not consider blood sampling as a problem for them. About one-third of the patients considered laboratory and imagine tests to be done before initiation

932

of the medication as a difficulty, and for 27-47% waiting time for qualification for the medication was a significant disadvantage. The route of drug administration was without importance for 4/5 of the patients.

Conclusions. Summing up, the results were similar in the patients suffering from various diseases although those with PS felt the highest satisfaction (possible due to positive aesthetic effect), and those with SA had significant improvement in sexual life (probably due to younger age). Relatively low satisfaction was found in patients with JIA. There was low influence of medication on financial status of the patients however some of them returned to work. Application of biologics has low disadvantages and most of them are associated with organization of health services (waiting time for the tests, transportation to the medical centers).

933

PO 463CRITICAL FLICKER FREQUENCY FOR DIAGNOSIS OF MINIMAL HEPATIC ENCEPHALOPATHY IN CIRRHOSIS PATIENT AT SANGLAH HOSPITAL DENPASAR BALICok Istri Yuliandari*, IDN Wibawa**, IGA Suryadarma**, N Purwadi**, K Mariadi**, Gd Somayana**

*Resident of Internal Medicine, Faculty of Medicine Udayana University/ Sanglah Hospital Denpasar Bali **Gastrorenterology and Hepatology Division, Department of Internal Medicine, Faculty of Medicine, Udayana University/Sanglah Hospital Denpasar Bali

Background: Minimal hepatic encephalopathy (MHE) show no clinical sign and recognizable cognitive impairment, but it can impair patient daily functioning of life. MHE is mainly diagnose by psychometric testing, but it need to be adjusted with local reference value and it is not widespread in routine clinical practice. We therefore performed the critical flicker frequency (CFF) for diagnosis of MHE and assess the predictor of MHE.

Methods: We performed a cross sectional study of 80 consecutive cirrhosis patient without overt encephalopathy seen at Sanglah Hospital Bali from December 2013 through January 2015. Cirrhosis was identified by biochemical parameters, ultrasound, endoscopic analyses. Liver dysfunction was determined based on child turcotte pugh (CTP) scores. Demographic characteristic of patient also assessed. CFF (hepatonom analyzer) were administered to all subject and MHE was diagnosed when CFF result less than 38 Hz. Descriptive analyses, univariate and multivariate logistic regression were performed to determine predictors of MHE.

Result: Twenty six (32,5%) patient ware diagnosed to have MHE, which are 2/26 (7,7%) in CTP A, 11/26 (42,3%) in CTP B, and 13/26 (50,0%) in CTP C. The mean of CFF score was 36,40±2,75 and 46,30±4,51 (p=0,00) in MHE and non MHE group respectively. The level of sodium (132,15±5,10 vs. 134,75±4,79/ p=0,03) and CTP score (9,46±1,86 vs. 7,87±1,69/ p=0,00) were significantly higher in MHE as compared to non MHE group. Age, sex, jobs, and education years were not significantly different between two groups. On multivariate analysis CTP score were significant associated with MHE (1,68 (95% CI (1,19-2,38) p=0,00), while sodium level (0,94 (95% CI (0,84-1,06) p=0,35) was not significant. This result shows CTP score is a predictive factor for MHE and the effect of sodium level are no longer significant after controlling for the correlated effect of other variable.

Conclusion: Prevalence of MHE in this study was 32,5%, and higher CTP score was predictive of MHE.

934

PO 464Rhabdomyolysis during telbivudine treatment in a chronic hepatitis B patient

Bahar Ozdemir, Zakir Guliyev, Betül Erismis, Hakan Kocoglu, Tarık Ercan, Yıldız Okuturlar, Mehmet Hursitoglu, Ozlem Harmanda

Bakırkoy Dr.Sadi Konuk Training and Research Hospital, Istanbul

Background: Telbivudine (β-L-2′-deoxythymidine) is a β-L-nucleoside analogue of thymidine that impairs hepatitis B virus (HBV) DNA replication. Initially, it was regarded as being generally well tolerated, with low adverse reaction profiles and no dose-limiting toxicity. Recently, with the result of the telbivudine worldwide phase III GLOBE trial, cases of myopathy has been reported undergoing long-term telbivudine treatments.

Case: A sixty-five-year-old man was admitted to our emergency room because of fatigue, nausea. Four years ago, the patient had been diagnosed with chronic hepatitis B. No other drug history of patients receiving telbivudine four years. She had no history of another sickness. Examination of cardiovascular, respiratory, abdominal systems and extremities were normal. Laboratory tests showed; urea 288 mg/dl, creatinin 6,2 mg/dl, creatinine phosphokinase (CPK) 1925 u/l, albumin 4,5 g/dL, hemoglobin 13,6 g/dl, sodium 138 mmol/L, potassium 5,3 mmol/L, calcium 9 mg/dl, phosphor 4,1 mg/dL, aspartate aminotransferase (AST) 52 U/L, alanine aminotransferase (ALT) 78 U/L, lactate dehydrogenase (LDH) 674 U/L, thyroid stimulating hormone (TSH) 1,9 uIU/mL. Arterial blood gas analysis values were; pH:7.25, pCO2:42 mmHg, HCO3:18. Abdominal ultrasound showed no pathological findings. The relationship between telbivudine and muscle damage has been confirmed by the Naranjo adverse drug reaction probability scale, that indicated probable connection between CPK increase and drug treatment. So telbivudine was discontinued, changed to entecavir and began fluid replacement. Laboratory parameters were checked approximately after 24 hours and normal results were detected.

Conclusion: Rhabdomyolysis can occur due to the use of telbivudine, however its pathophysiology was not explored because of the restriction of case-series study.

935

PO 465AUTOIMMUN HEPATITIS DUE TO PARACETAMOL: Case Report

Arda Cuma Yapar, İrem Kıraç Utku, Esra Demir, Güleren Yartaş Dumanlı, Ömür Tabak, Abdülbaki Kumbasar

INTRODUCTION: We describe an autoimmun hepatitis case induced by using of paracetamol.

CASE: 33 year old male patient who is paraplegic due to falling down from highrise place took 5 mg paracetamole nearly in 10 days. There is no history of using other drug, alcohol or xenobiotics. After he took paracetamol, nausea, vomiting, abdominal pain devoloped and he admitted to hospital. In physical examination his scleras were icteric and diffuse abdominal tenderness was present. In laboratuary anlyses; AST: 855 U/L, ALT: 844 U/L, GGT: 850 U/L, ALP 422 U/L,Total Bilirubin: 4.5mg/dl, Direct Bilirubin: 4.4 mg/dl, Albumin: 3.6, INR 1.3, IgG: 2282, viral hepatitis markers were negative, ANA and ASMA were positive. Portal doppler ultrasonography was normal. In upper abdomen MRI; micronodular structures, nodular steatosis in the liver parenchyma and diffuse parenchymal liver disease were detected. There were no findings of Wilsons disease and Hemachoromatozis. According to CIOMS scoring system the patient took 7 points ( probably autoimmune hepatitis). Liver biopsy was performed and found that cholestatic liver tissue with intensive intralobular bile duct injury, portal and lobular inflammation rich of eosinophils and mixt cholestatic- hepatic liver disease due to drug. We ordered steroid for the patient who has 7 points in CIOMS scoring system. Elevated transaminase levels and elevated biluribin levels decreased back to normal following days and the patient was discharged.

DISCUSSION: Some viruses, drugs, bacteria and chemicals can trigger immunity to hepatic proteins and can cause autoimmune hepatitis. 9% percent of automimmun hepatitis devolops due to drugs. Acute onset after using drug, abcense of choronic disease history, good response to steroids and short recovering process support autoimmune hepatitis. There are side effects such as of anemia, methemoglobinemia, hepatic necrosis, arrhythmia, encephalopathy, gastrointestinal system disorders in the literature due to using paracetamol but we have not come across the case of autoimmun hepatitits due to paracetamol reported in literature.

936

PO 466Therapeutic effect of Telmisartan compared with Valsartan on Serum Adiponectin Levels in Non-alcoholic Fatty Liver Disease (NAFLD) patients with Diabetes Melitus and Hypertension

Fahmi Indrarti, Neneng Ratnasari, Hemi Sinorita, Putut Bayupurnama, Sutanto Maduseno, Catharina Tri Wikatmani

Abstract

Background. Non-alcoholic fatty liver is a condition that can progress to advanced liver disease. The decreased level of serum adiponectin represents an independent risk factor for (NAFLD) and liver dysfunctions in humans. The inhibition of Renin-angiotensin system will improve intracellular insulin signaling through activation of PPAR-γ, improve production control adipokines, and prevent the activation of hepatic stellate cells that will eventually prevent liver inflammation and fibrogenesis. Telmisartan and valsartan are angiotensin II receptor blocker (ARB) that have potential effect to activated peroxisome proliferator-activated receptor-γ (PPAR-γ). The aim of the study to determine whether administration of telmisartan may increase serum adiponectin levels more significant than valsartan in NAFLD patients with diabetes and hypertension.

Methods. This is a quasi experimental study using before and after design. The study was conducted at Endocrinology Division polyclinic of Department of Internal Medicine in Dr. Sardjito General Hospital. The subjects who meet the criteria for NAFLD, divided into 2 groups. The first group received telmisartan 80 mg, while the second group received 80 mg of valsartan, were evaluated for 12 weeks. The mean difference of serum adiponectin levels from both groups were tested using an independent t-test.

Result. The mean difference of adiponectin levels in telmisartan group before therapy was 3.87 ± 1.40 μg/ml, after therapy 36.63 ± 13.68 μg/ml (p < 0.001). In the valsartan group mean difference adiponectin levels before therapy 3.69 ± 1.34 μg/ml, after therapy 40.74 ± 20.60 μg/ml (p < 0.001). There is no difference between the mean difference of delta adiponectin telmisartan compared with valsartan after therapy (p = 0.463; t = 0.74).

Conclusion. Administration of telmisartan equally increases the serum of adiponectin levels significantly than valsartan administration in NAFLD patients with diabetes mellitus and hypertension.

Key words: NAFLD, Adiponectin, BARD score, Telmisartan,Valsartan.

937

PO 467PRIMARY SCLEROSING CHOLANGITIS IN THE ELDERLY, A DIAGNOSTIC CHALLENGE, PRESENTATION CASE.

Pliego-Reyes CL, Tobar-Marcillo MA, Vela-Vizcaíno H, Delgado-Soler LA, Alemán-Velázquez P, De La Torre-Rendón F.

BACKGROUND: The primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic liver of unknown etiology disease characterized by inflammation, fibrosis and stenosis of small, medium and large intrahepatic and extrahepatic biliary ducts. With a mean age of onset of 41 years; however it is uncommon in patients older than 50 years, with Japan the only country that reported a second peak of incidence on the sixth decade of life.

Methods: As a clinical entity of low incidence in geriatric age, we present the case of a patient of 84 years who in the study of jaundiced syndrome, primary sclerosing cholangitis was concluded, in addition to literature review before a diagnostic challenge of jaundice in the elderly patient.

Case presentation: 84 year old man with a history of consumption of snuff with less than 1 year package index, distillate consumption reaching consuming toxic doses every two months and 5 years suspended. History of syphilis infection twice during his youth, eradicated using penicillin. Enter through box 40 days of evolution characterized by predominantly nocturnal itching, jaundice and dark urine evolve without added another manifestation. On admission bilirubin 17.2 mg/dl is documented predominance of direct bilirubin 13.1 mg/dl, alkaline phosphatase 158 U/L, gamma glutamyl transpeptidase 109.8U/L, alanine aminotransferase 46 U/L, aspartate aminotransferase 34 U/L. Blood count with slight increase in eosinophils and report negative viral hepatitis panel. An ultrasound liver without reporting data biliary tract dilation.Neoplastic causes were discarded by tumor antigens, which were within the normal limits and abdominal CT scan was performed without changes. It was decided to make endoscopic retrograde colagiopancreatografia (ERCP) and magnetic colagioresonancia to allow better visualization of the bile duct, however both studies were reported as normal.Reported mitochondrial antibodies negative, negative ANCA p, immunoglobulins and immunoglobulin G subclasses in normal ranges except for increasing immunoglobulin E 228 IU / ml. Faced with the absence of diagnostic conclusion liver ultrasound-guided biopsy which reported portal tracts atrophic or surrounded by concentric fibrosis implicating the entire portal space is done, the branches of the portal vein are dilated vein center lobular unchanged, the sinusoides show hyperplasia Kupffer cells that have phagocytosed, negative staining for orceína for hemosiderin and iron and copper being granular brown pigment as bile possibility is concluded that the changes were consistent with primary sclerosing cholangitis.

938

Discussion and conclusions: the approach to the jaundiced syndrome is a diagnostic challenge for the physician, which must be studying their etiologies depending on the profile of lab tests of liver function, clinical manifestations and age of presentation, pretending to rule out the most common causes to the rarest. We report the case of a male patient aged 84, in which it was concluded as etiology CEP by liver biopsy, despite being such a rare entity in geriatric patients, it is a condition that must be considered before a jaundiced picture with pruritus, elevated peripheral eosinophils and IgE.

939

PO 468HEPATOPROTECTIVE EFFECT OF ECLIPTA PROSTATA, AN INDONESIAN HERB PLANT, ON ISONIAZID- AND RIFAMPICIN-INDUCED HEPATOTOXICITY

Michael Jonatan1, Christian Jonatan2, Ricardo Adrian Nugraha1, Firas Farisi Alkaff1, Awalia31 Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia2Panarukan Community Health Center, Situbondo, Indonesia2Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Indonesia

Background: Anti-TB drugs, especially Isoniazid (INH) and Rifampicin (RIF), are one of the commonest group underlying idiosyncratic hepatotoxicity. Eclipta prostata, an Indonesian herb plant, may prevent INH- and RIF-Hepatotoxicity. This study aim to investigate the hepatoprotective effect of Eclipta prostata in TB patients.

Materials and Methods: We reviewed ScienceDirect, Medline, & Pubmed literatures under the MeSH: “Isoniazid”, “Rifampicin”, “Hepatotoxicity” & “Eclipta prostata”, with limitations on English article. 15 studies were reviewed. The inclusion criteria were trials, animal, and bio-molecular studies regarding the topic. Data & studies were analyzed based on PICOs checklist to create a comprehensive literature review.

Results: Hepatotoxicity is the main adverse event leading to death in TB patients. INH is the most common drug associated with toxicity. RIF when used alone has low risk of drug induced liver injury (DILI), but when combined with INH can potentiate the severity and incidence of DILI.Isoniazid in liver is converted to Hydrazine, an Isoniazid’s toxic metabolite, by CYP450. This reactive toxic metabolite induced the excessive production of free radicals, which in turn will cause cell death and hepatic necrosis.Rifampicin, a potent inducer of cytochrome P450 system, enhance the toxicity of Isoniazid through increased production of Hydrazine.α-amyrin, a triterpenoid mixture from Eclipta prostata, has hepatoprotective effect by suppressing the liver cytochrome P450 activity. Furthermore, α-amyrin also proven to be effective to reduce the liver toxicity caused by acetaminophen and improve the liver function.

Conclusion: The hepatotoxicity mechanism of TB drugs, especially Isoniazid and Rifampicin, are carried out by increased activity of CYP450. Suppression of CYP450 activity can prevent the hepatotoxicity caused by those drugs. Eclipta prostata with its active ingredient, α-amyrin, can be used as supplemental therapy to prevent the hepatotoxicity by suppressing CYP450 activity.

Keywords : Eclipta prostata, Isoniazid, Rifampicin, Hepatotoxicity

940

PO 469LEUKOCYTE ESTERASE TEST FOR EARLY DETECTION OF SPONTANEOUS BACTERIAL PERITONITIS IN PATIENTS WITH LIVER CIRRHOSIS

Juwita Sembiring1, Mabel Sihombing1, Leonardo Basa Dairi1, Lukman Hakim Zain1, Mawar Afrida2, Ricke Loesnihari21 Division of Gastroentero-Hepatology, Department of Internal Medicine, Adam Malik General Hospital, Medan, Indonesia2 Departement of Clinical Pathology, Adam Malik General Hospital, Medan, Indonesia

Background. Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection of ascites fluid that occurs in patients with severe liver cirrhosis, which require immediate therapy. Culture as the gold standard requires a longer time. The aim of this study was to determine diagnostic accuracy of leukocyte esterase test compare with culture of ascites fluid to establish the diagnosis of SBP earlier.

Methods. This study was a diagnostic study on 28 consecutive liver cirrhosis patients with ascites at Adam Malik General Hospital, Medan from January-March 2016. Ascites fluid were taken to assess leukocyte esterase and were cultured. A dipstick test (Combur-Test 10M, Roche) was used to examine leukocyte esterase. Statistical software was used for the univariate analysis. Sensitivity, specificity, and predictive value were calculated.

Results. Of the 28 ascites fluid culture, 11 samples (39.3%) showed positive culture results and 17 samples no growth of bacteria (61.7%). Of the 11 positive ascites fluid from the culture, there were five samples of gram-positive bacteria, 5 samples of gram negative bacteria, and one sample of fungus. +2 Leukocyte esterase test had a sensitivity of 63.6%, specificity of 94.1%, PPV of 35% NPV of 80%, and accuracy of 82% in predicting the occurrence of SBP.

Conclusion. Leukocyte esterase test has a good diagnostic accuracy in predicting the occurrence of SBP in liver cirrhosis patients with ascites that can be used for early detection.

Keywords. Spontaneous bacterial peritonitis, liver cirrhosis, ascites, leukocyte esterase, culture

941

PO 470Differentiation in Patients with Acute Hepatitis B and Chronic Hepatitis B with Acute Exacerbation

Myung Jin Oh

Department of Internal Medicine, CHA University School of Medicine, CHA Gumi Medical Center, Gumi, Republic of Korea

Background and Aims: Many areas of the world including Korea, China and Taiwan are known as endemic areas for hepatitis B virus infection. In these countries, it is difficult to distinguish acute hepatitis B (AHB) from chronic hepatitis B with acute exacerbation (CHB-AE) due to the similar serological profiles and clinical features. Distinction between AHB and CHB-AE is clinically important to decide the initiation of antiviral therapy. The aim of this study was to investigate clinical, biochemical and virological differentiation in patients with AHB and CHB-AE.

