Khazanah Riset

22

Evaluation of Drug Related Problems in Diabetes Mellitus Disease and Cellulitis in Hospital Center of Army (RSPAD) Gatot Soebroto Jakarta Samir, Rahmatillah, Diana Laila, Efi Aprilita Rinayanti Abstract Diabetes mellitus is a chronic disorder characterized by hyperglycemia due to insulin deficiency that function allows glucose to enter the cells metabolized as an energy source. Insulin hormone deficiency can be caused by the destruction of pancreatic beta cells that do not produce insulin and decreased receptor sensitivity, resulting increase in blood sugar. Cellulitis is an acute inflammation primarily affects the dermis tissue and subcutaneous with symptoms of fever and malaise, followed by signs of inflammation are swelling, pain and florid. Patient Mrs. SW, aged 45 years, entered the Emergency Room of Hospital Gatot Subroto Army Center on December 10, 2014 with a diagnosis of diabetes mellitus type II uncontrolled and cellulitis. Pharmacological therapy given profenid suppository, Novorapid, ampicillin-sulbactam, domperidone, omeprazole, sodium diclofenac, antacid syrup, Lantus, ramipril, ketorolac, metronidazole, ultracet and clindamycin. Results of clinical studies found a Drug Related Problems that interaction between ketoprofen with diclofenak sodium, ketoprofen with ketorolac, antacids with ramipril. Ketorolac, ketoprofen, sodium diclofenak with ramipril. Novorapid, Lantus with ramipril. There are side effects of adverse drug is sodium diclofenac, ketorolac, and ketoprofen. The use of klindamycin under therapeutic doses. 23

Peripheral Blood Mesenchymal Stem Cells Isolated from Indonesia Long Tailed Monkey (Macaca fascicularis) Agus Harsoyo, Dondin Sajuthi, Arief Boedion ,Yoga Yuniadi , Irma H. Suparto Abstract An experiment to compare age of Macaca fascicularis (Mf) as pheripheral blood (PB) mesenchymal stem cell (MSC) isolate sources and the impact of its concentration on the pheriperal blood mononucleous cells (PBMC) development has been conducted. Twelve male Mf were used in this experiment. Three different age groups (infant (A1), juvenil (A2) and adult (A3) of the Mfs were compared as treatments. Isolate of pheriperal blood MSC were created by taking 1 ml, 5 ml or 10 ml the Mfs pheriperal blood, processed them into PBMC, counted, isolated, cultured, subcultured, pelleted, extracted for their messenger Ribonucleic Acid (mRNA). Reverse transcriptase - polymerase chain reaction (RT-PCR) were conducted to obtain complentary Deoxyribonucleic Acid (cDNA). PCR amplification were performed to look cluster differentiation (CD) of the MSC gene expression. Incomplete block design was used and the data were analysed using descriptive statistic and T-Test. The results showed that PBMC counted from infant, juvenil and adult were 6.78 – 7.28, 6.18 – 7.30, and 6.01 – 7.34 log cell, respectively. The subculture and pelleting cells were only obtained from A3 with positive 73, 90, 105 and negative 34, 45 CD markers. It is concluded that pheriperal blood of adult Mf can be utilized as MSC source. Keywords: CD marker, Macaca fascicularis, mesenchymal stem cell, pheriperal blood 24

Differentiation and Identification of Cardiomyocyte and Cardiac Conduction Systems Connexin from Bone Marrow Mesenchymal Stem Cells Macaca nemestrina Agus Harsoyo Abstract The gap junctions (GJ) is one of the connecction of intercalated discs that are composed of cardiomyocyte. The role of GJ which is composed by connexin has function as ion and small molecules transporter. The morphological abnormalities of GJ cause cardiac conduction block (CCB). The handling of CCB, currently using single or double chamber pacemakers that causing increased costs and occurrence of complications. Therefore, the bone marrow mesenchymal stem cell (BMMSC) therapy using the Macaca nemestrina (M. nemestrina) model in vitro can be an alternative for treatment of CCB tested in vivo in the future. The procedure of isolation and development of BMMSC were as follows. The bone marrow aspirate was taken from the proximal os humerus of 4 adult male M. nemestrina and put in the heparin tube. The standard Ficoll – Hypaque method was used to harvest BMMSC by centrifugation with 800xg. Then washed with phosphate buffer saline 20% twice. Further, after that a small portion of single nucleated cells were calculated after stained with the trypan blue and most others single nucleated cells were cultured in a six well plate with growth media then incubated at 37 ºC and 5% CO2. If the confluence cells reached 70 - 80%, cells were further passage every seven days and the media were changed twice a week until 3 weeks. If the cells didn‟t reach confluence; so the cells was excluded from this research. The four sources of M. nemestrina cells had the level of viability more than 90%, however only the cells from Mn# 3 dead at the first 7th day and it was excluded from this research. The three sources ie. Mn# 1, Mn# 2 and Mn# 4 then continued to the next passage. The population doubling time (PDT) also extended accordingly to their number of passage and it follows 4 stages ie. reseedding, lag, log and stationary.The BMMSC M. nemestrina has been isolated and developed with the following evidence: gene expressed by CD73/ Nt5e (101 bp) and CD105/ Eng (104 bp), not gene expressed by Cd34 (380 bp) and CD45/ Ptrpc (167 bp). Also, gene was expressed by cTn I/ Tnni3,  actinin/ Actn2, Gata4, Nkx-2.5/ Nkx2-5, Cx40/ Gja5, Cx43/ Gja1 and control gene expressed by Gapdh (352 bp). Differentiation can be proved on osteocyte, chondrocyte, adipocyte, cardiomyocytes also Cx43 and Cx40. The differentiation of cardiomyocytes 25

and identification of connexin cardiac conduction system were successful obtained from the isolation and development of BMMSC M. nemestrina in vitro. Gen transcription and protein translation were detected and proven. Keywords: bone marrow stem cells, cardiac conduction system, cardiomyocyte, connexin, nonhuman primate. 26

Association Between Diagnosis of Hypertension and Findings of Cardiac Catheterization in Army Personnel Undergoing Medical Check-Up Emir Yonas, Raymond Pranata, Veresa Chintya, Bambang Pamungkas, Vireza Pratama, Bayu Arif Permana, Dina Evalina Syahlul, Agus Harsoyo Abstract Hypertension is the most important risk factor for premature cardiovascular disease, it is more common than cigarette smoking, dyslipidemia, and diabetes, which are the other major risk factors. Hypertension accounts for an estimated 47 percent of all ischemic heart disease events globally. The lifetime risk of developing the coronary vascular disease is significantly higher among patients with hypertension, with 63.3 percent lifetime risk. In A study of the INTERHEART group, hypertension accounted for 18 percent of the population-attributable risk of a first myocardial infarction. In this abstract, we present our observation regarding hypertension and cardiac catheterization results in medical check-up patients of Gatot Soebroto Central Army Hospital. Our aim is to know the magnitude of difference in findings of cardiac catheterization between subjects without a history of hypertension and those without. This was a cross-sectional observational study. Their subjects were 326 consecutive army personnel who were referred to cardiology and vascular department for further cardiovascular examination from medical check-up unit in Central Army Hospital Gatot Soebroto. 35 subjects underwent coronary catheterization in which 26 was not hypertensive and 9 was hypertensive. Data were analyzed using SPSS v23. There was no difference in frequency of findings of normal catheterization, myocardial bridging, tortuosity, one vessel disease and two-vessel disease. However, there is significant difference in presence of three-vessel disease through Fisher's exact test (p=0.044). In this small sample, hypertension was associated with findings of three-vessel disease but not the other. 27

Left Ventricular Hypertrophy in Army Personnel Undergoing Medical Check-Up: Is Hypertension The Cause of LVH? Emir Yonas, Raymond Pranata, Veresa Chintya, Bambang Pamungkas, Vireza Pratama, Bayu Arif Permana, Dina Evalina Syahlul, Agus Harsoyo Abstract Left ventricular hypertrophy (LVH), refers to an increase in the size of myocardial fibers in the main cardiac pumping chambers, such hypertrophy is usually the response of chronic volume or pressure load. Systemic hypertension and aortic stenosis are the two most important pressure overload states, while aortic and mitral regurgitation are the conditions associated with volume overload. This increase in mass predominantly results from a chronic increase in afterload of the left ventricle. A significant increase in the number and/or size of sarcomeres within each myocardial cell is the pathologic mechanism. This condition can be diagnosed with either electrocardiogram or echocardiography, however, a more accurate approach and quantification of mass are done with echocardiography. In this abstract, we present our observation regarding left ventricular hypertrophy and hypertension in medical check-up patients. Our aim is to know the magnitude of difference in LVH between subjects with a history of hypertension and those without. We also try to analyze whether there is a difference in physical activity, duration of exercise and BMI between hypertensive and non-hypertensive subjects with concentric LVH. This was a cross-sectional observational study. Their subjects were 326 consecutive army personnel who were referred to cardiology and vascular department for further cardiovascular examination from medical check-up unit in Gatot Soebroto Central Army Hospital. 208 subjects were excluded because echocardiography was not ordered. Out of 118 subjects, 45 were hypertensive and 73 were not. Data were analyzed using SPSS v23. Out of 45 hypertensive subjects, 30 had concentric LVH upon echocardiography. Among 73 non- hypertensive subjects, 40 had concentric LVH upon echocardiography. There was no significant difference in findings of concentric LVH in those who have a history of hypertension and without (p=0.135). No significant difference was found in physical activity, duration of exercise or BMI between hypertensive and non-hypertensive subjects with concentric LVH. In this population, hypertension was not associated with LVH. This may be either because of physical activity in the army was high enough to prevent LVH in hypertensive, cause LVH in non-hypertensive or a combination of both. 28