Methods: A total of fifty-nine patients with immunoglobulin M antibody to hepatitis B core antigen seropositivity from January 2005 to December 2014 were enrolled. The subjects were divided into the AHB group (n=40) and the CHB-AE group (n=19) according to previous history of hepatitis B infection or results of radiologic examination through review of medical records. Clinical, biochemical and virological features were analyzed and compared between the both groups retrospectively.

Results: Presence of jaundice and hepatitis B envelop antibody (HBeAb) seropositivity in the AHB group were significantly higher than those in the CHB-AE group (72.5% vs. 42.1%; p=0.042 and 60.0% vs. 26.3%; p=0.002, respectively). Levels of serum HBV DNA significantly differed between the AHB group and the CHB-AE group (4.9 log10IU/ml vs. 6.7 log10IU/ml; p=0.000). In addition, levels of serum alpha-fetoprotein significantly differed in the two groups (5.5 ng/ml vs. 135.5 ng/ml; p=0.001). However, no significant difference in seropositivity rates of hepatitis B surface antigen and hepatitis B envelop antigen was observed between the both groups (90.0% vs. 100%; p=0.294 and 55.0% vs. 78.9%; p=0.133, respectively). In addition, levels of hepatitis B surface antigen (ratio of the optical density of the sample to the cut-off value [S/CO] <20) was not significantly different from the AHB group and CHB-AE group (2041.2 vs. 2078.6; p=0.756).

Conclusions: This study showed that the presence of jaundice and HBeAb seropositivity as well as the levels of serum HBV DNA and alpha-fetoprotein might be used to distinguish between patients with AHB and patients with CHB-AE.

942

PO 471TREATMENT OF HEPATORENAL SYNDROME WITH ALBUMIN FOR CIRRHOTIC PATIENTS : A CASE SERIES

Danny P. Kuswadi1, Neneng Ratnasari21Department of Internal Medicine, Dr. Sardjito General Hospital, Yogyakarta, Indonesia 2Divison of Gastroenterology and Hepatology, Dr. Sardjito General Hospital, Yogyakarta, Indonesia

Background: Hepatorenal syndrome (HRS) is defined as a functional renal failure in patients with liver disease with portal hypertension and it constitutes the climax of systemic circulatory changes associated with portal hypertension. It is characterized by an intense renal vasoconstriction, which leads to very low renal perfusion and glomerular filtration rate (GRF). Cirrhotic hemodynamics can easily lead to arterial underfilling. Various vasoconstrictors, such as terlipressin and norepinephrine, have been shown to improve renal function in approximately two thirds of patients with HRS. Unfortunately, the use of vasoconstrictors has been associated with ischemic side effects in up to 5% of patients. Albumin is thought to increase central blood volume, increase cardiac output, bind to vasoconstrictors, and increase arterial vasoconstriction and blood pressure. For this reason, an albumin recommended for the treatment.

Methods: All cirrhotic patients were admitted as inpatients into Dr. Sardjito General Hospital with hepatorenal syndrome over two months (Mei 1, 2016-June 30,2016). Once admitted, all patients were taken blood sample for measurements of serum creatinine and urine sample for measurement of proteinuria. All patients then received medical therapy with albumin were evaluated by serum creatinine.

Results: We found improvement of renal function from albumin therapy without combination of vasoconstrictor.

Conclusion: HRS patients treated with albumin without combination of vasoconstrictor showed response to treatment with decrease serum creatinine.

943

PO 472CHRONIC Q FEVER HEPATITIS

Yusuf HANCERLI, Mustafa KAPLAN, Musa SALMANOGLU, Barbaros BASBUG, Muhammet YILDIRIM, Vedat TURHAN

GATA Haydarpasa Training Hospital, Istanbul,Turkey

BACKGROUND: Q fever is a zoonotic disease caused by infection of Coxiella burnetii. While majority of the cases recover spontaneously or with treatment, chronic infection develops in only 0.2-0.5% of them. 60-80% of Chronic Q fever cases are presented with endocarditis, and it can also rarely lead to chronic hepatitis.

CASE: A 25-year-old male patient presented to the medical center with the complaints of swelling in the abdomen. Bilateral pleural effusion and acids detected in the abdomen. Patient reported that he went to pulmonology, rheumatology, physical therapy, nephrology and cardiology clinics 2 years ago with the same complaint and they investigated in detail but they were unable to diagnose. He reported after using different antibiotics, he did not remember the names of them, he got better. As a result of investigations conducted, hepatosplenomegaly and thrombocytopenia was observed in the patient besides polyserositis. Autoimmune and malignant diseases were ruled out after investigations and patient, who was working as veterinary, was evaluated in terms of infectious diseases. Liver biopsy of the patient was reported as compatible with chronic liver disease and a wide range of research results, in the terms of infectious diseases, revealed positive Coxiella burnetii (Q fever) IFA IgG (Phase II): 1/64. After taking infectious disease consultation, the patient was given 18 months of doxycycline (100 mg twice a day) and hydroxychloroquine (200 mg 2 times a day) treatment due to the diagnosis of chronic Q fever hepatitis. Patient’s symptoms gradually reduced and eventually discontinued.

CONCLUSION: Q fever should be kept in mind when treating risk group of patients, such as farmers and veterinarians in terms of zoonotic diseases. If left untreated, the chronic Q fever disease mortality can be as high as 65%. Thereby, early diagnosis and treatment can be life saving.

944

PO 473Hepatotoxicity due to anabolic steroid use:case report

Ahmet Düzgün, Kader Irak, İrem Kıraç Utku, Hanişe Özkan, Ömür Tabak, Abdulbaki Kumbasar

Aim:Anabolic steroids are drugs that have similar effects with testosterone and androstenedione. We present a young patient who used anabolic steroid for body building but cholestatic hepatitis and acute renal failure occured after that.

Case: 26 year old male was admitted with abdominal pain, nausea and icterus in sclera. Physical examination revealed tenderness in epigastrium. Laboratory examinations showed that ALT: 496 U/L, AST: 215 U/L, GGT: 153 U/L, ALP: 172 U/L, Total Bilirubin: 9.45 mg/dl, Direct Bilirubin: 8.69 mg/dl, urea: 33 mg/dl, creatinine: 1.48 mg/dl. As a result of these, the patient was diagnosed as cholestatic hepatitis and acute renal failure. There was no patholoical finding in hepatobiliary ultrasonography or MRCP. Viral markers (HBsAg, antiHBs, antiHİV, antiHCV, anti HBC IGG, antiHBC IGM, antiHAV IGM, antiCMV IGM, EBV EBNA IGM) were negative. Iron, iron binding capacity,ferritin, copper, ceruloplazmin and alpha-1 antitrypsin levels were all in normal ranges. There was no pathology in protein electrophoresis. Autoimmune markers such as ANA, AMA, ASMA, ANTİ LKM-1were negative. Liver biopsy was performed in order to confirm diagnosis. Symptomatic therapy was given to the patient. In the third week of hospitalization, laboratory tests became normal except for bilirubin levels. His consciousness was good. Bilirubin levels gradually increased up to Total Bilirubin: 27, Direct Bilirubin: 23. Biopsy report was diffuse canalicular cholestasis in central regions, portal inflammation including eosinophils. Finally, the patient was evaluated as toxic hepatitis with cholestasis. His bilirubin levels regressed back to normal in the following weeks.

Discussion: Anabolic steroids can cause hepatotoxicity and renal failure in various degrees. These drugs are easily available and there is no restriction about these. So serious complications may occur like our case. The problem is that symptom range is wide and the beginning of symptoms after drug use is long. These drugs may just cause hepatosteatosis whereas peliosis hepatis, hepatic adenoma, hepatic adenocarcinoma and hepatic necrosis.

These patients must be followed up closely because fulminant hepatitis may even occur. Treatment is usually symptomatic while ursodeoxycolic acid and cholestyramine are also available. Liver transplant should be kept in mind from the beginning. Bilirubin levels can be high for 10-14 weeks and it can even be higher than 35 mg/dl. Such patients must be followed with daily protrombin, albumine, platelet and consciousness.

945

PO 474THE EFFECTIVENESS BETWEEN LACTULOSE, PROBIOTICS AND COMBINATION AS THE TREATMENT OF VARIOUS DEGREES HEPATIC ENCEPHALOPATHY DUE TO CIRRHOSIS

Azzaki Abubakar, Fauzi Yusuf

Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Medicine University of Syiah Kuala/ Dr. Zainoel Abidin General Teaching Hospital,

Banda Aceh- Indonesia

Background : Hepatic encephalopathy (HE) is one of the major complications in patients of liver cirrhosis , associated with poor quality of life. Lactulose and probiotics can provide benefits in improving hepatic encephalopathy. Aims of the study is comparing the effectiveness of treatment lactulose, probiotics and a combination of both in HE.

Methods : Forty-nine liver cirrhosis patients with HE has been diagnosed by West Haven criteria. Patients divided in to three groups, A (17) were treated by lactulose 30-60 ml/day, B (17) were treated by probiotics three times a day, and C (15 ) were treated with combination of both. Therapy was given for 2 weeks and response therapy was evaluated with West Haven criteria.

Results : Of 49 patients, there were 36 pts(stage 1), 7 pts(stage 2),5 pts(stage 3) and 1 pts(stage 4). Clinical improvement in group A were 7 from 17 pts (41%), B 8/17 (47%) and C 6 /15 (48%), but not significance (p > 0,644) in overall group.

Conclusion : Lactulose, probiotic or combination has equal effectiveness in improving various degress of hepatic encephalopathy.

946

PO 475Name : dr. Oska Mesanti, SpPD

Study Program : Internal Medicine

Title : The Difference in Levels of Procalcitonin between Decompensated Liver Cirrhotic Patients With and Without Bacterial Infection

Background: Decompensated liver cirrhosis may increase procalcitonin (PCT) level in patients without bacterial infection. Previous studies did not provide conclusive results about the difference in levels of PCT due to specific liver compensation and bacterial infection.

Objective: To examine the role of PCT in assisting the diagnosis of bacterial infection in decompensated liver cirrhotic patients.

Methods: A cross sectional study was conducted in decompensated liver cirrhotic patients who were outpatients and admitted to Cipto Mangunkusumo Hospital, Jakarta between April and May 2016. Procalcitonin were examined and bacterial infection were identified using standard criteria for each type of infection being suspected. Analysis were performed to determine the difference in levels of PCT among patients with and without bacterial infection, also to get cut off point of PCT for bacterial infection diagnosis using receiver operating curve (ROC).

Results: There were 38 patients with decompensated liver cirrhosis, 16 (42,1%) with bacterial infection and 22 (57,9%) of them without bacterial infection. Patients with bacterial infection (3,607ng/mL±0,643) had significantly higher PCT levels than those without bacterial infection (0,738ng/mL±1,185). From ROC, level of PCT for bacterial infection in decompensated liver cirrhosis was area under curve (AUC) 0,933 (IK 0,853-1,014). Cut off point of PCT for bacterial infection diagnosis in decompensated liver cirrhotic patients was 2,79ng/mL with a sensitivity of 87.5% and specificity of 86,4%.

Conclusion: Procalcitonin levels of decompensated liver cirrhotic patients with bacterial infection was higher than those without bacterial infection. Cut off point of PCT for bacterial infection diagnosis in decompensated liver cirrhotic patients was 2,79ng/mL.

Keyword: decompensated; compensated; procalcitonin; bacterial infection

947

PO 476Title: It will be beneficial perform chest CT angiography in all suspected pulmonary embolism?

Authors: Pedro Lopes, José Mateus, João Gomes, Diana Ferreira, Hugo Clemente, João Fonseca, João Porto, Manuel Veríssimo, Armando de Carvalho

Background: To evaluate the indication of chest CT angiogram performed in the emergency department for suspected pulmonary embolism (PE).

Methods: A retrospective study conducted between 2013 and 2015. The sample was selected by the database of the Radiology department, and the evaluated data were collected through the ALERT® base of the Emergency department They´re considered two patient groups with PE and without PE. The categories evaluated were sex, Wells criteria, D-dimers and blood gases (normal values: 83 <pO2 <108 and 35 <pCO2 <45).

Results: 2161 patients perform chest CT-angiography on suspicion of PE in the emergency. PE was diagnosed in 492 (23,8%), with a female predominance (53.4%), the same occurred in the group without PE (61.7%).

Applying the Wells criteria in patients PE group show: 51.2% high score, 31.7% moderate and 17.1% lower; individuals without PE: 15.1% high, 43.9% moderate and 41.0% lower score.

In gasometry 92.7% of patients with PE have hypoxemia and 2.4% normoxemia. Individuals without PE present hypoxemia 63.3% and normoxemia 30.2%.

The statistical analysis showed: Student’s t-test for D-dimers value between PE group and without PE group, and Student’s t-test for the Wells criteria between PE group and without PE group verifying in both statistical significance (p <0.01).

We used χ2 test and it showed statistical significance p <0.01 in PE patients with Moderate to High score risk in Wells Criteria. The set of High to Moderate score and hypoxemia in PE group showed significance also p <0.05.

Conclusion: The Wells criteria and the gas parameters are important for the diagnosis of PE, reaching statistical significance in our study. But 77.2% of patients who did chest CT angiogram didn’t have diagnosis of PE. So you should consider conducting of this exam, taking into account the costs and benefits.

948

PO 477FACTORS AFFECTING THE MORTALITY OF PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME IN INTENSIVE CARE UNIT, DR SARDJITO HOSPITAL YOGYAKARTA

Ika TrisnawatiDivision of Pulmonologi, Internal Medicine DepartementMedical Faculty of Gadjah Mada University/ Sardjito Hospital Yogyakarta

Background: ARDS is a critical disease that has mortality of 40-60%. Its mortality is influenced by some factors that can be predicted or can be taken into account in reducing the rate. Until recently, those factors are not well known.

Objection: The aim of this study is to observe factors that have high contribution to the mortality and to give recommendation based on those factors.

Methods: This a cross sectional study with subjects are patients with ARDS admitted to Intensive Care Unit Sardjito Hospital, Yogyakarta, January 2009 - December 2014. ARDS is defined based on AECC with inclusion criteria: ≥ 18 year old, diagnosed as ARDS, and treated in ICU. Demographic data, laboratory results, and its follow up are obtained from medical records. Data are analyzed using SPSS 17 commenced by bivariate analysis and forwarding to multivariate analysis using log regression to determine the proportion of contribution those factors to mortality. Significance is decided when p < 0,05, CI 95 %

Results: There are 101 subjects with 52 women are included, mean age is 51 years, 72 patients are died and 29 patients are alive. Bivariate analysis showed that there are six factors affecting to

mortality: pneumonia, COPD, MODS, leukocyte count, pleural effusion and vasopressor. Multivariate analysis showed five factors affecting: pneumonia, COPD, MODS, leukocyte count and vasopressor. Pneumonia has the highest Odds ratio (6,4) and the use of vasopressor has the less one (4,9).

Conclusion: There are five factors affecting to mortality to patients with ARDS admitted to ICU: pneumonia, COPD, leucosit count, MODS, and the use of vasopressor. Therefore, it is very important to give more intention to those factors and to give optimal therapy based on those actors in managing patients with ARDS to reduce its mortality.

Keyword: ICU, ARDS, mortality

949

PO 478Cutaneous and Pulmonary Aspergillosis in Elderly Immunocompromised Patient: A Case Report

Hadianti, EJ Nelwan

Division of Tropical and Infectious Disease. Department of Internal Medicine. Faculty of Medicine University of Indonesia

Abstract

Patient with malignancy disease had immunocompromised statues that increase a risk of fungal infection such as a systemic aspergillosis. We presented a case of cutaneous and pulmonary aspergillosis in a patient with squamous cell carcinoma of the tounge.

A 63-year-old woman visited emergency department Cipto Mangunkusumo hospital with complaints of easily fatique since five days after her fifth chemotherapy cycle for squamous cell carcinoma in the tongue. She complained of dry cough for one week, no bloody and breathlessness. Since two months ago there was red and black spots with squamation appearance in the skin of her back and buttocks, her nails were also fragile, yellowish and thickened. At initial, her laboratories test showed the unspecific signs of infection with Pro-calcitonin level of 2.46. Her sputum smear resulted of negative AFB, isolation of Acinetobacter baumanii (anitratus) and Candida albicans. After being adequately treated with antibiotics, her general condition wasn’t improved. The patient then consulted to Infectious Disease Department. The re-evaluation of Chest X-Ray suggestive a multiple nodules appearance in the right lung, therefore a thorax CT was asked, resulted to appearance of fibrosis and minimal ground glass opacity in the 9th to 10th segmens, The galaktomanan serum was taken and found to be positive. Intravenous antifungal Voriconazole 2x200mg daily was started. Clinical improvement was shown within 7 days of treatment. She had recovered after 21 days of voriconazole therapy with negative galaktomanan result during the follow up.

Conclusion: malignancy increase a risk of fungal infection. Consideration of fungal infection should be made particularly in a patient with any sign of superficial fungal infection.

Keywords: Malignancy, Systemic Aspergillosis, Antifungal

950

PO 479Title : A CASE OF PNEUMONIA ACCOMPANIED BY HIGH NT-PRO BNP

AUTHOR : Masayuki Kitagawa, Yoshihiro Yamanaka, Toru Adachi, Junitsu Ito, Jiro Akiba, Kazutoshi Fukase, Ikuro Ohta

AFFILIATION : Department of Internal Medicine, Yamagata Prefectural Kahoku Hospital

Introduction : Originally NT-pro BNP is an indicator of heart failure. NT-pro BNP has also been reported to be the indicator of pneumonia risk. This time, we will report the pneumonia patients with NT-pro BNP highs consistently.

Case Presentation : The case is 95-year-old. At the middle of January 2016, she was pointed out pneumonia in both sides and pyelonephritis. She was admitted to our hospital. In laboratory examination, a leukocytosis and an increase of NT-pro BNP, of C-reactive protein and of D-dimer were observed. In her chest X-ray, infiltration shadows were observed in both lungs. She was treated by diuretics and antibiotics. Since hospitalization, Cefozopran 2g was administered for 14 days. C-reactive protein was reduced once but was later re-rise. After Cefozopran administration, Sulbactam/Ampicillin 6g was administered for 11 days. Diuretic administration has been performed but NT-pro BNP was higher consistently. On the admission day 50, she died.

Discussion : The presence or absence of heart failure merger is important to consider the pneumonia treatment. For the judgment of the presence or absence of heart failure merger, NT-pro BNP seems to be a useful indicator. In this case, NT-pro BNP was higher consistently. From the clinical course, this case seemed to heart failure. However, myocardial damage appeared to be mild in the autopsy findings. From the clinical course, renal dysfunction seemed mild. However, severe chronic pyelonephritis was observed in the autopsy findings. Sometimes clinical course and autopsy findings differ. For accurate pathology grasp, autopsy was deemed important.

951

PO 480RIFAMPICIN INDUCED ACUTE INTERSTITIAL NEPHRITIS AND EXFOLIATIVE DERMATITIS COMPLICATING PULMONARY TUBERCULOSIS - A CASE REPORT

Farhana Afroz, Mohammad Delwar Hossain, Jamal Uddin Ahmed, Wasim Md. Mohosinul Haque. BIRDEM, Dhaka, BangladeshPresenter: Farhana Afroz

Introduction: Rifampicin is one of the most effective antitubercular agents. Among its rare adverse effects, acute interstitial nephritis is noteworthy. Although it typically occurs in patients receiving intermittent rifampicin therapy, cases occurring during continuous treatment with rifampicin have also been reported. Furthermore, exfoliative dermatitis caused by rifampicin is quite uncommon. Simultaneous occurrence of the both complications in the same patient has not been reported so far.

Case presentation: A 76-year-old male with diabetes, hypertension and chronic kidney disease (CKD) stage-3 presented with fever and cough for 4 weeks and was diagnosed as smear positive pulmonary tuberculosis. Modified anti-tubercular regime for CKD was started as per guidelines but gradual deterioration of his renal function along with appearance of skin lesion was observed. Further diagnostic workup revealed rifampicin induced acute interstitial nephritis and exfoliative dermatitis. His skin condition and renal function began to improve upon discontinuation of the drug. Serum creatinine returned to previous value after 2 weeks of stopping rifampicin. The antitubercular medication was tailored by omitting rifampicin and adding moxifloxacin and duration of treatment was extended. On subsequent follow-up visits he was finally declared as “Cured”.

Conclusion: Rifampicin associated exfoliative dermatitis and acute interstitial nephritis should be kept in mind while treating patients with tuberculosis who develop skin lesions and deterioration of renal function respectively. High index of suspicion is needed for early diagnosis and recovery by discontinuation of rifampicin.

952

PO 481COMPLEMENTARY MEDICINE IN PATIENTS WITH TUBERCULOSIS

Manik Retno Wahyunitisari*1,2, Wiwin Retnowati2, Eko Budi Koendhori1,21Departement of Clinical Microbiology, Dr. Soetomo Teaching Hospital, Surabaya, Indonesia2 Departement of Medical Microbiology, Faculty of Medicine Airlangga University, Surabaya, Indonesia

Correspondence Address: [email protected]

Background::The emergence of multidrug-resistant tuberculosis (MDR-TB) challenges the development of novel adjunct therapeutic agents. Early lung injury is an important target in the treatment of TB. Activated transcription factor nuclear factor-kappa-light-chain-enhancer of activated B cell (NF-κB) plays an important role in regulating the expressions of inflammatory genes. Lycopene, a potent dietary antioxidant, interacted with two key proteins of the NF-κB pathway: the NF-κB inhibitor (IκB) and the p65 subunit. Park et al (2009) suggest that the effects of dietary antioxidant supplementation are tissue-specifik. We investigated wether the addition of lycopene to the second-line anti-TB drugs, reduces the lung bacillary burden (colony-forming unit/CFU) and reduces early lung injury.

Methods: BALB/c mice 5-8 weeks of age were infected intratracheally with 105 CFU MDR isolates of M. tuberculosis and treatment was initiated 2 weeks post-infection. Separate groups of mice received second-line anti-TB drugs with or without oral uptake 250mg kg-1 of diet lycopene. The influences of intervention on NF-κB signaling pathways were assessed 1 month after treatment. Results: We found that co-treatment of lycopene and anti-TB drugs could supress NF-κB, lysosomal protease cathepsin B, and matrix degrading enzyme MMP8 expression as confirmed by immunohistochemistry. In parallel, suppress the bacillary burden in the lung.

Conclusion: We conclude that combination of lycopene with second-line anti-TB drugs reduces early lung injury by decreasing NF-κB signal pathway. Future translational work will need to assess the resulting synergies of rationally designed anti-TB mixtures.

Keywords: lycopene, MDR-TB, NF-κB, cathepsin B, MMP8, CFU

953

PO 482THE COMPARISON OF ASTHMA CONTROL LEVEL USING THE CRITERIA OF GLOBAL INITIATIVE FOR ASTHMA 2006 AND THE ASTHMA CONTROL TEST

Mohamad Guntur Mertosono, Harun Iskandar, Syakib Bakri, A. Makbul Aman, Haerani Rasyid, Faridin HP, Sudirman Katu

Department of Internal Medicine, Medical Faculty of Hasanuddin University, Makassar, Indonesia

Background. Asthma control level can be assessed using the criteria of Global Initiative for Asthma (GINA) 2006 and the Asthma Control Test (ACT). The criteria of GINA 2006 needs the spirometry, but not all of the health service setting had the spirometry. This study aimed to compare the asthma control level using the criteria of GINA 2006 and ACT.

Method. The research was conducted in outpatients with asthma at the pulmonology clinic of Dr. Wahidin Sudirohusodo General Hospital, Makassar, Indonesia, from February through May 2016. The research was an observational study with the cross sectional design. These data were analyzed using Statistical Package for Social Science version 22 with the appropriate test.

Result. A total of 68 patients, aged between 21-43 years, with a mean of 47,5 ± 13,1. 17,6% were controlled, 41,2% were partly controlled, 41,2% were uncontrolled by the criteria of GINA 2006. 29,4% were well controlled, 47,1% were not well controlled, 23,5% were poorly controlled by the ACT. Here was an agreement between the criteria of GINA 2006 and the ACT in assessing asthma control level (p<0,001) with the level of agreement was 0,659 (65,9%), the sensitivity and the specificity were 89,% and 91,7%.

Conclusion. There were an agreement of asthma control level between the criteria of GINA 2006 and ACT, so the ACT can be used in assess asthma control level in the health service setting without the spirometry.

Keywords. Asthma, asthma control test (ACT), asthma control level, global initiative for asthma (GINA).

954

PO 483FOOD IMPACTS THE PHARMACOKINETICS OF FIRST-LINE ANTI TUBERCULOSIS DRUGS IN TREATMENT NAÏVE TUBERCULOSIS PATIENTS

Objectives: Concomitant food influences pharmacokinetics of first-line anti-tuberculosis (TB) drugs in healthy volunteers and TB patients on steady state. In treatment-naïve TB patients who started their treatment, data on the influence of food intake on the pharmacokinetics are absent. This study aimed to quantify the influence of food on the pharmacokinetics of isoniazid, rifampin, ethambutol and pyrazinamide in this group of patients.

Methods: A prospective randomized cross-over study was conducted in treatment-naïve adults with drug-susceptible TB. They received isoniazid, rifampin and ethambutol intravenously and oral pyrazinamide on day one, followed by oral administration of these drugs in fasted and fed condition on the two consecutive days. Subjects were recruited from the governmental chest clinics in Yogyakarta and Sardjito General Hospital, Yogyakarta, Indonesia. Primary outcome was the bioavailability while fasting and with concomitant food. Serial blood samples were collected 11 times/day, and plasma samples were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS).

Results: 20 subjects completed the study protocol. Absolute bioavailability in fasted and fed state for isoniazid was 93% and 78%, for rifampin 87% and 72% and for ethambutol 87% and 82%. Food decreased absolute bioavailability of both isoniazid and rifampin by 15%. Pyrazinamide Area Under the Curve 0-24 hours was comparable for fasted (481 mg*h/L) and fed state (468 mg*h/L). The maximum concentration of isoniazid, rifampin and pyrazinamide was lowered by food by 44%, 22% and 10% respectively. Time to maximum concentration was delayed. The pharmacokinetics of ethambutol were unaffected by food.

Conclusions: Food decreased absolute bioavailability and maximum concentration of isoniazid and rifampin but not of ethambutol or pyrazinamide in treatment-naïve TB patients. In patients prone to low drug exposure, this may further compromise treatment efficacy and increase risk of acquired drug resistance.

955

PO 484The Correlation Between D dimer Levels in Community Acquired Pneumonia Patients on the degree of CURB-65 score at Early Admission in Hospital

Herlina Yani, E.N. Keliat, Alwinsyah Abidin,Pulmonology and Allergy-Immunology Division of Internal Medicine DepartmentMedical Faculty of University of Sumatera Utara Haji Adam Malik General Hospital Medan - Indonesia

Background: The assessment of level severity in patient with community acquired pneumonia (CAP) is very important to determine the next management of disease. D dimer (DD) is known as one of biomarker coagulation may be helpful in predicting the severity of CAP at the early admission in hospital. The application of DD is known to be used in diagnosis and to help clinician to make prognosis.

Aim : To determine the correlation between D dimer and CURB-65 score in CAP patients at the early admission in hospital.

Methods : This was an cross-sectional study. We had examined CAP subject with CURB-65(Confusion, Urea, Respiratory rate, Blood pressure, Age >65 years), DD, other laboratory assessment and sputum and blood culture at the early admission at emergency room (ER). We had correlate the DD levels with CURB-65 to determined prognostic utility of DD.

Result : Total of CAP subject was 57, there were 10 subjects (100%) with DD <500 μg/ L included in the mild-moderate CURB-65, 12 subjects (100%) with DD 500-999 μg/ L included in the mild-moderate CURB-65, 11 subjects (100%) with DD 500-999 μg/ L included in the mild-moderate CURB-65, and from 24 subjects with DDl > 2000 μg/ L consists of 2 subjects (8.3%) included in the mild-moderate CURB-65 and 22 subjects (91.7%) included severe CURB-65

Conclusion : D dimer is a biomarker of coagulation that has correlation with clinical scoring system CURB-65. D dimer can be use to determine the prognosis in CAP at early admission.

Key Word : community acquired pneumonia, CURB-65 score, D dimer

956

PO 485Asymptomatic lung tuberculosis presenting with panuveitis

Muhammad Ikhsan Mokoagow 1,2and Soedarman Sjamsoe21Dept of Internal Medicine, Fatmawati General Hospital, Jakarta2Jakarta Eye Center Hospital @ Kedoya, Jakarta

Abstract

A 29 year-old- female was consulted from an ophthalmologist in a work up of panuveitis on her right eye. Her chief complaint was experiencing hazy vision with a red eye. Opthalmology evaluation revealed a posterior synechiae and vitreous haze with hyperemic optic nerve on the right eye. A diagnosis of panuveitis of the right eye was established and topical treatment along with oral steroid was prompted. Furthermore, underlying systemic condition was suspected and subsequently sought. Antibodies against: Antinuclear (ANA), Viral hepatitis, Toxoplasma, Rubella, Cytomegalovirus and Herpes Simplex Virus (HSV) 2 were all negative. Positive IgG for HSV 1 but negative for IgM. Nevertheless, her Tuberculin skin test was positive and prompted her ophthalmologist to internist clinic. History of constitutional symptoms of tuberculosis was denied. No weight loss was observed and patient had no episode of chronic coughing or having shortness of breath. Her physical examination was not significant apart from having BMI of 27 kg/m2. Laboratory result showed high Erytrhocyte Sedimentation Rate (ESR) 108 mm/hour. To investigate further, patient underwent Interferon Gamma Release Assay (IGRA) and glucose levels since the patient was obese and has been receiving steroid therapy. The result come back positive and a fasting glucose level of 112 mg/dL, indicating an impaired fasting glucose. Sputum was not feasible to be collected since she was not coughing at all. Her radiologic finding did not reveal a clear and noticeable infiltrate with an increased bronchovascular pattern. Treatment with fixed dose combination (FDC) of antituberculous agents was prompted. During first two months of treatment on her regular visit to internist clinic, neither significant complaints nor liver injury occurred with FDC. Repeat thoracic radiology was ordered and came back with an improvement in infiltrate that was not previously suspected. She was then prompted to isoniazide and rifampicin in the continuing phase. Her eye complaint was alleviated with an improved result while tapering off her steroid therapy and receiving antituberculous agents.

Keywords: Lung tuberculosis, panuveitis tuberculosis

957

PO 486Is there a role for risk stratification for ambulatory management of Pulmonary Embolism?

Authors: Farhaanah Kadri, Keith Siau, Mayumi Hamada, Jinha Kim, Sujatha Mathew

Affiliations: NHS, The Royal Wolverhampton NHS trust, Wolverhampton, United Kingdom

Background: The European Society of Cardiology recommends the use of risk stratification scores in the assessment of pulmonary embolism (PE), such as the PE severity index (PESI) or simplified PESI (sPESI) scores. This strategy may allow identification of a subset for patients for ambulatory management of PE, as well as predict mortality risk. We aimed to: 1) evaluate the role for risk stratification in PE, 2) define the most appropriate statistical model for risk stratification, 3) analyse the impact of risk stratification in a district general hospital within the UK (catchment population of 350,000 patients).

Methods: We performed a retrospective cohort study on consecutive patients with a confirmed radiological diagnosis of PE between November 2013 and November 2014. Clinical, radiological, treatment and follow-up data were recorded. Outcome measures included: 30-day mortality, 1-year mortality, and haemorrhagic complications. Patients were categorised into low a high risk PE groups, with categorical variables compared using Fisher’s Exact testing, and risk modelling performed using receiving operator curve analysis. Kaplan-Meier survivals were produced using SPSS. 2-tailed p-values were significant if <0.05. Cost analysis was performed using UK Department of Health costing data (2015).

Results: Over a 12 month period, 186 patients had confirmed diagnoses of PE. The median age was 70 (SD 16.6) with 51.1% of patients being male. 151 (81.2%) had acute PE with 9 (6.0%) being inpatient diagnoses. The median time from admission to imaging was 1.5 days. In the low sPESI group, the 30-day mortality was 0% (0/60) compared to 7.9% (10/126) in the high sPESI group (p=0.03). Similarly, the 30-day mortality was 0% (0/76) in low PESI groups (Class 1-2) compared to 10/114 (8.7%) in the high PESI groups (p=0.007). ROC analysis showed superiority of PESI over sPESI for prediction of 30-day survival. On Kaplan-Meier analysis, patients with low risk PESI had 1-year survival rates of 96.0% compared to 30.4% for high risk PESI (hazard ratio 0.12, p<0.001). Our study was underpowered to correlate troponin with mortality. 2/186 (1%) had bleeding complications over 1-year follow-up. From cost effectiveness analysis, we surmised that managing all patients with low-risk PE in an ambulatory manner may save up to 800 hospital bed days, and over £230,000 per annum.

Conclusion: We demonstrate that low PESI and sPESI effectively predict 30-day and 1-year mortality. PESI appears to be superior to sPESI for risk stratification. Application of risk stratification with PESI scoring appears to be safe and may negate the need for admission for low risk patients.

958

PO 487Epidemiologic study of lung cancer in north of Iran

Manouchehr Aghajanzadeh1, Melina Rouhi Rad1, Seyed Ali Alavi1, Sina Khajeh Jahromi1, Armita Rezazade Kalashami1, Zahra Pourkazemi11.Guilan University of Medical Sciences, Rasht, Iran

Background: Lung cancer is the main cause of cancer death in all sides of the world. As the risk factors of the cancer should be modified, epidemiological study of lung cancer is essential. Therefore the aim of this study was to determine the epidemiological situation of lung cancer in Guilan province.

Method: In this descriptive (epidemiological) study, all patients who had diagnosed as one kind of lung cancer and referred to subspecialty lung and surgery clinics of Razi and Arya Hospitals in Rasht between 2012-2013 were included. . Demographic characteristics, symptoms, first presentation sign, the history of smoking and using tanbaco, lung cancer characteristics, such as the type and method of treatment were recorded in a questionnaire. Finally the data were analyzed using SPSS software.

Results: 243 patients with primary lung cancer with a mean age of 62.47 ± 12.4 years were studied. 74.5% of patients were smokers. The most frequent chief complaint of patients was cough (46.5%) and muffle on auscultation with frequency of 50.4% was the most clinical sign. Pathologic investigation revealed that squamous cell carcinoma with 33.9% was the most prevalent form of cancer in these patients. About 70% of patients were referred for the frist time in stages III and IV. Chemotherapy was the most common method of treatment used. (78.6%)

Conclusion: Most of our data are consistent with previous studies. Unfortunately, most of our patients admitted to the clinics in advanced stages of the disease, which the patients would not be cured. This issue could be very important in terms of socioeconomic status.

959

PO 488Factors that affect sputum smear conversion at the end of the second month of tuberculosis treatment in new cases tuberculosis with diabetes mellitus patients in Persahabatan Hospital

Iceu Dimas Kulsum, Rochismandoko, Erlina Burhan

Abstract

Background: The link of DM and TB is more prominent in developing countries where TB is endemic and the burden of DM is increasing. Diabetes mellitus increases the risk of TB infection, delayed sputum smear conversion and TB treatment failure. This study would like to evaluate factors associated with delayed sputum smear conversion in the end of two months of TB treatment in new cases TB with DM patients in Persahabatan Hospital.

Methods: This retrospective cohort study was conducted in Persahabatan Hospital, included all new cases TB with DM patients in the period from July 2012 - June 2015. All the risk factors performed bivariate and multivariate analysis in association with sputum smear conversion in the end of two months of TB treatment.

Results: The proportion of sputum smear conversion failure is higher in TB-DM than non-DM patients (43,04 vs 22,75%) (p<0,001, CI95% 0,11-0,30) with the relative risk (RR) for sputum conversion failure 1,89 higher in TB-DM patients. Bivariate analysis resulted in significant higher of initial sputum smear level (p=0,021), HbA1c (p=0,014), FBG (p=0,047), post prandial Blood Glucose (p=0,030) and cavity at chest x-ray (p=0,033) and significant lower of serum albumin (p=0,013) in non-conversion patients. Multivariate analysis resulted in risk factors strongly associated with sputum conversion failure are low albumin level (p=0,046, CI95% 0,218-0,986), high initial sputum smear level (p=0,009, CI95% 1,230-4,349) and high HbA1c level (p=0,018, CI 95% 1,047-1,610).