Profile of Cardiovascular Risk Factors of Army Personnel Undergoing Medical Check-Up Raymond Pranata, Emir Yonas, Veresa Chintya, Bambang Pamungkas, Vireza Pratama, Bayu Arif Permana, Dina Evalina Syahlul, Agus Harsoyo Abstract A number of risk factors are strongly and independently associated with the development of hypertension, these risk factors include; age, obesity, family history, race, reduced nephron number, high-sodium diet, excessive alcohol consumption, and physical activity. Some of these risk factors are modifiable while some are not. The modification of risk factors with a healthier lifestyle can contribute to a lower baseline blood pressure in individuals diagnosed with hypertension. In this abstract, we present our observation regarding hypertension and possible risk factors in medical check-up patients of Gatot Soebroto Central Army Hospital. Our aim is to describe the cardiovascular risk factors of army personnel who were referred to cardiology and vascular department for further cardiovascular examination from medical check-up unit. This was a cross-sectional observational study. Their subjects were 326 consecutive army personnel who were referred to cardiology and vascular department for further cardiovascular examination from medical check-up unit in Central Army Hospital Gatot Soebroto. 42 subjects were excluded. 284 subjects were assessed for risk factors. This was a cross-sectional observational study. Their subjects were 326 consecutive army personnel who were referred to cardiology and vascular department for further cardiovascular examination from medical check-up unit in Central Army Hospital Gatot Soebroto. 42 subjects were excluded. 284 subjects were assessed for risk factors. Mean age was 51 years old. Mean total cholesterol and LDL was 208 and 132 respectively. Mean for ureum and creatinine was 27.78 and 1.10 respectively. There was 66 (23.2%) with normal BMI, 179 (63%) with overweight and 39 (13.7%) were obese. 155 (54.6%) subjects didn‟t smoke while 129 (45.4%) subjects smoked. 29 (10.2%) were diagnosed with diabetes were 255 (89.8%) without diabetes. 217 (76.4%) subjects were not dyslipidemic and 67 (23.6%) subjects were dyslipidemic. 274 (96.5%) of the subjects has no history of hyperuricemia and 10 (3.5%) had. 107 (37.7%) was diagnosed with hypertension and 177 (62.3%) was not. 34 (12%) had a family history of premature coronary artery disease and 250 (88%) of them had not. Most of the subjects are overweight and hypertension was the most prevalent risk factor in this patient. Mean cholesterol and LDL was slightly high. 29

Association Between Diagnosis of Hypertension and Hypertensive Response During Treadmill in Army Personnel Undergoing Medical Check-Up, How Influential Is It? Raymond Pranata, Emir Yonas, Veresa Chintya, Bambang Pamungkas, Vireza Pratama4, Bayu Arif Permana, Dina Evalina Syahlul, Agus Harsoyo Abstract Hypertensive response to exercise (HRE) is defined as a peak systolic blood pressure >210 mmHg in Men and >190 in women or difference between peak and baseline SBP for at least 60 mmHg in men and 50 mmHg in women during exercise testing. Non-hypertensive individuals with exaggerated blood pressure responses during exercise stress testing are more likely to develop hypertension. A HRE is not associated with increased mortality when baseline blood pressure is taken into account. However, a HRE during submaximal exercise may be associated with an increased risk for cardiovascular death in non-hypertensive individuals. Our aim is to know the magnitude of difference in HRE during treadmill exercise between subjects with a history of hypertension and those without and factors affecting or affected by it. This was a cross-sectional observational study. Their subjects were 326 consecutive army personnel who were referred to cardiology and vascular department for further cardiovascular examination from medical check-up unit in Central Army Hospital Gatot Soebroto. 55 subjects were excluded because treadmill test was not ordered. Out of 271 subjects, 102 were hypertensive and 167 were not hypertensive. Hypertensive response to exercise was more frequently found in those with a history of hypertension (OR 1.941, 95% CI 1.16-3.25, p=0.011). There was a decreasing trend in HRE with higher physical activity (p=0.009). Presence of LVH is more common in those with HRE (OR 1.835, 95% CI 1.033-3.261, p=0.037). There was no significant difference between those with or without HRE and presence of diseased vessel. There was also no difference in prevalence of one VD, two VD and three VD. We analysed subjects with HRE, there was 47.4% with history of hypertension and 50.5% without. There was no association between LVH and presence of traditional risk factors, physical activity and impaired renal function in subjects thissubjects. Hypertensive response to exercise during treadmill exercise test was significantly higher in patients with a history of hypertension and tends to lower with increasing physical activity. Left ventricular hypertrophy was also more frequently found in these subjects. 30

Hydrogels as An Alternative Treatment for Callus Formation in Diabetes Foot Ulcers Siti Anisah Abstract Backgrounds: As the complication of diabetic neurophaty callus formation is a common finding in diabetes foot ulcers. It‟s affecting patient quality of life by causing chronic wound, to activity restriction, disabilities or the loss of mobility and increasing the longevity for the wound to heal. Aim: to show the ability of hydrogel in removing callus. Methods: this was a case series study reporting three cases of diabetes foot ulcers with callus formation located on plantar surface of the foot. Patient was given modern dressing with hydrogels and the dressing was changes every 2-5 days depend on each case. Results: Case patient 1 was healed 4 weeks, patients 2 was healed 7 weeks and patient 3 was healed 8 weeks. Conclusion: Hydrogels had a promising effect in treatment of callus by providing moist environment of callus and aid in autolytic debridement. 31