Conclusions: Higher initial sputum smear level, uncontrolled diabetic status, cavity at chest x-ray and lower albumin level associated with sputum smear conversion failure in TB-DM patients.

Keywords: risk factors, sputum smear conversion, TB-DM patients.

960

PO 489Case report: Jejunal Arteriovenous Malformation (AVM) Found by Enteroscopy

Backgrounds: Enteroscopy is an endoscopy procedure performed to assess the small intestine. Enteroscopy was used as diagnostic, therapeutic, and surveillance. As a diagnostic tool, enteroscopy is carried out to find ulterior gastrointestinal bleeding, evaluate the cause of malabsorption and unknown diarrhea, as well as abnormal radiological presentation. For therapeutic use, enteroscopy plays a role as an access for thermocoagulation bleeding lesions and feeding jejunostomy. As a surveillance tool, enteroscopy is used to evaluate the growth of polyp indicating a malignancy.Gastrointestinal bleeding occurs at around 5% of total incidence of gastrointestinal bleeding. The enteroscopy ability to diagnose obscure bleeding ranged between 12% and 80%. This case report will discuss the role of enteroscopy to diagnose and manage gastrointestinal bleeding.Blood vessel anomaly is one of the cause of small intestine bleeding which commonly happen in those age over 40 years old. The condition happens 34.82% in adult between 41 and 64 years old, while 54.35% in people aged more than 65 years old from total event of small intestine bleeding. The most frequent anomalies are angiodysplasia, telangiectasia, phlebectasia, AVM, Dieulafoy’s lesion and varicose veins. The common location for AVM are caecum and right colon (78%), jejunum (10.5%), ileum (8.5%) and duodemum (2.3%).

Case report: A male 34 years old came with chief complaint of black stool since two weeks prior to hospital admission. This complaint had been recurrent since 6 months ago. The patient was first experience black stool in December 2015 and the complaint was not accompanied by haematemesis. Colonoscopy and gastroscopy examination were carried out with normal results. Then the patient was referred to RSCM for enteroscopy examination.The patient denied the history of hypertension, diabetes mellitus, heart disease and kidney disease. There was no history of anti-pain drug consumption and herbal medication.When the patient was admitted in the hospital, vital sign examination showed blood pressure 110/70 mmHg and pulse rate 108 x/minute. On physical examination, there were pale conjunctiva, sclera not icteric, flat abdomen without tenderness, normal bowel sounds, liver and spleen were not palpable, and warm extremities. Rectal examination showed black stool and no mass was found.Laboratory examination showed hemoglobin 8.23 g/dL, hematocrit 27.3%, aPTT 61(34). The patient was given packed red cell (PRC) and fresh frozen plasma (FFP) transfusion as much as 500 cc for each. After the laboratory value was corrected, the patient underwent enteroscopy examination and jejunum ulcer bleeding was discovered, subsequently hemospray procedure was carried out. However, the black stool did not resolve, hence the patient was consulted to digestive surgeon and laparotomy resection anastomosis guided by enteroscopy was done for the patient. During operation, dilated

961

blood vessels in jejunum and duodenum pars ascenden was discovered in accordance with the picture of arteriovenous malformation (AVM). Therefore, it was decided that duodenal pars ascenden until jejunum was resected.

Figure 1. Enteroscopy view on patients showing active ulcer with jejunum spurting located ± 150 cm from the incisive.

Figure 2.Enteroscopy view during hemospray procedure at the site of bleeding in jejunum.

Figure 3. Clinical presentation during operation

Discussion: Enteroscopy is an endoscopic examination to assess the small intestine. In the past 20 years, enteroscopy examination was dominated by the use of push enteroscopy tools which has limitation in reaching further area. Therefore, a new tool with overtube technology was developed. This tool can be divided into double balloon enteroscopy (DBE) (Fuji Photo Optical Co, Ltd, Saitama, Japan), single balloon enteroscopy (SBE) (Olympus Ltd, Tokyo, Japan) and spiral enteroscopy (Spirus Medical, Inc, Stoughton, MA, USA). All those three new tools can extend the depth of insertion of the enteroscopy.The main indication for enteroscopy is to assess obscure gastrointestinal bleeding after esophagogastroduodenoscopy and colonoscopy failed to find the source of bleeding. This condition happens around 5 % in gastrointestinal bleeding. The diagnosis is often delayed due to slow and intermittent bleeding which is hard to be identified by endoscopy and angiography. Diagnostic success rate of enteroscopy to recognize obscure gastrointestinal bleeding ranges from 12 % to 80%.In this patient, AVM was found during enteroscopy and macroscopically featuring as nodule erythema lesion with telangiectasia shape, spurting from the small intestine artery. The management for AVM depends on the hemodynamic conditions of the patients including angiography with embolization, double balloon enteroscopy and surgery. In this case, hemospray procedure using enteroscopy was performed in this patient. Nevertheless, the bleeding was still on going. Then surgical procedure was performed in accordance with anastomosis duodenojejunostomy.

Conclusion: Enteroscopy is a modality that can be used as a diagnostic tool and management for ulterior bleeding.

962

PO 490UPPER GASTROINTESTINAL ENDOSCOPIC FINDINGS AND HELICOBACTER PYLORI INFECTION IN PATIENTS WITH DYSPEPSIA IN NIAS ISLAND AND HUMBANG HASUNDUTAN DISTRICT, SUMATERA UTARA PROVINCE INDONESIA

OK. YULIZAL1,2, LEONARDO B DAIRY1, LUKMAN HAKIM ZAIN1, ARI FAHRIAL SYAM 3, MUHAMMAD MIFTAHUSSURUR 4,5, YOSHIO YAMAOKA 51. Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Sumatera Utara, Haji Adam Malik Central General Hospital Medan, Indonesia. 2. Department of Internal Medicine, Faculty of Medicine, University of Prima Indonesia Medan, Indonesia. 3. Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia. 4. Gastroentero-Hepatology Division, Department of Internal Medicine, Airlangga University Faculty of Medicine, Surabaya, Indonesia. 5. Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu, Japan

INTRODUCTION : Dyspepsia and Helicobacter pylori (Hp) infection are associated with various upper gastrointestinal (UGI) pathologies. UGI endoscopy is the most sensitive investigation for diagnosing UGI diseases.

OBJECTIVE : The aim of this study was to assess UGI endoscopic findings and Hp infection in patients presenting with dyspepsia.

MATERIAL AND METHODS : We conducted a cross sectional observational analytic study to outpatients ethnic Nias from Nias Island and ethnic Batak from Humbang Hasundutan with dyspepsia (based on Rome III criteria) from February to March 2016 in Department of Internal Medicine Gunung Sitoli General Hospital Nias and Doloksanggul General Hospital Humbang Hasundutan. A questionnaire were administered to all subjects before underwent UGI endoscopy and biopsy of the gaster. The rapid urease test was applied to fragments of the antral mucosa. All subjects data were described and tabulated. Data analysis using descriptive and bivariat analysis. Significant P < 0.05.

RESULTS : A total of 79 patients were enrolled (33 patients from Nias Island: male 51,5%, female 48,5% ; 46 patients from Humbang Hasundutan: male 47,8%, female 52,2%). Majority of patients (96,2%) had abnormal endoscopic findings. In Nias, most common lesions were gastritis (85%), esophagitis (18%), gastric ulcer (3%) and duodenal ulcer (3%). Rapid urease test was positive in 6% (n=2) of patients. In Humbang Hasundutan we found gastritis (77%), esophagitis (29%), gastric ulcer (17%), gastric mass (9%), duodenal ulcer (9%) and duodenal mass (4%). Rapid urease test was positive in 24% (n=11) of patients. There was a significant difference in the severity of gaster endoscopic findings between Humbang Hasundutan and Nias patients’ (X2 = 7.43, P = 0.02, OR = 11.29, 95% CI (1.39 – 91.89).

963

CONCLUSIONS : There was a difference in the severity of gaster endoscopic findings between Humbang Hasundutan and Nias patients’. Hp infection was more prevalent in Humbang Hasundutan.

KEYWORDS : Upper gastrointestinal endoscopic, Helicobacter pylory infection

964

PO 491DEEP IRON-DEFICIENCY ANEMIA CAUSED BY CHRONIC GASTRITIS, AND BOUGIE DILATATION OF GASTRIC INCOMPLETE APICAL STENOSIS

E.ARSLAN1, S. DEMIRBAS1, H. SARLAK 2, T. KURT1, I. CETINDAGLI1, K. SAGLAM11 Gulhane Military Medical Faculty, Department of Internal Medicine, Ankara , TURKEY2 Diyarbakir Military Hospital, Department of Internal Medicine, Diyarbakir , TURKEY

BACKGROUND: Anemia is the condition of low hemoglobin level, that is appointed by the World Health Organization according to age and gender. This level is considered as 13g/dL for adult men and 12g/dL for adult women. Small amount of iron intake in the diet, lack of absorption and chronic blood loss can cause to anemia. Here we present a case of severe anemia due to malabsorption.

CASE: 85-year-old female, admitted with the complaints of unable to walk and widespread body pain. Patient had the diagnoses of iron deficiency anemia and osteoporosis. In physical examination skin and conjunctivas were seen pale. In her assays hemoglobin: 2.6g/dL, MCV: 58.77fl, serum ferritin: 4.5ng/ml, folate: 5.23ng/mL, vitaminB12: 330pg/mL were detected. On peripheral blood smear, hypochromia, anisocytosis, poikilocytosis, basophilic stippling, pencil cells and helmet cells were observed. Bone marrow was evaluated as hypocellular. No evidence of myelofibrosis or neoplastic infiltration was detected in bone marrow biopsy. Enteral feeding was stopped because of high residues. Deformed pylorus, gastritis and incomplete apical stenosis were seen in upper-gastrointestinal endoscopy. Bougie dilation process was performed for stenosis, 3-times. The patient benefit from treatment and began to feed orally.

CONCLUSION: Deep iron-deficiency anemia and gastric apical stenosis can occur due to chronic gastritis in patients, who are not monitored for a long term. Consequently, protein energy malnutrition may develop. In the patients who have apical stenosis, bougie dilatation can provide significant benefits for the continuity of oral nutrition.

965

PO 492EVALUATION OF COLONOSCOPIC POLYPECTOMIES

Aysun Temel İncebacak, Kader Irak, İrem Kıraç Utku, Güntuğ Güngör, Ömür Tabak, Abdulbaki Kumbasar

OBJECTIVE: Colonoscopic polypectomy is effective in reducing the incidence of colorectal cancer. We aimed to evaluate the incidence of malignant polyps and factors affecting this.

MATERIAL-METHOD: We investigated 2267 patients who underwent colonoscopy in our gastroenterology unit between September 2013 and December 2015 retrospectively.

RESULTS: Between September 2013 and December 2015, 2267 patients have received colonoscopy with several indications and 302 of them have been diagnosed with colonic polyp (13.3%). 61.9% of patients were male, while 38.1% of patients were female. Average age of the patients diagnosed with polyp was 58.3 ±13.4. 239 of patients have got only one polyp, 60 patients have got 2 or more and 51 of them have multiple polyposis. 21.2% of the patients have sessile and 11.3% of them have stalked polyp. 57.3% of the subjects have polyps at rectosigmoid, 22.7% at descendant colon, 15.6% at transverse colon, 11.6% at ascendant colon and 4.3% at cecum. According to pathological findings; %55.6 of them were adenomas (39.7% tubular, 13.6% tubulovillous, 2.3% villous) 3% of them were inflammatory polyp, 0.7% lipoma, 17.2% adenocarcinoma and 23.5% hyperplastic polyp. According to classification of dysplasia, 152 of the subjects were evaluated and 14% were mild whereas 15.6% were severe.

CONCLUSİON: In the recent years colonoscopic screening have been frequent with the etiologies such as anemia, bleeding and malignancy screening. In the light of literature colonoscopy is gold standard diagnostic method especially for colonic polyps and colon cancer. Polyps are the most common lessions seen in colon and the most frequent ones are adenomatous polyps. A part of these adenomas has risk to transform into cancer according to villous component and level of dysplasia. It is really difficult to calculate the risk through colonoscopy. Therefore all the polyps have to be coagulated or removed and then they should be kept in surveillance. Malign degeneration of an adenoma can last 7-10 years. In our study we achieved the same results according to literature.

966

PO 493A CASE REPORT OF ACHALASIA

Zanurul Rifhan, Ilhamd, Lukman Hakim ZainGastroenterohepatology DivisionDepartment of Internal MedicineFaculty of Medicine, Sumatera Utara University / H. Adam Malik General Hospital

Achalasia was first described by Hannary in 1933. Achalasia is characterized by esophageal nonperistaltic contraction and incomplete relaxation of the lower esophageal sphincter. The onset is insidious and more often the patient seeks attention after presenting the symptoms for many years. The most common symptom are dysphagia, regurgitation and heartburn.

A 48 years old male was admitted into H. Adam Malik Medan General Hospital with a chief complaint of dysphagia since adulthood. The patient had to drink a lot of water to help swallow solid or soft foods that were eaten. Complaint worsened in the last three months followed by odynophagia, nausea and vomiting undigested, retained food eaten by the patient. Patient also complained about heartburn and was previously diagnosed with a variant of angina pectoris but his symptoms didn’t improve with medication. Patient had history of weight loss but no anorexia. Patient had no prior history of corrosive ingestion. Patient were active smoker, but not alcoholic.

Physical examination of the patient reveal no abnormality. Blood works were normal. Oesophagogram were done and showed a dilated distal oesophagus with a rat tail appearance. Gastroscopy revealed a dilatation on the lower third of the oesophagus. Computed Tomography revealed dilataion of the distal oesophagus.

Based on the results of the exams, we concluded the diagnosis as achalasia. The patient was treated with medication, which is calcium channel blocker and proton pump inhibitor. The patient showed clinical improvement after treated and was discharged. The patient was planned for once a month follow up in the outpatient clinic.

Keywords : Achalasia, Dilatation of the distal oesophagus, Dysphagia.

967

PO 494COMPLETE HEALING OF ESOPHAGOBRONCHIAL FISTULA DUE TO CORROSIVE SUBSTANCES BY CONSERVATIVE TREATMENT

Amelia Rifai, A.M.Luthfi Parewangi, Fardah Akil, Nu’man AS Daud, Susanto HKCentre of Gastroentero-Hepatology, Department of Internal Medicine,Faculty of Medicine, Hasanuddin University, Makassar

Introduction. Acquired esophagobronchial fistula (EBF) is a rare condition and its is challenging. Management depends on the cause and degree of the injury. Caustic ingestion can cause severe injury to the esophagus and stomach. Corrosive substances can be alkaline or acidic in nature. Alkali ingestion commonly causes esophageal injury. We present one case of EBF due to alkaline ingestion.

Case Report. The patient was an 47-year-old woman with past history of hypertension, under regular outpatient departemen follow-up and medication. She was came with chest pain, prolonged chest discomfort, difficulty swallowing water, difficulty handling secretion, choking. Five days ago she having ingested a bathroom cleaning. From the physically examination was normally, from laboratory test was found electrolyte disturbance and hypoalbuminemia. Some of the mediastinal lines and stripes seen on chest radiographs are formed by esophageal-lung interfaces. Barium swallow is possible if the patient is able to sit or stand. From barium swallow illustrating a dilated oesophagus and the EBF with resultant contamination of the bronchial tree. Computed tomography revealed esophagus fistulas. Due to the poor clinical condition of the patient, we treat the patient with PPI full dose, adequate central venous access for nutrition, correction of the electrolyte disturbance, respiratory therapy and psychological support. In a patient with EBF, the use of a high-protein-specific formula with a similar caloric percentage of fat and carbohydrates brings about an improvement in both nutritional status and biochemical parameters. One month later, we performed barium swallow shown improvement of EBF. The patient underwent to esophagogastroduodenoscopy, which shown that the fistula complete healing over the original EBF was noted without any visible wall defect. After one month the patient was discharged from the institute and was able to eat a regular meal instead of artificial nutrition.

Keywords: esophagobronchial fistula, corrosive injury, alkali ingestion

968

PO 495Rockall score in nonvariceal upper gastrointestinal bleeding: A predictor of in-hospital rebleeding

Afshin Shafaghi (MD) 1, Mahsa Mohtasham (MD) 1, Farahnaz Joukar (MSn) 1, Sina Khajeh Jahromi (MD) 11. Gastroenterologist, Gastroenterology and Liver disease research center, Guilan

university of medical sciences, Rasht, Iran

Background: The Rockall scoring system was designed to predict morbidity-mortality and bleeding in patients but, the accuracy and validity of these indicators had not been reviewed in Iranian patients. The aim of this study was to evaluate the Rockall scoring system in Iranian patients with nonvariceal upper gastrointestinal bleeding (NVUGIB).

Methods: This cross-sectional study was performed on 197 patients with an initial manifestation of upper gastrointestinal bleeding. All patients underwent endoscopy within 12 hours of presentation of symptoms. Demographic data, endoscopic findings and history of gastrointestinal diseases were recorded. Rockall scores were calculated and patients were divided into three groups: low risk, intermediate risk and high risk. Data were collected by SPSS (Version 20) and chi-square and T-tests were used for statistical analysis. The reliability of the Rockall system in predicting re-bleeding was evaluated using a receiver operating characteristic (ROC) curve.

Results: 27 patients were classified as high risk - 21 males and 6 females; 11 patients aged 60-80 years old and 6 patients were older than 80 years; 3 patients with a history of alcohol consumption and 7 patients with a history of smoking; 4 patients with a history of gastrointestinal bleeding and 4 patients with a history of endoscopy. 6 of 8 patients with re-bleeding were in the high risk group. The mean Rockall score for patients without re-bleeding was 2.9±1.7, while a mean score of 6±1.8 was found in patients who had re-bleeding (P= 0.02). Validation of Rockall score showed accuracy of 0.995 with 95% confidence between 0.983-1.000. Patients in the high risk group (with Rockall scores greater than 6) had the possibility of re-bleeding with the sensitivity of 100% and the specificity of 93.3%.