Rifampicin-Induced Acute Pancreatitis Trian Satrio, Deka Larasati, Ruswhandi Abstract Introduction: Acute pancreatitis is an acute inflammatory condition of the pancreas that may extend to local and distant extra-pancreatic tissues.Gallstone and alcohol are responsible for more 90% case, but medication have been recognized as a potential cause. Total of 1612 patients was treated for acute pancreatitis in Germany in 1993, drugs were in 22 cases (1,4%), had been recognized as the causes were Dideoxyinosine, Estrogens, Furosemide, Hydrochlorothiazide and Rifampicin. Case Illustration: A 25 years Woman, referred to Gatot Soebroto Central Army Hospital with history of Default lung Tuberculosis and anaphylactic caused by Rifampicin. Patient had been treated with separated Anti-TB Drugs because history of severe nausea and abdominal pain after taking Fixed-Dose-Combination Anti-TB Drug. Patient complained sudden high fever, severe abdominal pain and loss of consciousness after being taken Rifampicin she had been diagnosed for anaphylactic shock. Patient regain conciousness after been injected with adrenaline and antihistamin. Patient still complained abdominal pain, diarrhea, vomitting. Physical examination showed general icterus and upper right abdomen tenderness. Laboratory showed abnormality in WBC (40.790), liver function test (SGOT/PT : 361/22) Total, Direct, Indirect Bilirubin (11,8/ 6,97 /1,83) negative HbsAg and anti HCV, Amylase/Lypase (157/312) Procalcitonin (13,1) and metabolic acidosis (pH : 7,243 pCO2 : 16,3 HCO3 6,9). No billiary obstruction in MRCP. Patient diagnosed as Drug-induced pancreatitis drug- induced liver injury and treated with adequate fluid, Ocreotide, antibiotics, symptomatic medications, Anti-Tuberculosis Drug discontinuation and food restriction. Patient have improved and discharged with Rifampicin free Anti-Tuberculosis Drug. Discussion: Acute pancreatitis is a severe condition caused by many etiologies. In our case it caused by drugs-induced. Rifampicin was suspected for the cause of of pancreatitis because of complaints arises after the administration of Rifampicin. Given treatment for pancreatitis and 32

discontinuing Rifampicin improved the patient condition. Rifampicin classified as Class IV Drug according to Badalov criteria. 33

Grazoprevir Plus Elbasvir in Routine Hemodialysis Patients with Chronic Hepatitis C Virus Infection and Factors Associated with Sustained Virological Response Dwi Edi Wahono, Aida Lydia, Irsan Hasan, and Ikhwan Rinaldi Abstract Background : Patient on hemodialysis (HD) at risk of Hepatitis C Virus (HCV) infection. HCV infection increase mortality related chronic liver and cardiovascular disease. Direct-Acting Antiviral (DAA) Drugs cure rate for HCV infection above 90%. Most DAA metabolite eliminated by kidney is not safe for hemodialysis patients. Grazoprevir+Elbasvir is the drug of choice for chronic HCV infection in hemodialysis patients, and have higher cure rates and less adverse events. Until now the factors that influence therapeutic response of Grazoprevir+Elbasvir in HDpatients is still unknown. Objective : Assessing therapeutic response and side effect of Grazoprevir+Elbasvir for Hepatitis C Virus in routine hemodialysis patient. Methods : Cohort prospective observational study on all patients with Chronic HCV infection with routine HD. Clinical and Laboratory Data was collected and analysed for therapeutic response and determined the factors that related with therapeutic response. Viral load, degree of fibrosis, and duration of HD treatment and relation with respons SVR12 as analysed using bivariate method of statistical analysis. Results: 75 subjectsthat met inclusion criteria. The average age is 50.2±13.2 years, subjects with more female were found. The duration of HD is 6.9±4.7 years. Seventy of 72 (97.2%) patients achieved SVR12 (undetectable virus<10 Iu/mL). Relative risk of SVR12 based on viral load <800.000 IU/mL versus ≥800.000 IU/mL were 1.01 (95%Cl 0.93-1.10; p=1.00) F4 versus to F0-F3 were 0.95 (95%Cl 0.81-1.10; p=0,35), duration of HD <3 years versus ≥ 3years were 1.04 (95% Cl 0.99-1.09; p=100) Three deaths while on Grazoprevir+Elbasvir, not related to this therapy. The side effect of this drug are minimal. Conclusions : Grazoprevir+Elbasvir therapy in HD patient with chronic HCV is effective, and minimal side effects. SVR12 is not influenced by viral load, degree of fibrosis or duration of HD. Keywords: Hemodialysis; Hepatitis C Virusinfection; SVR12; DAA; Grazoprevir, Elbasvir 34

Study of Bone Turnover in Premenopausal Women Type 2 Diabetes Mellitus: Levels of Serum Tumor Necrosis Factor-α and Sclerostin Sugiarto, Bambang Setiyohadi, Dyah Purnamasari, Hamzah Shatri Abstract Introduction. The risk of fracture in type 2 diabetes mellitus (T2DM) subjects increases. In subjects with T2DM, a bone mineral density (BMD) shows normal or increased results, so an increased risk of fracture is caused by a decrease in bone quality. One element that determines bone quality is bone turnover. Some factors that influence bone turnover include tumor necrosis factor-α (TNF-α) and sclerostin. This study aimed to obtain a profile of serum TNF-α and sclerostin levels in premenopausal female subjects of T2DM and non-DM. Method. A cross-sectional study was conducted on 80 premenopausal female subjects consisting of 40 T2DM subjects and 40 non-DM subjects. Examination of serum TNF-α and sclerostin was carried out using the enzyme-linked immunosorbent assay (ELISA) method. Results. Median serum TNF-α levels in T2DM subjects (43.0 pg/mL) were higher than non-DM subjects (23.86 pg/mL) but not significant (p = 0.900). The mean serum sclerostin level in T2DM subjects (132.05 pg/mL) was significantly higher (p <0.001) than non-DM subjects (96.03 pg/mL). Conclusion. The subjects of premenopausal T2DM had higher serum TNF-α levels but were not significant compared to non-DM subjects. Subjects of premenopausal T2DM had significantly higher serum sclerostin levels compared to non-DM subjects. Keywords., bone turnover; premenopause; sclerostin; TNF-α; T2DM 35