Conclusion: Based on the results of this study, we recommend that patients with a Rockall score greater than 6 should receive additional monitoring and treatment.

969

PO 496Factors Associated with Re-bleeding in 904 Patients with Peptic Ulcer Bleeding: Analysis of Korean Peptic Ulcer Bleeding (K-PUB) Study

Gi Jun Kim, Byung-Wook Kim

Department of Internal Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea

Objectives: Rebleeding is a major risk factor associated with mortality in peptic ulcer bleeding (PUB) and risk stratification is important for the management of patients with PUB. The purpose of our study was to examine the risk factors associated with rebleeding in patients with PUB.

Methods: The registry of Korean Peptic Ulcer Bleeding (K-PUB) is a large prospectively collected data base of patients with hospitalized PUB between 2014 and 2015 at 27 medical centers in Korea. We examined the basic patient characteristics and clinical outcomes from this registry. Logistic regression models were performed to identify factors associated with rebleeding.

Results: Between May 2014 and March 2015, 904 patients with PUB were registered in the K-PUB data base. Median age was 63 years and 76% were males. Rebleeding occurred in 6.8% (58 patients) and 30 day mortality was 1.0% (9 patients). Risk factors for rebleeding by multivariate analysis were the use of non-steroidal anti-inflammatory drugs (NSAIDs) (OR, 0.428; 95% CI, 0.227-0.808; P=0.009), blood urea nitrogen (BUN) level (≥30: OR, 0.486; 95% CI, 0.249-0.950; P=0.035), albumin level (<3: OR, 2.089; 95% CI, 1.186-3.680; P=0.011) and transfusion (OR, 2.277; 95% CI, 1.126-4.605; P=0.022).

Conclusion: Use of NSAIDs, elevated BUN, decreased albumin levels, and transfusion are associated with rebleeding and should be carefully investigated for patients triage and management. The wide use of proton pump inhibitors and prompt endoscopic intervention may be the reason for the low rebleeding and mortality rates in Korea

970

PO 497Recent epidemiology of peptic ulcer disease and its complications in Korea: results from the nationwide population-based study

Eun Young Ji, Byung-Wook Kim

Department of Internal Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea

Background: Several studies have demonstrated that epidemiology of peptic ulcer disease (PUD) is affected by environmental conditions, racial differences, genetic factors, cultural factors, and geographic variations. We aimed to evaluate the contemporary epidemiology of PUD and its complications in Korea.

Methods: We used the Health Insurance Review and Assessment Service claims database, which covers 97.2% of the Korean population. We analyzed data from 2009 to 2013 for the trend in PUD incidence by age, sex, seasonal variation, and regional difference as rates per 10,000 populations. In addition, its complications, such as bleeding and perforation, were expressed as a percentage of total PUD.

Results: The average PUD incidence ranged from 0.99% in 2009 to 0.52% in 2013. From 2009 to 2013, the annual incidence of gastric and duodenal ulcers (GU and DU, respectively) decreased from 73.9 to 40.2 per 10,000 and 19.6 to 11.2 per 10,000, respectively. These decreasing trends were observed across all age groups and sex in both GU and DU. The incidence of GU was higher in females (54.5 vs. 60.8 per 10,000) while the incidence of DU was higher in males (18.5 vs. 12.6 per 10,000). The peak age of GU was 70–79 years (126.1 per 10,000), which was nearly twice that of the 30–39-year-old group (62.6 per 10,000). Meanwhile, the incidence of DU had two peaks, 30–39 (10.3 per 10,000) and 70–79-year-old groups (15.0 per 10,000). The incidence of PUD was the highest in winter, whereas the incidence was the lowest in fall. The incidence of PUD in metropolitan and urban areas was higher than that in rural areas. The bleeding rate related to GU slightly increased from 8.3% in 2009 to 10.7% in 2013. However, bleeding of DU and perforation of PUD remained the same.

Conclusions: This is the first nationwide report that showed the decreasing trend of PUD incidence and distinct characteristics, including seasonal variation and regional difference in Korea. The complication rates showed no significant change, except for GU bleeding, which showed a slightly increasing trend.

971

PO 498PREVALENCE OF HELICOBACTER PYLORI INFECTION IN KINTAMANI BALI AND THE ASSOCIATION WITH SEVERITY ENDOSCOPIC FEATURES.

IK Mariadi1, IDN Wibawa1, IM Siswadi2, IGN Mayura2, N Purwadi1, IGA Suryadarma1, G Somayana1.

Gastroenterohepatology Division, Department of Internal Medicine, Udayana University, Sanglah General Hospital, Bali, Indonesia

Background. There is high morbidity and mortality related to H. pylori infection, ranging from chronic gastritis to gastric malignancies. Prevalence of H. pylori infection varies between country and region. Previous study in urban area found the prevalence of H. pylori infection still high. This study aims to know the recent prevalence of H. pylori infection in Kintamani, a rural area in Bangli, Bali and its association with severity endoscopic features.

Methods. A cross-sectional study was performed in dyspepsia patients from district area of Kintamani, Bangli. H. pylori infection was diagnosed with detection of IgG H. pylori by immunochromatography technic. All patients were asked for upper gastrointestinal endoscopy procedure. Data analysis was carried out using computer software.

Results. In this study we involved 83 dyspepsia patients. Male was 47 (56.6%) out of 83 patients. Age of patients 22-71 years old, with mean age 45.512 years old. The prevalence of H. pylori infection was 33.7% (28/83). There are no association between age and sex to H. pylori infection. The most frequent infection was in group of age 50-59, 36.8%. only 57 patients followed endoscopy procedure. Endoscopic findings were 34 (41%) superficialis gastritis, 18 (21.7%) erosive gastritis, 1 (1.2%) athropic gastritis, 4 (4.8%) ulcer. There are no association between H. pylori infection and severity endoscopic features (p=0.4).

Conclusions. The prevalence of H. pylori infection in Kintamani Bali was 33.7%. There are no association between H. Pylori infection with severity endoscopic feature.

972

PO 499ACCURACY OF DIAGNOSING GERD BY GASTROESOPHAGEAL REFLUX DISEASE QUESTIONNAIRE AND FREQUENCY SCALE FOR THE SYMPTOMS OF GASTROESOPHAGEAL REFLUX DISEASE

Azzaki Abubakar

Division of Gastroenterology-Hepatology, Department of Internal Medicine, School of Medicine University of Syiah Kuala/ Dr. Zainoel Abidin General Teaching Hospital,

Banda Aceh- Indonesia

Background : Gastroesophageal reflux disease (GERD) defined as pathological condition marked by reflux of gastric contents to esophagus. GERD frequently manifests in various symptoms aside its classical presentations causing difficulties in accurately diagnose its presence in daily clinical practice. Several questionnaires based on symptoms filled by the patients themselves may help in diagnosing GERD without previous endoscopic examination.In this study, we try to compare GERD questionnaire (GerdQ) and frequency scale for the symptoms of GERD (FSSG) in terms of sensitivity and specifity and its relationship with endoscopic findings.

Methods : This study was conducted in cross-sectional design involving 92 patients from January to March 2015 in Zainal Abidin Centre Hospital, Banda Aceh. Subjects were asked to fill both FSSG and GerdQ and underwent endoscopy. Diagnoses made were classified as GERD and non-GERD

Results : GerdQ is concluded to be superior in terms of specificity and accuracy compared with FSSG with the following percentages in terms of sensitivity, specificity, negative predictive value, positive predictive value, and accuracy respectively: 76,8%, 60,8%, 85,5%, 46,6%, 72,8% vs. 75,3%, 17,4%, 73,2%, 19,0%, 60,8%.

Conclusion :. The GerdQ has modest sensitivity and specificity compared to FSSG at diagnosing for GERD in daily practice.

973

PO 501CORRELATION BETWEEN SERUM 25(OH) VITAMIN D LEVEL AND DEPRESSIVE SYMPTOMS IN ACQUIRED IMMUNODEFICIENCY SYNDROME PATIENTS IN AMBULATORY CLINIC OF DR. MOHAMMAD HOESIN HOSPITAL PALEMBANG

Mediarty S, M. Ikhsan AN, Erial B, M. Ali A,

Hematology and Medical Oncology Division, Department of Internal Medicine Sriwijaya University,

Mohammad Hoesin Teaching Hospital Palembang

Background. Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially life threatening condition caused by the Human Immunodeficiency Virus (HIV). Prevalence of hypovitaminosis D in people with HIV/AIDS varies between 29 and 73%. Meanwhile, the prevalence of psychosomatic disorders among people living with HIV was reported between 5% and 23%. There are no reports on correlation between serum 25(OH) vitamin D level and depressive symptoms in AIDS patients. This study was conducted to analyze correlation between serum 25(OH) vitamin D level and depressive symptoms in AIDS patients in Dr. Mohammad Hoesin Hospital Palembang.

Method. Analytical cross-sectional observational study at an ambulatory clinic of Dr. Mohammad Hoesin Hospital Palembang. The study was conducted between October 1, 2014 and April, 30 2015. The subjects were all AIDS patients with depressive symptoms based on the Beck’s Depression Inventory (BDI). The serum 25(OH) vitamin D level were measured by Chemiluminescent Immunoassay (CLIA).

Results. There were 41 subjects with 25 (61%) men. Four (9%) subjects had serum 25(OH) vitamin D level of more than 30 ng/mL, 28 subjects (68.2%) had the level of between 10 and 30 ng/mL and 9 subjects (22%) had serum 25(OH) D level of less than 10 ng/mL. There were 21 (41.2%) subjects with mild depression symptoms, 16 (39%) subjects with moderate depression symptoms and 4 (9.8%) subjects with severe depression. Statistical analysis showed significant correlation between serum 25(OH) vitamin D level and depressive symptoms (r=0.511, p<0.001).

Conclusion. This study demonstrates that there is correlation between the serum 25(OH) vitamin D level and depressive symptoms in patients with AIDS.

Keywords. serum 25(OH) vitamin D level, depressive symptoms, AIDS

974

PO 502AN ASSESSMENT OF EMPATHY IN INTERNAL MEDICINE RESIDENTS TRAINING IN COMMUNITY-BASED HOSPITALS

Background: Research among internal medicine (IM) residents in large, university programs shows empathy declines with increasing years of training (Ref). In a previous study of our Flint, Michigan, community-based IM program we found empathy did not decrease and, in some comparisons, increased with increasing years of training. However, the number of responders was small and the data may not be generalizable. We wanted to repeat the study in a larger population to confirm our hypotheses that empathy does not decrease with increased years of training in our community setting.

Methods: In 2014, we conducted an observational study in three Flint, Michigan community hospitals. Incoming residents (PGY 0) and residents in their postgraduate years (PGY) 1 through 3 were included. Trainees included MD, DO, and international graduates. We used the Jefferson Scale of Physician Empathy, a self-reported, validated survey with a possible score of 20 to 140. ANOVA was used for statistical comparisons.

Results: Forty-five IM residents participated; response rate was 35%. The cumulative Flint residents’ empathy score for all years was 112.5, which is comparable to residents’ scores found in the literature. The PGY 0, 1, 2 and 3 scores were not statistically different when compared by year. Only 2 programs had a response rate high enough to compare programs across all years. When comparing PGY 0, 1, 2 and 3 residents in program 1 to similar residents by year in program 2, no significant differences were found, except between PGY 2 residents.

Conclusions: We did not find a decline in empathy with increasing years of training, as reported in the literature. We now have two studies that show empathy can be maintained over the duration of an IM residency program, perhaps due to targeted curricula.

975

PO 503Screening of Depression and Anxiety in Hepatitis C Patients in Cipto Mangunkusumo Hospital Year 2013-2015

Khomeini A*, Mudjaddid E*, Shatri H*, Putranto R**Psychosomatic Division of Internal Medicine Department, Medical Faculty, Indonesia University, Jakarta – Indonesia

Background : Incidence of hepatitis C virus (HCV) in Indonesia is rising. Some of patients already have depression and other psychological distress even before the therapy started. This condition should be treated before the patients get the interferon. They need monitoring during therapy.

Objective : The aim of this study is to investigate the proportion of depression and anxiety among HCV patients before the interferon-based therapy started.

Methods : This is a retrospective study. We collect adult HCV patients data from medical record, who planned to treat with interferon-based therapy. They were consulted from hepatology clinic to psychosomatic clinic from year 2013 to 2015. Beck Depression Inventory are used to evaluate depression. While to evaluate the anxiety, we use Beck Anxiety Inventory.

Results and Discussion: A total of 58 HCV patients who going to get interferon-based therapy were consulted to pyschosomatic clinic from hepatology division. There are 37 (63.8%) male and 21 (36.2%) female patients.We found 24 (41.4%) with depression, 15 (25.9%) patients with anxiety, and 19 (32.8%) patients without depression nor anxiety. Median age of sample is 44, starting from 28 to 67 years old. Our finding is little bit higher comparing to another research that conducted by Golden et al who found 28% prevalence for depression and 24% prevalence for anxiety. Golden et al said that drug abuse one of the common cause for this prior psychological distress.

Conclusion : The proportion rate of depression among HCV patients was 41.4%, with depression. For anxiety we found prevalence at 25.9%. This finding is significant and requires more evaluation.

Keywords : Anxiety, Depression, Hepatitis, Interferon.

976

PO 504DEPRESSION STATE RELATED WITH URINARY INCONTINENCE AMONG ELDERLY PATIENT HOSPITALIZED AT GERIATRIC WARD IN SANGLAH HOSPITAL

IDG Teguh Krisna Murti1, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

ABSTRACT

Background and Objective: Urinary incontinence is one of impairment and become one of a major health problem in the elderly. Elderly women are the most likely to develop urinary incontinence. Depression was a physicological problem that often find in elderly with urinary incontinence. The objective of this study was to study the correlations of depression state and urinary incontinence among elderly.

Method: Cross-sectional design using the analytical observational was conducted with purposive sampling. Total subject of this study who met the inclusion criteria was one hundred twenty nine person elderly, taken at Sanglah Hospital Denpasar Bali Indonesia from January 2016 until may 2016. Urinary Incontinence assessed using Sandvix Severity Index (SSI) criteria and status of depression are based on Geriatric Depression Scale (GDS-30) criteria. Based on SSI criteria, incontinence status divided into two categories, with urinary incontinence (score ≥1) and without urinary incontinence (score=0). Based on GDS-30 criteria, depression status divided into two categories, depression (score ≥10) and no depression (score <10). Statistical test using chi-square test and Lamda’s bivariate correlation test..

Result: Thirty one hundred twenty nine person elderly at Sanglah Hospital Denpasar Bali Indonesia were included. The prevalence of urinary incontinence and depression were 51,3%(67) and 43,3%(56) .The correlation between depression and urinary incontinence was found significant (p=0.001) with r=0.482.

Conclusion: Depression state has moderate correlation with urinary incontinence among elderly.

Keywords: depression, urinary incontinence, SSI, GDS-30

977

PO 505CORRELATION NUTRITIONAL WITH MINI NUTRITIONAL ASSESMENT (MNA) AND DEPRESSION AT ELDERLY PEOPLE IN SANGLAH HOSPITAL

Kadek Dwi Wulandari1, RA Tuty Kuswardhani2, IGP Suka Aryana21PPDS-1 Ilmu Penyakit Dalam Universitas Udayana, Denpasar2Bagian/SMF Ilmu Penyakit Dalam FK UNUD/RSUP Sanglah Denpasar. Divisi Geriatri

ABSTRACT

Background: Nutritional status in elderly patients affected by socioeconomic status, physiological changes associated with aging, disease and treatment for chronic diseases, a decline in functional status, psychosocial factors and psychiatry. Depression is a problem that is commonly found in the elderly population which causes emotional disturbance, as well as increasing risk of mortality, disability, and incapability to do daily activity. Depression can exacerbate the risk of malnutrition in older patients

Methods : This study aims to know the correlation between nutrition with Mini Nutritional Assesment (MNA) and depression at elderly population in Sanglah Hospital. Using this research methode an analytical cross-sectional study design taken from databased medical record in Sanglah Hospital from April until June 2016. A total of 70 patients with > 60 years old were consecutively enrolled to be subject to this research. Mini Nutritional Assesment (MNA) and status of depression. Performed statistical analysis with Spearman Corelation.

Result: Of the total 70 patients, male is 36 people (51,4%), female 34 people (48,6%). The prevalence of good nutrition 28 (40%), moderate risk malnutrition is 29 (41.4%), high risk malnutrition is 1 (1.4%). The prevalence of no depression is 59 (84,3%), mild depression is 10 (14.3%), severe depression is 1 (1.4%). There is a significant correlation between nutrition and depression at elderly in Sanglah Hospital (p=0,002; r =0,365).

Conclusion The conclusion for this study is nutrition has correlation with depression elderly people Sanglah Hospital.

Key Words : Depression, cognitive function, elderly people

978

PO 506CORRELATION BETWEEN INSOMNIA AND DEPRESSION IN ELDERLY PATIENTS HOSPITALIZED AT GERIATRIC WARD SANGLAH GENERAL HOSPITAL

Erick Lios1, RA Tuty Kuswardhani22Geriatric division, 1Department of Internal MedicineUdayana University/Sanglah Hospital

Background: For the past three decades, Indonesia has made significant progress in economic and human development, which has resulted in longer life expectancy, creating a growing population of older people. Globally, Indonesia has the fifth-largest elderly population in the world. In 2012, there were nearly 21 million older people. Life expectancy has increased dramatically, from 45 in 1970 to 69.2 for males and 71 for women in 2010. In elderly people, the prevalence of insomnia and depressive symptoms is increased lately. Insomnia is one of risk factors for developing depression. Elderly patients who had insomnia are tends to experience depression in their life and since depression in elderly is associated with an increased risk of mortality therefore it becomes necessary to study the correlation between insomnia and depression in elderly. The objective of this study was to find relationship between insomnia and depression among elderly patients.

Method: cross-sectional design using analytic observational was conducted with purposive sampling. Total subject of this study was eighty seven elderly patients, taken at geriatric ward Sanglah general hospital from January to May 2016. Insomnia was screened using structure questionnaire consists of 9 questions while depression was screened using geriatric depression scale (GDS). Statistical analysis were done using SPSS 16.

Result: Eighty seven elderly age from 60 until 98 years old were enrolled. The mean age is 69.23 ± 7.95 while according the gender, 69% of total samples were women while the remain 31% were men. From 76 samples with insomnia, 65 samples (85.5%) were having depression and only 11 samples (14.5%) were not depressed. On the other hand, among 11 samples who didn”t suffering from insomnia only 3 samples (27.3%) were showing sign of depression and the remains 8(72.7%) were free from deression. We found significant association between insomnia and depression in elderly (P <0.05) in CI 95% using chi square test analysis (x2 score = 19.103, α=0.05). We found that insomnia and depression was correlate significantly (p<0.05) where the coefficient correlation test showed R scored =0.424 which means insomnia and depression was corellated moderately in elderly patients.

Conclusion: there was significant association and significant moderate correlation between insomnia and depression among elderly patients at geriatric ward Sanglah general hospital.

Keywords: Insomnia,depression, elderly

979

PO 507CORRELATION BETWEEN DEPRESSION AND FUNCTIONAL DECLINE IN ELDERLY PATIENTS IN SANGLAH HOSPITAL, BALI: A CROSS-SECTIONAL STUDY

S Aryana, R Purnami

Geriatric Division of Internal Medicine Department,Udayana School of Medicine/ Sanglah HospitalBali, Indonesia

Abstract

Background: Although cognitive impairment and depressive symptoms are associated with functional decline, it is not understood how these risk factors act together to affect the risk of functional decline.

The aim of this study is to evaluate whether depression has correlation with functional decline in elderly patient at Sanglah Hospital on July 2015 until December 2015.

Methods: A cross sectional study was carried out from July 2015 to December 2015 at Sanglah hospital, with primary data from 139 medical records consecutively included in the study.

Results: As basic characteristics from geriatric patients (age ≥60 yo) that hospitalized in Sanglah hospital during July 2015 until December 2015, we found that: there are 64 males (46%) and 75 females (54%) included in this study. Based on age, we divided into 3 groups: 60-70 yo (44,6%), 71-80 yo (33,1%), only 22,3% samples more than 80 yo. We found that there are 42 patients (30,2%) with depression, and 97 (69,8%) without depression. In screening of functional decline, we found 15 (10,8%) independent, 42 (30,2%) mild dependency, 26 (18,7%) moderate dependency, 36 (25,9%) severe dependency, and 20 (14,4%) total dependency patients. We analyzed data using Lambda correlation test and found that there are significant correlation (p = 0,001) between depression and functional decline in elderly patients with r = 0,155.

Conclusions: There are significant correlation between depression and functional decline in elderly patients. Screening test to depressive symptom is the best way to prevents more severe functional decline in elderly patients.

Keywords: Depression, Functional Decline, Elderly.

980

PO 508SIX-YEAR REVIEW OF DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS SYNDROME PATIENTS IN DR SOETOMO GENERAL HOSPITAL SURABAYA INDONESIA

Deasy Fetarayani, Gatot Soegiarto, Ari Baskoro, Chairul Effendi, Wita Kartika Nurani

Division of Allergy and Immunology, Department of Internal Medicine, Faculty of Medicine, Airlangga University - Dr Soetomo Hospital, Surabaya, Indonesia

Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a serious hypersensitivity reaction to drug with variable clinical features. This study was conducted to obtain information about the clinical features, laboratory findings, and treatment outcome of DRESS syndrome patients.

Methods: This was a retrospective study. Clinical records of the patients who were hospitalized in internal medicine ward Dr Soetomo General Hospital Surabaya Indonesia with a diagnosis of DRESS syndrome from June 2010 to May 2016 were reviewed.

Results: A total of 23 patients were enrolled in this study. The male to female ratio was 2.28 to 1. Patients ranged in age from 19 to 66 years with mean 39 years. The most common probable culprit drugs were cefadroxil (34.8%), followed by antituberculous drugs (30.4%), phenytoin (13.0%), allopurinol (8.7%), ceftriaxone (4.4%), and undetermined drug (8.7%). The latency period ranged from 7 to 60 days with median 27 days. Most patients (78.3%) had fever, whereas palpable lymphadenopathy was recorded in only 4.4% cases. Facial edema was noted in 30.4% cases. All patients (100%) revealed a generalized erythematous rash with some cases (30%) followed by exfoliative dermatitis. Hematologic abnormalities included eosinophilia (100%), lymphopenia (26.1%), lymphocytosis (21.7%), the presence of atypical lymphocytes (8.7%), and thrombocytopenia (17.4%). At least one internal organ were involved, i.e liver (65.2%) and kidney (4.4%). Both liver and kidney involvement were reported in 30.4% cases. All patients (100%) were treated with systemic corticosteroids of different durations. The final outcome included 73.9% survived, 21.7% died, and 4.4% undetermined.

Conclusion: DRESS syndrome is not uncommon drug reaction with high morbidity and mortality. The clinical and laboratory features in our study generally is not far different from previous published studies. Early diagnosis, prompt discontinuation of the culprit drug, monitoring for organ involvement, and using systemic corticosteroids are essential.

981

PO 509ATTITUDES AND OPINIONS OF HEALTH CARE WORKERS TOWARDS INFLUENZA VACCINATION IN A TERTIARY HOSPITAL IN ATHENS, GREECE

Tsifi A, Samarkos M, Theodoridis D, Solomos Z, Daikos G, Rosenberg T

Background: Influenza can be a serious illness, not only in high risk patients, but also in previously healthy individuals. Therefore, healthcare workers should be vaccinated against influenza not only for their own protection, but to protect their patients as well.

Aim: The study aimed to examine the attitudes and opinions of healthcare workers at “Laikon” General Hospital, Athens Greece, towards influenza vaccination.

Methods: The study was conducted at “Laikon” Hospital, a 565 bed teaching tertiary hospital. A standardized anonymous questionnaire was distributed to nurses, physicians and medical students. The questionnaire contained 3 sections of questions regarding demographics of the responders, their opinions towards influenza vaccination and their sources of information about influenza vaccination.

Results: 317 questionnaires were distributed and 293 healthcare workers responded (response rate 92.4%). The responders were 35.5% physicians, 38.2% nurses, and 22.1% medical students. Only 38.6% of the responders self-reported that they had ever been vaccinated against influenza in the past. The majority (62.8%) agreed that influenza vaccination was necessary, however only 55,3% thought vaccination was safe and a minority (44.7%) believed it was effective. Reported reasons for non-vaccination were: distrust against vaccinations in general (20.5%), neglect (16%), vaccine side effects (15.4%) & vaccine lack of effectiveness (15.1%). 68.6% of the responders had received information regarding influenza vaccination the last 5 years but only 42.3% believed it was adequate.Only 35.5% of the responders intended to be vaccinated in the future. In multivariate analysis predictors of future vaccination were previous vaccination (Odds Ratio = 8.7), belief that the vaccine was necessary (OR = 8.2), and trust to the vaccine (OR = 5.6).

Conclusion: The low rate of influenza vaccination in healthcare workers is a fact and a problem that needs to be addressed. However, the question still remains whether this specific vaccination should become mandatory for healthcare infrastructures.

982

PO 510SARCOIDOSIS: A CASE REPORT

AP Putra1, EJ Nelwan21Department of Internal Medicine. 2Division of Tropical and Infectious Disease. Faculty of Medicine University of Indonesia.

Sarcoidosis is a systemic often multiorgan disease of unknown cause, characterized by inflammatory activity with the formation of non-caseating granulomas in various organ systems. The presentation and course of sarcoidosis are highly variable, depending on the site and extent of organ involvement, fluctuating activity of the granulomatous process, and individual’s ethnicity. We report a case presented as prolonged fever in a patient with sarcoidosis.

A 66 year old woman was admitted with prolonged fever for the past six months. She also had stiffness on both hands and the on-off pain in lower-back. Recently she started of having difficult to breath which usually got worse during activity witn minimal improvement after rest. She had complete examination in the laboratory and procedures. Her data showed: no remarks in routine laboratory test, d-Dimer 1400, CRP 11.01, ANA>1/1000 smooth speckled pattern. The Chest X ray showed a bilateral hilar adenopathy with infiltrates. The Chest CT scan revealed bronchiectasis with ground glass opacity in both lungs. The MRI vertebra shows multiple bulging disc with spondylosis and spondylolisthesis vertebra lumbalis.

From the clinical appearance and all data available, we considered the patient had sarcoidosis as her main problems. She then was performing ANA profile test with strong positive result of Ro-52 recombinant +3, Jo-1 +3. The transthoracal biopsy from ground glass opacity on the lungs was then considerated to be done.

No specific therapy was given, a low dose anti inflamation-steroid base was given and tappering-off.

Keywords: Sarcoidosis, Autoimmune

983

PO 511Protective effects of melatonin on muscle tissue in streptozotocin (STZ)-induced diabetic rats

Ozlem Sacan1, Nurten Ozsoy2, Ayse Can2, Goksel Sener3, Levent Kabasakal3, Refiye Yanardag11. Department of Chemistry, Faculty of Engineering, Istanbul University, Istanbul,

Turkey.2. Department of Biochemistry, Faculty of Pharmacy, Istanbul University, Istanbul,

Turkey.3. Department of Pharmacology, Faculty of Pharmacy, Marmara University, Istanbul,

Turkey

Diabetes mellitus is a chronic disease group which is characterized with insulin defect-related hyperglycemia, causes defects in protein and fat metabolism and is genetically and clinically heterogeneous. Melatonin is an important agent which is released from pineal gland and reported to have antioxidant, anticarcinogen and neuroprotective effects on the biological systems. This study was designed to determine the possible protective effects of melatonin and/or insulin treatment on the biochemical changes in the muscle tissues of streptozotocin (STZ)-induced diabetic rats. We have divided male rats into 5 groups. Group I: Control group, received saline, i.p. Group II: Diabetes group, after induction of diabetes via a single dose of STZ (60mg/kg, i.p.), rats were given vehicle during 12 weeks. Group III: Diabetic + melatonin (10 mg/kg/day, i.p.) for 12 weeks. Group IV: Diabetic + insulin (6U/kg, s.c.) for 12 weeks. Group V: Diabetic + insulin + melatonin at the same doses and time. At the end of the experiment, animals were decapitated and muscle tissues were collected. Tissues were homogenized in saline to make 10% (w/v) homogenate and were centrifuged. In supernatants, alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase (GR) and glutathione-S-transferase (GST) activities and protein levels were determined. All the parameters investigated were increased in the diabetic group. Insulin administration reversed these aforementioned changes. On the other hand AST, ALT, GPx and GST activities were significantly decreased by melatonin administration alone. Moreover, in the diabetic + insulin + melatonin group, the amelioration in ALT, CAT, SOD and GR activities was significantly better than the only insulin given diabetic group. We can conclude that, melatonin treatment has a protective effect on muscle tissue damage induced by diabetes, probably by activating antioxidant defense of the body.

984

PO 512Giant Scrotal Hydrocele and Bilateral Leg Lymphoedema as a Manifestation of Chronic Lymphatic filariasis

Indra Wijaya, Winfrey Pangestu

Department of Internal Medicine, Faculty of Medicine University of Pelita Harapan, Siloam Karawaci Hospital

Background: Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical disease. It is most commonly caused by Wuchereria bancrofti accounts for 90% of all cases. Other causative agents are Brugia malayi and Brugia timori. Infection occurs when filarial parasites are transmitted to humans through mosquitoes. It is not common, patient with such giant scrotal elephantiasis came to health care professionals even in region endemic for filariasis.

Case Report: A 51 year old male came with the complaint of recurrent swelling in the scrotum and legs. Swelling of the scrotum first appeared 17 years ago in the left scrotum and gradually increasing in size in both scrotum. The patient lives in Sarmi regency Papua province. From the physical examination, the patient was afebrile, conjunctiva pallor, bilateral inguinal lymphadenopathy, bilateral leg swelling, and hypertrophied, pendulous bilateral scrotal hanging down with complete buried penis. On standing position swelling was hanging up to mid leg with 40 cm x 39 cm x 12 cm in size and multiple wart like protuberances in suprapubic area. There were shallow skin folds in both legs and rounded small knobs clustered together in the left foot mainly the toes, giving rise to peculiar appearance of “mossy foot”. Dual source computed tomography whole abdomen non contrast revealed large septated fluid in bilateral scrotum not clearly visible testicular structure inside suggestive filarial hydrocele and lymphadenopathy multiple inguinal bilateral, paraaortic, and parailiac. Midnight blood smear result was positive for microfilaria.

Conclusion: This case highlights the rare manifestation of chronic lymphatic filariasis and its complications. This is a good case to learn lymphatic filariasis as a differential diagnosis for genital swelling mainly scrotal tumor and incarcerated herniation.

985

PO 513CYP2C19 gene polymorphisms and the effect of adjunctive cilostazol in Japanese ischemic stroke patients having clopidogrel

Background: The antiplatelet effect of clopidogrel is associated with the CYP2C19 gene polymorphisms. The purpose of this study is to investigate the relationship between CYP2C19 gene polymorphisms and the effect of adjunctive cilostazol in Japanese ischemic stroke patients having clopidogrel. Methods: 138 ischemic stroke patients (Group A; 110 patients with clopidogrel alone, group B; 28 patients with clopidogrel and cilostazol) were analyzed. Based on the CYP2C19*2 and CYP2C19*3 genotyping obtained using PCR direct sequencing method, the patients were divided into extensive, intermediate and poor metabolizer (EM, IM and PM, respectively). The platelet function was measured with 20 μM of adenosine diphosphate using VerifyNow P2Y12 test. Clopidogrel resistance was defined as a P2Y12 Reaction Units (PRU) >230. Results: The distribution of CYP2C19 genotype was 36.2% in EM (group A=40, group B=10), 43.5% in IM (group A=48, group B=12) and 20.3% in PM (group A=22, group B=6). The rate of PRU>230 of group A was 2.5% in EM, 8.3% in IM and 31.8% in PM. However, no patients of group B showed PRU>230 (clopidogrel resistance). Conclusion: Cilostazol may intensify the antiplatelet effect of clopidogrel in ischemic stroke individuals irrespective of CYP2C19 gene polymorphisms.

986

PO 514COST COMPARISON STUDY IN INTENSIVE CARE UNITS OF LOW COMPLEXITY HOSPITAL VS. HIGH COMPLEXITY HOSPITAL IN LIMA, PERÚ.

Alva Pinto Juan Carlos

Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú.

BACKGROUND: The aim of this study is to compare the cost effectiveness of an intensive care unit in a hospital of low complexity (Uldarico Rocca Fernandez Level I hospital) versus intensive care unit in a hospital of high complexity (Edgardo Rebagliati Martins National Hospital) in Lima, Peru.

METHODS: Costing the day/bed in each intensive care units during year 2015 was made, then it made an adjustment of costs in the critical care unit of low complexity hospital based on the percentage of references made to the high complexity hospital. This percentage of references made was founded in a previous study (1).

RESULTS: The day/bed cost in the intensive care unit of high complexity hospital during the year 2,015 was estimated at S/. 1423.64 (USD 418.72), day/bed cost for intensive care unit of low complexity hospital during 2015 was estimated at S/. 780.66 (USD 229.60), but a reference rate of 17.1% was founded. Adjusted day/bed cost was estimated at S/. 941.68 (USD 276.96). It is noted that the day/bed cost in the intensive care unit at a hospital in low complexity is equivalent to 66% of the day/bed cost in the intensive care unit of the hospital of high complexity.

CONCLUSION: The management of critically ill patients in intensive care units of hospitals with low complexity was less expensive in comparison with the management of critically ill patients in intensive care units of hospitals with high complexity.

REFERENCES:1. Alva, JC. “Level of resolution and management of critical patients in the Uldarico

Rocca Fernandez Level I Hospital, Lima, Peru”. Journal of Critical Care, Aug 2016, Vol 30, Issue 4, Page 831.

987

PO 515THE S-DDD MAPPING OF OPIOID ANALGESIC IN JAVA, BALI, SOUTH SULAWESI, AND NORTH SUMATERA

Opioid analgesic is one of therapeutic option needed in moderate-severe pain (cancer pain, angina pectoris, post orthopaedic surgery, etc) management (WHO, 1998). The total use of analgesic opioid in Indonesia was less than 2 S-DDD (INCB, 2013). S-DDD is the measure of opioid analgesic use adequacy consumption in certain population. The ideal number of SDDD is 100 (WHO). This means that there is an inadequate pain treatment for moderate to severe pain patients. Several factors identified by INCB are the lack of awareness, opioid phobia, limited resources, sourcing problem, cultural/social attitudes, fear of diversion, control measures of trade, fear of prosecution, onerous and regulatory framework. Nowday, S-DDD data for analgesic opioid is calculated by INCB formulated by country. Kimia Farma (KF) is the only one legal distribution of opioid analgesic in Indonesia. Data from KF reflectst Indonesia’s data. This study aims at measuring the S-DDD of opioid analgesic at the regions level : Java, Bali, North Sumatera and South Sulawesi. This data will be used as the baseline that will be expanded to the national level.

Method: This study uses survey methods, conducted from June-July 2016. Data availability and distribution of analgesic opioid since 2010 to 2015 will be collected from KF. The population in each province refers to BPS data annually. Data will be calculated in term of S-DDD and presented on graph S-DDD vs year.

Result: The Result will be SDDD mapping in each region and it is used as a baseline to monitor the use of opioid analgesic for medication in Indonesia.

Conclusion: This is a preliminary phase to map the SDDD at Region level and will be expanded to National Level as the monitoring tool of the opioid analgesic use for medication.

988

PO 516COMORBIDITY AND DISABILITY IN INTERNAL MEDICINE PATIENTS – A CORRELATIONAL STUDY

Background: Disability is largely overlooked in patients admitted acutely, yet it has been shown to associate with a number of morbidity outcomes (e.g. length of hospital stay, mortality). This is particularly relevant in the context of aging populations, when patients present with a myriad of complex problems. Among these, the coexistence of multiple chronic conditions, termed comorbidity, contributes to complexity. We aim to study the relationship between disability and comorbidity which are significant overlapping domains in complex patients.