Incidence of Acute Kidney Injury and Use of Renal Replacement Therapy in Intensive Care Unit Patients in Indonesia Jonny, Moch Hasyim , Vedora Angelia , Ayu Nursantisuryani Jahya, Lydia Permata Hilman , Venna Febrian Kusumaningrum and Nattachai Srisawat Abstract Background: Currently, there is limited epidemiology data on acute kidney injury (AKI) in Indonesia. Therefore, we assessed the incidence of AKI and the utilization of renal replacement therapy (RRT) in Indonesia. Methods: Demographic and clinical data were collected from 952 ICU participants. The participants were categorized into AKI and non-AKI groups. The participants were further classified according to the 3 different stages of AKI as per the Kidney Disease Improving Global Outcome (KDIGO) criteria. Results: Overall incidence of AKI was 43%. The participants were divided into three groups based on the AKI stages: 18.5% had stage 1, 33% had stage 2, and 48.5% had stage 3. Primary diagnosis of renal disease and high APACHE II score were the risk factors associated with AKI (OR = 4.53, 95% CI: 1.67–12.33, p = 0.003 and OR = 1.14 per 1 unit increase, 95% CI: 1.09–1.20, p < 0.001, respectively). Chronic kidney disease was the risk factor for severe AKI. Sepsis was the leading cause of AKI. Among the AKI participants, 24.6% required RRT. The most common RRT modalities were intermittent hemodialysis (71.7%), followed by slow low- efficiency dialysis (22.8%), continuous renal replacement therapy (4.3%), and peritoneal dialysis (1.1%). Conclusions: This study showed that AKI was a common problem in the Indonesian ICU. We strongly believe that identification of the risk factors associated with AKI will help us develop a predictive score for AKI so we can prevent and improve AKI outcome in the future. Keywords: Acute kidney injury, Intensive care unit, Incidence, Survival, Renal replacement therapy 36

A Simple Tenckhoff Catheter Placement Technique for Continuous Ambulatory Peritoneal Dialysis (CAPD) Using The Bandung Method Jonny, Rudi Supriyadi, Rully Roesli, Goh Bak Leong, Lydia Permata Hilman, and Fidelisa Cita Arini Abstract Insertion of Tenckhoff catheters for continuous ambulatory peritoneal dialysis by nephrologists remains uncommon in most developing countries, including Indonesia. %e aim of this study is to describe our experience on a simple technique of Tenckhoff catheter insertion by a nephrologist called the Bandung method. We conducted a retrospective observational study from May 2012 until December 2018 in 230 patients with end-stage renal disease using the Bandung method, a blind percutaneous insertion approach modified from the Seldinger technique. Early complications after insertion were assessed. %e mean age of patients was 47.28 years (range 14–84 years). Within 1 month after insertion, complications occurred in 34 patients: 13 (5.7%) malposition, 8 (3.5%) omental trapping, 6 (2.6%) outlow failure, 3 (1.3%) peritonitis, 1 (0.4%) catheter infections, 1 (0.4%) bleeding, 1 (0.4%) kinking, and 1 (0.4%) hernia. None of these complications led to catheter removal. One patient experienced a late (>1 month) post-insertion complication of malposition that could not be repositioned and led to catheter removal. %e Bandung method is a simple, cost effective, and minimally invasive technique for Tenckhoff catheter insertion that is associated with the same rate of complications compared to other techniques. %is technique may useful for application in developing countries. Keywords: CAPD, Tenckhoff Catheters, Bandung Method 37

Metabolic Syndrome in HIV Patients on Antiretroviral Therapy Nyoto Dwi Astoro, Soroy Lardo, Jimmy Abstract Background : Antiretroviral drugs for HIV patients have become easily accessed, so that the number of HIV patients significantly increase, Methabolic syndrome is one of ARV complication side effect. Aim : to address methabolic syndrome prevalence in HIV patients on ART (AntiRetroviral Therapy) more than one year. Methods : this a observational cross sectional study. Thirthy HIV patients who have ART more than one year at Gatot Soebroto Central Army Hospital in 2009. Metabolic syndrome is evaluated using NCEP (National Cholesterol Education Program Adult) ATP III Criteria. Results : Thirty HIV patients consists of 22 males and 8 females included in this study. The prevalence of metabolic syndrome in HIV patients who have ART more than one year is 10th . the mean of age is 31,38 ±7,31 years. The mean of therapy duration is 29,14 ±12,53 months. The mean of body mass index is 21,69 ± 3.90 kg/m2. the mean of abdominal circumference is 73,91 ± 10,52 cm. the mean of HDL laboratory test is 44,48 ± 11,93mg/dl. Mean of fasting blood glucose 101,07±51,65mg/dl. The mean of CD4 is 220±99,92 (x106 cell/l). the mean systolic blood preassure is 112,21±6,43 mmHg and diastolic blood preassure is 81±3,32 mmHg ARV regimens are zidovudin-lamuvudin-efavirenz (63,33%), zidovudin-lamuvudin-efavirenz (10%). D4T-lamivudin-nevirapin(13,33%), d4t-lamivudin-efavirenz (13,33%). Discussion : metabolic syndrome prevelance In HIV patients who have ART more than one year is 10%, if it compared with foreign country the prevalence about 17 % The mean of age HIV patients are young with higher abdominal circumference. The mean of systolic blood pressure, body mass index, HDL and fasting blood glucossed within normal. Conclusion : the prevalence of metabolic syndrome in HIV patients who have ART more than one year is 10% Keywords : HIV, ARV, Metabolic syndrome 38