Methods: All patients admitted under IM to a single medical team from 2008 to 2012 (n=500) were recruited prospectively in this study. Three comorbidity measures were used: the Charlson Comorbidity Index (CCI), a count of diseases and a count of medications. The Functional Independence Measure (FIM) score was the primary disability measure. 71.6% of our patients were male. The mean age was 69.6 ± 16.9 and mean total FIM score was 74.9 ± 36.9. The top 3 reasons for admission were: UTI, 20.2%; pneumonia, 14.2% and cellulitis, 12.2%. The most common comorbidities encountered in this sample were: hypertension, 62%, hyperlipidaemia, 52.4%, diabetes, 40% and ischaemic heart disease, 38.6%. A partial correlation was run to determine the relationship between the CCI, disease count and medication count with total FIM whilst controlling for age.

Results: There was a moderate, but statistically significant (P <0.0005) negative correlation between disease count (r = -0.227, 95%CI: -0.31 to -0.14) and CCI (r = -0.223, 95%CI: -0.30 to -0.14) with total FIM, even after controlling for age. Correlation between medication count and total FIM was not statistically significant after controlling for age (P = 0.791).

Conclusion: Our results show that patients with higher comorbidity burden also have greater disability and thus, management of a patient’s comorbidities as part of acute care should be considered as it may lead to better functional outcome.

989

PO 517CHANGES IN GENE EXPRESSION AFTER DIETARY INTERVENTION BASED ON MEDITERRANEAN DIET AND PHYSICAL ACTIVITY IN COMPARISON WITH A CONTROL GROUPGonzález-Monje I1, Corella D1,2, Barragán R1,2, Sorlí JV1,2, Godoy D3, Asensio EM1,2, Fernández-Carrión R1,2, Ortega-Azorín C1,2. 1. Department of Preventive Medicine and Public Health, School of Medicine. University

of Valencia. Spain2. CIBER-OBN (Center of Biomedical Research Network Obesity and Nutrition). Carlos

III Health Institute, Spain3. Department of Internal Medicine, University General Hospital. Valencia. SpainBackground: Weight loss due to following a Mediterranean diet (MD) pattern involves variations in gene expression levels in genes related to oxidative stress, circadian rhythms and other metabolic processes, such as DNA repair or diabetes metabolism. PER1 and CLOCK are circadian rhythm genes, CAT and GPX3 are oxidative stress genes, DDIT4 is associated with DNA repair and ARRDC3 plays a role in diabetes. Thus, our aim is to analyse whether weight loss due to a hypocaloric diet based on MD and physical activity affects selected genes expression.

Methods:We performed a 6-months longitudinal trial and we studied 48 randomly selected participants in the PREDIMED-PLUS-Valencia study. We compared the effect of a hypocaloric diet combined with physical activity (n=23) with the control group (n=25). Participants were 50% women aged 55-75 years, with an initial body mass index of ≥27<40kg/m2. We obtained socio-demographic, anthropometric and biochemical information. We compared gene expression levels from selected genes between the baseline and 6-months after intervention. RNA was isolated in each visit from peripheral blood using an automatic technique (AS1310 Maxwell 13 LEV simplyRNA Blood Kit).Gene expression was validated by individual RT-qPCR and fold-change between both groups was calculated.

Results:Weight loss after 6-months in the intervention group was -5,06kg, being this figure 0,62kg in the control. Those differences between the control group and the intervention group were statistically significant (p<0,001). We obtained significant differences in gene expression at 6-months versus baseline in the whole population (CLOCK,p=0,028;PER1,p=0,004;CAT,p=0,010; GPX3,p=0,008;ARRDC3,p=0,020;DDIT4,p=0,005). However, in the analysis by intervention groups, we only observed differences in the intervention group (CLOCK,p=0,006;PER1,p=0,028;CAT,p=0,005;GPX3,p=0,044;ARRDC3,p=0,025;DDIT4,p=0,028). Otherwise, we did not found statistically significant differences in gene expression comparing control group with intervention group after 6-months.

Conclusion:Intervention with a hypocaloric diet based on MD and physical activity, involves weight loss and increases CLOCK, PER1, CAT, GPX3, DDIT4 and ARRDC3 gene expression.

990

PO 518COMORBIDITY AND DISABILITY IN INTERNAL MEDICINE PATIENTS – A CORRELATIONAL STUDY

Relationship between uric acid and lipid profiles in patients with type 2 diabetes Jae-Hoon Lee1, Hyun-Ae Seo21. Division of Vascular and Endovascular Surgery, Department of Surgery, Daegu

Catholic University Hospital, Daegu, Republic of Korea2. Departments of Internal Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea

Background: Uric acid is known to associate with stroke, coronary artery disease and metabolic syndrome. Some epidemiologic research suggested that high uric acid level is connected with dyslipidemia. However, this relationship was not studied in type 2 diabetic patients. The aim of this study was to investigate the association between serum uric acid level and lipid profiles in type 2 diabetic patients.

Methods: A total of 972 type 2 diabetes patients were included in the present study. We measured height, body weight, blood pressure and biochemical parameters. Lipid profiles included low density lipoprotein (LDL), high density lipoprotein (HDL), triglyceride (TG) and total cholesterol (TC).

Results: The mean age of total subjects was 56.90±13.91 and men were 507 (52.2%). The mean body mass index (BMI) was 23.89±3.88. In the univariate analysis, TG and uric acid level was significantly positively correlated (r =-0.155, P <0.001). HDL was significantly negatively associated with serum uric acid (r =-0.171, P <0.001). LDL and TC were not related with uric acid level. Multiple regression analyses were then performed by adjusting for age, sex and body mass index. The significantly positive association between TG and uric acid was retained (beta coefficient = 0.131, P < 0.001). The negative connection between HDL and uric acid was persisted (beta coefficient = -0.111, P = 0.001).

Conclusion: In the present study, we found that serum uric acid levels is significantly positively associated with TG, whereas serum HDL cholesterol levels are significantly inversely associated in type 2 diabetic patients. Management for hyperuricemia may help control dyslipidemia in patients with type 2 diabetes.

991

PO 519Autores: Jorge A. Esteban; M. Florencia Grande Ratti; José H. Peroni; Mario H. Díaz; Gabriel D. Waisman; Diego H. Giunta; Bernardo Martínez

PATIENTS RECEIVING UNDERTRIAGE IN THE EMERGENCY DEPARTMENT: CHARACTERISTICS AND MORTALITY

Background: The emergency department (ED) of Hospital Italiano de Buenos Aires uses a standardised triage at patient admission. The accuracy of triage is crucial since the subcategorization exposes the patient to the risk of worsening their condition and it’s a determining factor in delay admission to critical care units, that could be associated with increased mortality. The aims of this study were to estimate frequency of undertriage; to describe the characteristics of patients under triaged; and to estimate inhospital mortality.

Methods: We conducted a cross-sectional study that included all adults patients who were admitted to the ED between January and December 2014 in Argentina. Data collection was performed with secondary databases. Undertriage was defined as those patients who were categorized in care levels 3, 4 or 5 at admission, but required hospitalization in intensive care unit then. A random sample of correct triage -defined as patients who required hospitalization in intensive care unit but who received triage level of attention 1 or 2 at admission care- were included too with ratio 1:1.

Results: During 2014 a total of 104,832 consultations were carried out at ED; 12,954 requiring subsequent hospitalization; 1,461 admitted in critical care unit: 316 undertriage and 1143 correct triage. The undertriage rate was 0.30%(95%CI 0.26-0.33). Patients classified as undertriage had a median age of 68 years, 59.49% were male, 60.76% with mild comorbidities. Patients were subcategorized in greater proportion between 7 and 21 p.m.; 42.4% correspond to the first 3 months of the year. There were no differences in-hospital mortality (10.7% correct triage group versus 6.9% undertriage; p0.09).

Conclusion: The undertriage is not a frequent occurrence in our population, it is relevant information for management and improvement opportunity.

992

PO 520AUTORES: Peroni, H. José; Pedretti, Ana; Elizondo, Cristina M.; Grande Ratti, M. Florencia; González Bernaldo de Quirós, Fernán; Giunta, Diego H.; Waisman, Gabriel D.; Martínez, Bernardo

DESCRIPTION OF THE CHARACTERISTICS OF CROWDING IN THE EMERGENCY DEPARTMENT: RETROSPECTIVE COHORT STUDY

Background: Crowding -saturation of the Emergency Department (ED)- represents the imbalance between the simultaneous demand for health care and the ability of the system to respond. The scale of the National Emergency Department Crowding Scale (NEDOCS) measures the degree of crowding in a ED. The objective of the present study was to describe the characteristics of Crowding in an ED in Latin America through scale NEDOCS.

Methods: A retrospective cohort study was performed with all adult patients consultations between July 2013 and July 2014 at the ED of Hospital Italiano de Buenos Aires, a tertiary level hospital in Argentina. We included all hours in the analysis period (365 days x 24 hours = 8760), and the value of NEDOCS for each hour was calculated using an automatic algorithm. This result was categorized in 6 strata: levels 4, 5 and 6 were defined as overcrowded. Profiling chart analysis were applied to identify patterns.

Results: During the period of the study 124,758 consultations were held. Most patients 92.2% (115,035) entered wandering around on their own, 45.6% (56,888) were classified as green at triage admission. 57,7% (5,055) of the ED hours analyzed remained overcrowded. We observe the following: 4 and 5 were predominant strata levels, between 10 a.m. and 24 hours. The months predominantly overcrowded were June, July and August.

Conclusion: This NEDOCS calculation and timing analysis is highly relevant to identify opportunities for improvement and develop prevention mechanisms of the highest categories of overcrowding.

993

PO 521An educational of critical care in internal medicine; It is not only needed, but it is a must

Emmy H Pranggono, Lilik Sukesi, Uun Sumardi

Emmy Hermiyanti PranggonoDepartment in Internal MedicineFaculty of Medicine Universitas PadjadjaranDr Hasan Sadikin BandungWest java- Indonesia

WeMedical intermediate care (MIC) has been generated since 2007 by our head of InternalMedicineDepartment at that time. The location of MIC is at theInternalMedicine Department building, starting with 4 beds because of limitation human resources (nurse). Nowadays we have 8 beds already available.There are three intensivistsconsultant who come from internist pulmonologist , tropical medicine internist and internist nephrologist. Theygraduated fromUniversitas Indonesia and UniversitasPadjadjaran. We care septic patient with their complication such as renal, pulmonary, hematologic, stress ulcer and others, and of course we treat the patient with lung problem such as pneumonia and COPD.As anintensivist we can handle the invasive mechanical ventilation if needed, with the confirmation if there are no beds in ICU.Now we serve 6 beds which are almost always full with manyqueerer behind.Our hospital is a teaching hospital;therefore our MIC is the place for the candidate internist to manage critically ill patients. There are about more than 100 new internist since 2009 with new and applicativeknowledge of critical care especially for internal medicine field ; spreading at many region of Indonesia ( now we realized that internal medicine is the core of intensive care knowledge). Not only the education of the internist candidate, there arealso many research come from our MIC, some of them presented in local dan international symposium.So we can see how much we needed and the benefit of medical criticalcare programmeduring internist education. Unfortunately we face the big problemfor continuing thisspecific education, because there are some rules which isnot suitable to educate an intensivist consultant with internist backgroud.For these reason we want to try to discuss the situation with others condition of the Internal MedicineSocietyin the world who have the experience with critical education in internal medicine. Now we realized itsnecessity, not just because we needed, but it isabsolutelya must.

994

PO 522In vitro Screening of Hyaluronidase Activities of Some Medicinal Plants

Refiye Yanardag, Hilal Demirbay Ozmen, Sevim Tunali

Istanbul University, Faculty of Engineering, Department of Chemistry, Biochemistry Division 34230-Avcilar, Istanbul, Turkey

Hyaluronidase (EC.3.2.1.35) is known to be a family of key enzymes involved in human tissue remodeling during allergy, migration of cancer, inflammation responses. This enzyme is found in organs (testis, spleen, skin, eye, liver, kidney, uterus and placenta) and in body fluids (tears, blood and sperm). Previous reports have shown that the action of activated hyaluronidase can be involved in the allergic inflammation along with the histamin release from mast cells. Hyaluronidase inhibitory activity has been considered as a model for screening antiinflammatory materials from natural sources. In our study, we have examined hyaluraonidase inhibitory activities of different plant extracts such as apricot, banana, apple, parsley, mint, camomile, and blueberrries. Plant materials were washed with distilled water and dried at room temperature. The extracts were prepared with water. Hyaluronidase inhibitory activities of the different plant extracts were increasing in a dose dependent manner. As a result all the plants showed hyaluronidase inhibitory activity. Among the extracts studied apricot and banana showed the highest inhibitory activity. It can be suggested that several plant extracts which are potential sources of hyaluronidase inhibitors may be appropriate to be used as an additional support to drug treatment in the field of health as antiallergic activity.

995

PO 523PARAQUAT POISONING- CHALLENGE TO THE DEVELOPING COUNTRY

Paraquat (1, r-dimethyl-4,4’-bipyridium dichloride), a member of the bipyridyl group of herbicides, has been demonstrated to be an effective weed killer. Paraquat is a rapidly-acting, nonselective herbicide that is relatively inexpensive. These characteristics contribute to its widespread use in much of the developing world. Paraquat is reasonably safe to use in agriculture: dermal or spray exposure generally causes only limited, localized injury. However, accidental or deliberate ingestion has an extremely high case-fatality rate. In the rural areas of countries where it remains readily available, it is a common method for intentional self-poisoning. Paraquat ingestion is a leading cause of fatal poisoning in many parts of Asia including Bangladesh. In the Rajshahi Medical College Hospital, Rajshahi, Bangladesh, we report four adult cases of paraquat poisoning among them three died. All took paraquat to commit suicide. Till now paraquat poisoning has no antidote so we could not save the patients only given supportive management including ICU support. All four patients had come from rural areas. Died three cases were taken around 10ml of paraquat and Initially they presented normally but within 3-5 days, developed hepatic, renal failure subsequently ARDS and died within one week. Other one case had only renal involvement and with the supportive management survived. As case fatality is very high so right now we concerned people have to think how we can overcome this situation. Either we have to restrict the use and availability of paraquat, or should have an alternative otherwise we will lose many lives in our country as well as developing country.

All correspondence to:Dr. Abu Shahin Mohammed Mahbubur RahmanAssistant Professor, Department of Medicine,Rajshahi Medical College, Rajshahi, Bangladesh,Email: [email protected]: 8801763248448.

996

PO 524GENETIC VARIANT GC GENE AND VITAMIN D STATUS AMONG JAVANESE ETHNICITY IN INDONESIA

Dwi Astuti Handayani1, Jinia Lilianty1,2, Miftakh Nur Rahman1,3, Miswar Fattah11Prodia Clinical Laboratory, Indonesia; 2Univesity of Melbourne, Australia; 3Padjadjaran University, Indonesia*email: [email protected]

Background: The Javanese are the largest ethnic group, constituting 45% of Indonesia’s population, live mainly in central and eastern Java, but millions have migrated to other islands. The prevalence of vitamin D deficiency in Indonesia is very high which are influenced by genetic factor, diet, and sun exposure. Vitamin D Binding Protein is the primary vitamin D carrier protein in circulation, and its polymorphism has been shown to vary across different ethnicities and populations. Data from Indonesian population related to VDBP gene variation and its association to serum Vitamin D concentration have not been observed. Aim: To observe VDBP genotypes and phenotypes frequency among Javanese ethnicity in Indonesian population and its association to Vitamin D concentration.

Methods: An observational cross-sectional study was conducted with healthy male and female from 18-50 years old from 4 cities in Indonesia, with Javanese ethnicity. Serum 25-dyhydroxyvitamin D [25(OH)D] level were measured by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS), and subjects were grouped into Vitamin D deficiency, insufficiency, and sufficiency. A common variant of VDBP, rs7041 and rs4588 were genotyped by restriction fragment length (RFLP) polymerase chain reaction (PCR).

Results: From 146 subjects, we found 17.8% was Vitamin D deficient, 81.5% insufficient and 0.6% sufficient. GC1F variant was most frequently observed (53%), followed by GC1S (29.9%) and GC2 (17.1%). The highest Vitamin D level was in GC1F and the lowest was in GC2 phenotype. We also found significant difference of Vitamin D level in GC1F subjects from Bandung and Jakarta (19.9 vs 13.2 ng/mL, p<0.05). Regardless of the phenotype, we found no deficient subjects from Denpasar, but higher prevalence of deficiency in Jakarta (17.4%), Bandung (20.9%), and Surabaya (18.2%).

Conclusions: Our results suggest that the common variants of GC are one of genetic determinants of serum 25(OH)D among Javanese ethnicity, in addition to well-known environmental and geographical factors.

Keywords: Vitamin D, GC Gene, Javanese

997

PO 525DIABETES KNOWLEDGE AND QUALITY OF LIFE IN TYPE 2 DIABETES MELLITUS

Filemon MWS1, Audrey SS1, Aurea SS1, Hiensen H1, Renaldy T1, Stevent S2

1. Faculty of Medicine, Universitas Pelita Harapan, Lippo Village, Tangerang, Indonesia2. Internal Medicine Department, Faculty of Medicine, Universitas Pelita Harapan,

Siloam Hospital Lippo Village, Tangerang, Indonesia

Background: Diabetes is a chronic diseases with many complication, studies report worse quality of life (QOL) for people with diabetes compared to the general population. A higher diabetes knowledge have been shown to have better glycaemic control, enhance the patients to cope and adjust to their illness. This study examined the associations of diabetes-related knowledge to the health-related quality of life.

Methods: Crossectional study conducted on 74 type 2 diabetes mellitus (T2DM) patient of Rumah Sakit Umum Siloam (RSUS), Tangerang, Indonesia between January-May 2016. Patients were evaluated for diabetes duration, diabetes knowledge using Diabetes Knowledge Questionnaire (DKQ-24), and QOL (Physical Component Summary [PCS] and Mental Component Summary [MCS]) using SF-12. For the analysis, we used independent T-test to find the mean differences and Spearman correlation.

Results: Of 74 patients, 30 male and 40 female were measured. About 78.6% of the patients have a low knowledge and 20.5% patients have a high knowledge. The mean PCS and MCS in low knowledge and high knowledge were 40.7 vs 39.31 and 39.42 vs 42.72 (p=0.54; 0.259) respectively. The mean PCS and MCS in male and female were 38.15 vs 41.93 and 39.3 vs 40.70 (p=0.043; 0.57) respectively. Duration of diabetes had a correlation with better knowledge in diabetes (p=0.006) but there were no correlation between duration of diabetes with PCS (p= 0.738), MCS (p=0.309)

Conclusion: This studies shows that diabetes knowledge didn’t related to a better QOL.

998

PO 526INTERNAL MEDICINE CASESES PROFILE VISIT IN EMERGENCY UNIT DR. SARDJITO GENERAL HOSPITAL YOGYAKARTA, WITHIN SEVEN DAYS AFTER FIRST DAY EID MUBARAK

Endro Tanoyo1, Probosuseno21Resident of Internal Medicine Departement at Gadjah Mada University/ dr. Sardjito General Hospital, Yogyakarta, Indonesia2Gereatrician of Internal Medicine Departement at dr.Sardjito General Hospital, Yogyakarta, Indonesia

Abstract

Background : Indonesia is the biggest muslim country in the world and Eid Mubarak is very important day. The celebration in Indonesia has tradition named “Mudik”, is a tradition for Indonesian to come back to their hometown/village for family gathering. Mudik phenomena in Indonesia begin first day until about seventh day of Eid Mubarak. Hospital as health care center stayed operating during this holiday, with limited health care providers/workers on duty caused by this tradition. Mostly specialist doctors were not stand by in hospital during this celebration, specially at academic hospital. Emergency unit is the only installation operated within this holidays and majority cases visit are internal medicine cases. Data about patients characteristics and internal medicine cases visit in emergency unit should be figured out to prepare the optimum service with all limitations during Eid Mubarak celebration.

Objective : figured out the patients characteristics and internal medicine cases visit in emergency unit dr. Sardjito General Hospital within seven days after first day Eid Mubarak.

Methode : This study is descriptive and retrospective. Data of cases collected from registry book in emergency unit of dr. Sardjito General Hospital Yogyakarta, which sent or consulted to internal medicine department within seven days after first day Eid Mubarak from July 18th until 24th, 2015. Data presented as percentage of age and cases related to sub-division of internal medicine department.

Result : There are150 pasients registerd, 9 patients were excluded because incomplete data and it remain 141 patients underwent further analysis. In this study show that 46,8% patients were elderly (age more than 60 years old), 35,58% patients within 40 to 60 years old, and 15,60% patients were below 40 years old. From 141 patients sent or consulted to internal medicine department, mainly geriatric with multiple pathologic 66 cases (46,80%), nephrologic and hypertension 59 cases (41,84%), pulmonary 39 cases (27,65%), gastro-entero-hepatologic 39 cases (27,65%), hematologic and oncology medic 35 cases (24,82%), endocrine and metabolic (21,98%), cardiology 30 cases (21,27%), tropic infections 14 cases (9,92%), psychosomatic 1 cases (0.70%), and rheumatology

999

1 cases (0,70%). Limitation of this study were some incomplete registry data and small sample.

Conclusion : The most pasients visit in emergency unit dr. Sardjito Hospital, Yogyakarta were elderly with multiple pathologic, and top 5 cases related sub-division are geriatric, nephrology and hypertension, gastro-entero-hepatology, hematology and oncology medic, endrocrine and metabolic, and cardiology.

Key words : eid Mubarak; “mudik” tradition; emergency unit; epidemiology.

1000

PO 527Dehydration among Hajj Indonesia

At Mecca in 2015

Deske Muhadi

Rheumatology Division, Internal Medicine Department

Faculty of Medicine, University of Sumatera Utara /Adam Malik General Hospital – Medan - Indonesia

Hajj is mandatory for everyone muslim done for those who can afford. To perform the pilgrimage would require long preparation and opportunity, will generally take a wait until more than 10 years for the chance the trip. Age over 60 years for Indonesian pilgrims are common, some circumstances may become a serious problem in that journey. Dehydration is the most common as a cause or trigger mortality rate on pilgrims premises.

This study aims to assess the status of dehydration on the premises pilgrims aged over 60 years in the 2016 pilgrimage season in Mecca. Samples were pilgrims age above 60 years, who was in Mecca in 2015. An urine sample examination 2 times on different occasions well done. Assessment of the color of the urine will show mild to severe dehydration.

Dehydration is generally found in over 70% of Indonesian pilgrims were aged over 60 years.

1001

PO 528FAHR DISEASE PRESENTED WITH SYNCOPE

Yusuf HANCERLI, Musa SALMANOGLU, Mustafa KAPLAN, Barbaros BASBUG, Muhammet YILDIRIM, Emrullah SOLMAZGUL

GATA Haydarpasa Training Hospital, Istanbul,Turkey

BACKGROUND: Fahr’s disease (FD) is a very rare pathology characterized by intracranial bilateral symmetrical calcification and neuropsychiatric symptoms. Although there is no clear cause of FD; calcium and phosphorus metabolic disorders besides genetic factors are also implicated in the etiology. We presented here a case of 72-year-old male patient with FD who had recurrent syncope.

CASE: A 72-year-old male patient presented to the emergency department with recurrent syncope episodes and recently increased ataxic gait. The patient with prosthetic mitral valve had history of hypertension. The test results were as follows; calcium: 5.5 mg / dL, albumin: 3.35 g / dl, phosphorus: 7.1 mg / dL, parathormone: 4 pg / ml. Patient who did not have any known history of thyroid or parathyroid surgery, reported that he stopped 1500 mg of calcium carbonate - 400 IU d3 2x1 regimen which was prescribed for him after diagnosis of idiopathic hypoparathyroidism 4 months ago. Brain tomography revealed widespread symmetrical calcifications in the brain including the areas of caudate nucleus, thalamus, lentiform nucleus and cerebellar hemispheres. Patient’s disease was considered as Fahr’s disease in light of current findings. The patient was discharged with recommendation of regular neurology follow-up.

CONCLUSION: Fahr’s disease should be considered among initial diagnoses when the patients with underlying calcium metabolism disorders suddenly develop neuropsychiatric disorders, or when cranial computed tomography or magnetic resonance imaging reveals calcifications that are not connected to any cause.

1002

PO 529From less common to very likely, a case of cerebellum stroke

Introduction: Isolated cerebellar infarct without brainstem ischemia is very uncommon (2%). Clinical presentation is acute and characterised by imbalance that might seem vestibular pathology, also vomits, dysarthria, cerebellar ataxia and nystagmus. Serious presentations, edematous, that may need to be surgically treated due to brainstem compression, block threatening and tonsillar hydrocephaly development.

Clinical report: 44 year-old woman who presented headache, vomits and dizziness. Medical background: right eye open-angle glaucoma, left eye visual acuity partially impaired, strabismus, hypertension, dyslipidemia, oral contraceptives –ethinylestradiol, levonogestrel-, 2 pregnancies, 2 births.

Physical examination: Walking imbalance with left inclination, CT scan without positive findings. Symptoms remain plus nuchal stiffness, positive Brudzinsky. Cerebrospinal fluid normal, palpebral ptosis, right eye horizontal nystagmus with a rapid component to the right, severe systolic HBP, right hemicranial headache and tiny walking imbalance.Brain MRI showed acute extended ischemic infarct in inferior zone of right cerebellum, right hemivermix, inferior cerebellar-peduncle, with mass effect in the rear side of the bulb-protuberal transition and base cisterns mitigation. The patient had a slow recovery improving her neurological condition, helped by physical therapy. There has not been found neurological aftermath in the follow-up as outpatient. Normal control CT-scan after 6 months, she carried on having physiotherapy, controlled BP, cutting off oral contraception.

Discussion: Particular clinical presentation of cerebellar stroke in woman under oral anticoagulants who takes contraceptives that act as a left risk factor forgotten when prescribing. Despite this, the patient got a complete clinical recovery in contrast to most of patients, maybe because of her young age.

Conclusions: It is important to suspect this kind of events in patients with risk factors to be able to make the correct diagnosis and to focus the therapy. Physiotherapy improves patients’ physical condition and quality of life.

1003

PO 530(POSTER) THE WARD PHARMACIST AS CHAMPION OF VTE RISK ASSESSMENT, A NOVEL ATTEMPT TO INCREASE PROPHYLAXIS UPTAKESarbroop Dhillon

BACKGROUND:• Venous thromboembolism (VTE) is a major cause of inpatient morbidity and mortality.

Although risk factors are well known and prophylaxis guidelines widely available, VTE prophylaxis is greatly under-utilised.

• We conducted a two-part audit to determine whether empowering the ward pharmacist to a more central role could improve VTE risk assessment and prophylaxis rates amongst medical inpatients.

METHODS:• After a baseline audit, a VTE prophylaxis assessment was incorporated into the

pharmacist medication review performed within twenty-four hours of admission, and the pharmacist was empowered to prompt the treating doctor if VTE prophylaxis was not appropriately prescribed.

• Patient files were also supplemented with a prompt to consider VTE prophylaxis, along with a summary page of VTE risk factors and contraindications.

• A re-audit was then performed assessing for improvement in the two primary endpoints: VTE risk assessment documentation, and appropriate prescription of VTE prophylaxis.

• An individual was deemed at risk of VTE if they possessed any one VTE risk factor as specified by the guidelines produced by the Australian Medical Council.

• Data was analysed using the Fisher Exact Test with a P value less than 5% considered statistically significant.

RESULTS:• A total of 227 patients (audit 1; 146, audit 2; 81) were included in the study. Baseline

rates of VTE prophylaxis risk assessment documentation was 19.4% and prophylaxis prescription in at risk inpatients 80.6%.

• Repeat audit post intervention failed to show any statistically significant change. (TABLE)

CONCLUSION:• Our overall VTE prophylaxis rates in at risk patients compared favourably against

studies performed in Australia and internationally, suggesting that our medical staff do acknowledge VTE risk. However, risk assessment documentation rates remain poor.

• Utilisation of the pharmacist as VTE champion was a somewhat unique approach. Their knowledge and experience may prove pivotal in reducing VTE rates, but further studies are required to evaluate how they can best contribute.

1004

PO 531Correlation Between Lipid Plasma,Transaminase Level And Body Mass Index With Liver Fibrosis In Nonalcoholic Fatty Liver Disease Patients

Femmy Nurul Akbar*, Edi Mulyana**

Department of Internal Medicine, Medical Education Program, Faculty of Medicine and Health Science Islamic State University Syarif Hidayatullah, Jakarta

**Division Gastroenterology and Hepatology Department of Internal Medicine Fatmawati General Hospital, Jakarta

Backgrounds : Non alcoholic fatty liver disease (NALFD) is one of fatty liver disease that are not associated with alcohol consumption but related to high body mass index, dyslipidemia and diabetes. NALFD will develop liver fibrosis and at the end will develop liver cirrhosis or hepatocellular carcinoma. Aim of this study is to know relationship between body mass index, lipid plasma and transaminase with liver fibrosis by transient elastography (Fibroscan) examination.

Methods: It was correlation study with cross sectional method. They were examined lipid panel , transaminase, body mass index and undergone liver transient elastography (Fibroscan) to determine liver stiffness or fibrosis. Patients with chronic hepatitis B or C, alcoholic fatty liver and drug induce hepatitis or patients could not perfomed liver transient-elastography (massive ascites, etc) were excluded from this study. Liver fibrosis were defined as 6 .5 kPa or higher respectively using Fibroscan.

Results : There were total of 23 male and 7 female were enrolled in this study. Mean of age was 48.5 years Mean of body mass index was 27.08 kg/m. Mean of liver transient elastography was 7.1 kPa.

Conclusion : There were only weak positive correlation between transaminase AST /S with liver fibrosis by liver transient elastography (Fibroscan).

1005

PO 532AKURASI DERAJAT FIBROSIS HATI BERDASARKAN KING’S SCORE TERHADAP FIBROSCAN PADA PENYAKIT HEPATITIS B KRONIK

Yudi Andre Marpaung, Juwita Sembiring, Lukman Hakim ZainDivisi Gastroenterologi dan Hepatologi, Departemen Ilmu Penyakit DalamFakultas Kedokteran Universitas Sumatera Utara, RSUP.H.Adam Malik Medan

Latar belakang : Dalam beberapa tahun terakhir ini, perhatian yang besar telah didedikasikan bagi pengembangan model prediksi non-invasif dalam mengurangi tingkat kebutuhan biopsi hati untuk penilaian dan evaluasi fibrosis hati. Cross, dkk telah mengusulkan King’s Score, dengan mengukur Usia (thn) x AST (IU/L) x [ INR / Jml Platelet (109/L)], sebuah model sederhana yang terdiri dari penanda laboratorium rutin untuk memprediksi fibrosis hati pada pasien penyakit hepatitis B kronis dalam rangka mengoptimalkan manajemen klinisnya.

Tujuan : Untuk menilai akurasi King’s Score dalam memprediksi derajat fibrosis hati pada pasien penyakit hepatitis B kronik.

Metode : Selama Pebruari 2013 sampai Juli 2013, pada enam puluh dua pasien penyakit hepatitis B kronik menjalani Fibroscan di divisi Gastroenterologi dan Hepatologi, RS Haji Adam Malik, Medan dan dilakukan pemeriksaan serum AST, INR, PLT serta selanjutnya mengkalkulasi King’s Score. Patologi fibrosis hati digradasi berdasarkan sistem penilaian Fibroscan dari skala F0 sampai F4. Digunakan nilai-nilai prediktif diagnostik dalam menilai akurasi King’s Score.

Hasil : King’s Score ≥12,3 memiliki sensitivitas sebesar 48,1%, spesifisitas 88,6%, PPV 76,5%, NPV 68,9%, LR (+) 0,54, LR (–) 0,53 dalam memprediksi significant fibrosis. Untuk memprediksi sirosis, King’s Score ≥16,7 memiliki nilai akurasi yang tinggi dengan sensitivitas sebesar 83,3%, spesifisitas 85,7%, PPV 38,5%, NPV 98%, LR (+) 0,98, LR (–) 0,96. Nilai AUROC untuk masing-masing non-significant dan sirosis adalah 0,684 (95% CI, 0,545-0,822, p value = 0,014) dan 0,845 (95% CI, 0,664-1,027, p value = 0,006).

Kesimpulan : King’s Score memiliki kemampuan memprediksi sirosis ( fibrosis grade 4) pada pasien penyakit hepatitis B kronik dengan tingkat akurasi yang tinggi, sehingga pasien dengan nilai King’s Score ≥16,7 tidak membutuhkan biopsi hati lagi. Sedangkan untuk significant fibrosis, model ini tidak menunjukkan tingkat akurasi yang tinggi.

Kata kunci: King’s Score, Fibroscan, fibrosis hati, penyakit hepatitis B kronik

1006

ACCURACY OF KING’S SCORE PREDICTS LIVER FIBROSIS BASED ON FIBROSCANIN PATIENTS WITH CHRONIC HEPATITIS B

Yudi Andre Marpaung, Juwita Sembiring, Lukman Hakim Zain Division of Gastroenterology and Hepatology, Department of Internal Medicine Medical Faculty, University of North Sumatera, H.Adam Malik General Hospital Medan

Background: A great interest has been dedicated to the development of noninvasive predictive models in recent years to substitute liver biopsy for fibrosis assessment and follow-up. Cross, et al proposed King’s Score, Age (years) x AST (IU/L) x [INR / Platelets (109/L)], a simpler model consisting of routine laboratory markers for predicting liver fibrosis in patients with chronic hepatitis B in order to optimize their clinical management.

Objective: To investigate the accuracy of King’s Score for predicting liver fibrosis in patients with chronic hepatitis B.

Methods: Since 2013 February until July, sixty two patients confirmed chronic hepatitis B, underwent Fibroscan in division of Gastroenterology and Hepatology at Haji Adam Malik hospital, Medan. Serum obtained and analyzed for AST, INR and PLT activity, and the King’s Score was computed. Liver fibrosis pathology was staged according to a defined system on a scale of F0 to F4 in Fibroscan. We used predictive values to assess the accuracy of King’s Score.

Results: King’s score greater than or equal to 12,3 in predicted significant fibrosis has 48,1% sensitivity, 88,6% specificity, 76,5% PPV, 68,9% NPV. King’s score greater than or equal to 16,7 in predicted cirrhosis has 83,3% sensitivity, 85,7% specificity, 38,5% PPV, 98% NPV. The validation set confirmed the utility of this index, area under receiver operating characteristic curves for each non-significant and cirrhosis was 0,684 (95% CI, 0,545-0,822, p value = 0,014) and 0,845 (95% CI, 0,664-1,027, p value = 0,006), respectively.

Conclusion: The King’s Score predicts cirrhosis ( grade-4 fibrosis ) in patients with chronic hepatitis B with a high degree of accuracy, potentially decreases the need for liver biopsy.

Key words: King’s Score, Fibroscan, liver fibrosis, chronic hepatitis B.

1007

Congress SecretariatMedical Conference Organizer (MCO®) by PT. Pharma-Pro InternationalKomplek Perkantoran Duta Merlin Blok C/35-36, Jl. Gajah Mada 3-5, Jakarta 10130, Indonesia

www.wcimbali2016.org+62-21-6386-9502 +62-21-6386-9503/6386-9505

REGISTRATION & EXHIBITIONMs. Evi +62-811-101-8517Ms. Wendy L. +62 812 1880 2756 Phone: +62-21-6386-9502, ext.101 [email protected]

ACCOMMODATIONMs. Isma +62-852-1551-0055 +62-21-6386-9502, ext.112 [email protected]

SCIENTIFIC & GENERAL MATTERSMs. Gita +62 812 9181 0522Ms. Santi Anwar +62 8888 435 226 +62-21-63869502, ext.115/ 103 [email protected]

MCO® is certified by Indonesia Authority of MICE Industry and registered trademark of PT. Pharma-Pro International This name is protected by Indonesia copyright laws

abstract book - universitas udayana

Documents