Unusual Case of Acute Liver Dysfunction Associated with Drug- Induced Rhabdomyolysis and Acute Kidney Injury Fatwiadi Apulita Ginting Munte, Deka Larasati, Eny Ambarwati, Ruswhandi Abstract Introduction: The presence of liver damage in patients with rhabdomyolysis has not been well recognized. Objective: To present a case report. Case Illustration: A 31-year-old man admitted with right-upper abdominal pain, jaundice and nausea since 4 days ago. He also complained general weakness, muscle ache and dark-colored urine. He had history of heart failure due to valvular heart disease since 6 months ago and took bisoprolol, furosemide, spironolactone, digoxin, clopidogrel, acetylsalicylic- acid and alprazolam as medication. He denied any rigorous exercise, fever or extreme-heat exposure. At admission, his vital sign was unremarkable. His physical examination showed generalized jaundice, distended abdomen and shifting-dullness. There were tenderness in right-upper and epigastric region of abdomen, jugular vein distention, systolic murmur, and mild leg edema. Laboratory test revealed AST 11160U/L, ALT 4270U/L, total bilirubin 7.99mg/dL, BUN 107mg/dl, creatinine 4.5mg/dL, INR 1.82, CPK 566U/L and normal troponin-I. There was no sign of myocardial infarct/ischemia on ECG. Abdominal ultrasound showed ascites, hepatic congestion and dilated hepatic vein. During hospitalization, his kidney function was deteriorating with anuric episode, so we decided to hemodialyse him. We found that AST/ALT and bilirubin concentrations decreased in concert with BUN/creatinine and CPK normalization. Discussion: When interpreting liver function tests in rhabdomyolysis, we needs to consider that AST is also released from damaged muscle, whereas elevated ALT to the degree seen in this case is rarely occurred. In this patient, liver function normalized after hemodialysis and all possible culprit medicine had been stopped. Conclusion: Acute reversible liver dysfunction could be rare manifestation of rhabdomyolysis. Keywords : Acute Liver Dysfuction, Acute Kydney Injuri, Rhabdomyolysis 39

The Hypoglicemic Effect of Andrographis paniculata Extract Capsules as Additional Therapy on Type 2 Diabetes Mellitus at The Army Central Hospital Gatot Soebroto, Jakarta, Indonesia Yaman Nizmawardini, Hanani Endang, Ruray Djunaidi, Santi Purna Sari Abstract Background: Andrographis paniculata Nees. (AP) leaves, empirically used as an alternative medicine for various diseases including diabetes mellitus, but the scientific evident for treatment in humans are still limited. Objectives: This study analyzed the effects of hypoglycemic AP capsules (APC) as an additional therapy in patients with type 2 diabetes mellitus. Methods: Double-blind randomized controlled trial, cross-over design in 34 subjects who were divided into two groups. The first group received 2 capsules 2 times daily for 14 days, and the second group received placebo capsules for 14 days. Both groups kept taking metformin as standard therapy, then the evaluation of blood glucose levels on day 14. Results: showed that administration of APC for 14 days fasting blood glucose levels (13.47 mg/dl) greater compared to placebo (-8 mg/dl) but not significantly. The APC significantly reduced blood glucose 2 hours after meal at 34.91mg/dl and significant (p<0.05). Conclusions: APC showed how to reduced blood glucose levels, but only in 2 hours after meal. Keywords : Andrographis paniculata Nees (AP), clinical trial, diabetes mellitus, blood glucose levels, hyperglycemic, metformin. 40

Positive Correlation of ECG Dispersion Mapping (Heartvue™) in Prediabetic Patients Internal Medicine Polyclinic of RSPAD Gatot Subroto Acil Aryadi, Djoko Wibisono Abstract Background: The risk of cardiovascular events increases long before Diabetes Mellitus type 2 is diagnosed, that is, since there is a disturbance of fasting blood glucose and or impaired glucose tolerance. Heartvue ™ 6s System is a new technology developed to provide non invasive coronary heart The inspection by analyzing the change of low amplitude of conventional ECG signals (ECG dispersion mapping-ECG-DM). Purpose: To determine the description of the ECG dispersion mapping (Heartvue™) in prediabetic patients.. Methods: corelative Analytical research with a design case control that uses 80 consecutive sampling patients who come to medicine at the general outpatient Polyclinic Gatot Subroto. Results: obtained average weight (64.1 ± 6. 7 vs 58. 4 ± 5. 2, p = < 0.01), body mass index (BMI) (24. 6 ± 2. 9 vs 22. 2 ± 0.0, p = < 0.01), fasting blood glucose (GDP) level (105.8 ± 9.2 vs 87.1 ± 8.3, p = < 0.01), two-hour blood glucose level post fasting (G2PP) (143.9 ± 20.6 vs 118.6 ± 10.9, p = < 0.01), total cholesterol levels (199. 8 ± 34.7 vs 175.9 ± 20.0, p = < 0.01) and LDL-cholesterol levels (147. 7 ± 28.2 vs 130.9 ± 21.2, p = < 0.01) in group of higher predibetes significantly compared to normal group. Hacyl ECG dispersion mapping (ECG-DM) in prediabetes Group is found more abnormal criteria than normal group (25. 0% vs 5.0%, p = 0.01), performed a correlation test by using a LAMBDA contigency, obtained a positive correlation between the abnormalities of the ECG-DM examination with prediabetes with a weak strength (r = 0. 28; P = 0.01). Conclusion: There is a positive correlation between the ECG-DM (Heartvue™) Overview with the condition of prediabates. Keywords: ECG dispersion mapping, prediabetes, PJK 41

Positive Correlation of ECG Dispersion Mapping (HeartVue ™) in DMT2 Patients in Endocrine and Metabolic Clinic of Central Army Hopital Gatot Soebroto Sidhi Laksono, Susi Setyowati, Djunaidi Abstract Background: Diabetes mellitus type 2 (DMT2) is the largest metabolic disease worldwide and is associated with coronary heart disease (CHD). The proportion of CHD patients with T2DM is found to be of varying value worldwide, but one fifth of clinical studies (18%) and patient registry data (15.1-21.4%). Asymptomatic CHD is a cardiovascular disease that often occurs in T2DM patients. Several methods have been developed to increase the sensitivity and specificity of ECG examination at rest in detecting asymptomatic CHD. HeartVue ™ is a recently developed technology that may be used as a non-invasive assessment of myocardial ischemia by analyzing changes in low amplitude of conventional ECG signals (ECG) dispersion mapping). Objective: To find out the correlation between ECG dispersion mapping (HeartVue ™) images in DMT2 patients in Metabolic Endocrine Clinic Department of Internal Medicine Central Army Hopital Gatot Soebroto Method: The study was conducted with a case control study design in the Endocrine Metabolic Clinic in July-August 2013 Results: From the baseline characteristic data, the number of women with T2DM was greater (n = 29; 50.9%) compared to the number of men with T2DM (n = 28; 49.1%). While the non-DMT2 group was the opposite of the DMT2 group, with more men (n = 31; 54.4%) compared to the number of women. Numerical data in this study are in the normal distribution with Kolmogorov-Smirnov test results greater than p = 0.05, with age (63.77 ± 7.73 vs 48.25 ± 10.67), height (161.09 ± 6.73 vs 162.39 ± 5.98), and weight (63 ± 11.43 vs 63.74 ± 4.92). Obtained greater blood sugar values in the T2DM group compared to the non T2DM group with blood sugar 2 hours post prandial (229.56 ± 94.98 vs 122.79 ± 12.10) and fasting blood sugar (156.88 ± 58.45 vs 100.19 ± 8.18). Meanwhile the lipid profile obtained total cholesterol levels (209.09 ± 41.31 vs 189.68 ± 29.10) and triglycerides (148.44 ± 67.70 vs 133.33 ± 44.97) were higher in the DMT2 group. However, not at HDL levels (41 ± 7.88 vs 44.68 ± 6.66) and LDL (144.33 ± 33.45 vs 144.61 ± 26.89), where the DMT2 group was lower than non- DMT2. As for BMI criteria, the DMT2 group found more normoweight 42

criteria compared to overweight (49.1% vs 43.9%), similar to the non-DMT2 group (63.2% vs 36.8%). Conclusion: There is a positive correlation between ECG-DM (HeartVue ™) images and DMT2 patients. Keywords: ECG-DM –HeartVueTM 43

Prevalence of Atrial Fibrillation in Chronic Kidney Disease Patients with Hemodialysis in Gatot Soebroto Army Center Hospital Shahab F. I, Wibisono D. Abstract Introduction: Chronic kidney disease is a predisposition factor in the occurrence of cardiovascular events, with the prevalence of high enough arrhythmias is atrial fibrillation (AF). Atrial fibrillation can trigger the incidence of angina pectoris, hypotension, congestive heart failure, and increased risk of thromboembolism. Patients with chronic kidney disease undergoing hemodialysis have the risk of ischemic stroke and also hemorrhagic stroke. Method: Design research is a descriptive research cut latitude by using data collection based on the record of chronic kidney disease patients in the hemodialysis room of the Central Army Hospital Gatot Subroto Jakarta period April 2013. Affordable populations that meet the inclusion criteria of 55 people. The electrocardiogram readings are found in the medical records. Results: The subject of this study is at most about 45 – 54 years (30.95%). Gender, males are more than females of 37 people (67.3%). Patients with an electrocardiogram rhythm in the form of sinus rhythm,50 person (90.9%), while the rhythm of atrial fibrillation as much as 5 people (9.1%). Patients with diabetes mellitus as much as 18 people (32.7%). Patients with long HD > 1 year as much as 35 people (63.6%). The history of accident disease (CVD) is a non-hemorrhagic stroke experienced by 4 patients (7.3%). Conclusion: Based on the research done, it is found that the prevalence of atrial fibrillation in chronic kidney disease patients conducted hemodialysis at Gatot Subroto Army Central Hospital in April 2013 is 9.1%. Keywords: Atrial fibrillation, chronic kidney disease, hemodialysis 44

Effectiveness Comparison of Metformin-Sulfonylurea and Metformin- Acarbose on The Glycemic Parameters of Type 2 Diabetes Mellitus Patients: A Retrospective Cohort Study at Gatot Soebroto Army Hospital Jakarta Wafa, Rani Sauriasari, Renni Septini Abstract Objective: To analyse the effectiveness comparison of combination therapies of metformin-sulfonylurea and metformin-acarbose on the glycemic parameters in patients with type 2 diabetes mellitus in Gatot Soebroto Army Hospital, Jakarta. Methods: This study employed a retrospective cohort with primary and secondary data collection using purposive sampling technique to examine the effectiveness of different treatments for type 2 diabetes mellitus among outpatients at Gatot Soebroto Army Hospital in Jakarta. Primary data used are the results of filling out the questionnaire and secondary data obtained from medical records and hospital information systems. Participants had consumed the same drug from January 2017 to March 2019 and were divided into two groups, as follows: metformin-sulfonylurea combination group (n=100) and metformin-acarbose group (n=100). The effectiveness of treatment was evaluated by considering Hemoglobin A1c (HbA1c), two hours postprandial glucose and fasting blood glucose. Results: The analysis showed that there was no significant difference between participants who used metformin-sulfonylurea compared with participants who used metformin-acarbose to changes in the HbA1c value (p value=0.060). The analysis also showed that there was no significant relationship between metformin-sulfonylurea and metformin-acarbose with 2 hours postprandial blood glucose value (p value=0.655) and fasting blood glucose value (p value=0.460). Sports variable affects the effectiveness of metformin-sulfonylureas and metformin-acarbose on changes in HbA1c values, gender variable on changes in postprandial 2 hours blood glucose values and dietary variable on changes in fasting blood glucose values. Conclusion: The effectiveness comparison of metformin-sulfonylurea and metformin-acarbose combination therapy is not significant. Keywords: Acarbose, effectiveness, fasting blood glucose, Gatot Soebroto Army Hospital, glycemic parameters, HbA1c, metformin, postprandial 2 hour blood glucose, sulfonylurea 45

Relation Between Peripheral to Central Pulmonary Artery Diameter Ratio with Chronic Obstructive Pulmonary Disease Severity Vininta Fazharyasti Ilyas, Aziza G, Icksan, Retno Wihastuti, Joedo Prihastono Abstract Chronic Obstructive Pulmonary Disease (COPD) is a pulmonary disease that has an extrapulmonary effect that can worsen the patient‟s condition and is one of the major causes of mortbidity and mortality in the world, but is now less widely recognized by the public. One of the morphological changes occurring in COPD is a change in pulmonary vascularization, which can lead to pulmonary hypertension. There has been no published study on the peripheral to central pulmonary artery diameter ratios in COPD patients measured on chest CT examination without the use of specialized software and their relationship to the severity of COPD based on spirometry examination result. This study attempted to assess the characteristics of peripheral pulmonary artery diameter, central pulmonary artery diameter, peripheral to central pulmonary artery diameter ratio and its relation to severity of COPD. This study is correlative study using cross sectional design to assess the relationship between the ratio of peripheral vascular diameter ratio to central with the degree of severity of COPDfrom spirometry result. Conducted at Gatot Soebroto Central Army Hospital from February 2017 to May 2018 with a sample size of 41 subject. From this study it is found that there is a greater tendency of peripheral pulmonary arterial to central ratios with worsening spirometry result. Although it is not potensial to be used as a parameter of severity of COPD. Chest CT still plays an important role in the management of COPD. Keywords : COPD, chest CT, peripheral to central pulmonary arteri ratio 46

The Correlation Between LVEF Gated-SPECT with Hemodialysis, Calcium-Phosphorus Products and Parathyroid Hormone in Patients with Chronic Kidney Disease Djoko Nariman, Eko Purnomo Abstract Background: In patients with chronic kidney diseases can occur metabolic disorders of calcium, phosphorus, and vitamin D, cardiovascular disorders, hematology, and others if often perform hemodialysis. Cardiovascular events are major phsoporus and vitamin D can lead to impaired vascular andsecondary hyperparathyroidism. It can also cause cardiovascular problems. Cardiovascular disorder was evaluated left ventricular ejection fraction using nuclear medicine techniques Gated-SPECT. Assessment of left ventricular ejection fraction was associated with the number of hemodialysis has been done, calcium-phosporus product and parathyroid hormone levels. The aim of this study was to correlated left ventrivular ejection fraction Gated-SPECT with the number of hemodialysis has been done, tehe levels of calcium-phosphorus product, and parathyroid hormone levels. Materials and Methods: the data was taken as a retrospective study. Subject consisted of thirteen patients with cronic kidney disease (8 men and 5 women) who underwent routine hemodialysis more than a year.regular hemodialisys who has been done between 172 to 1236 times. Ages between 43 to 67 years old. Causes of chronic kidney diseases were diabetic nephropathy three subjects and ten subjects glomerulonephritis. Parathyroid hormone levels between 83.07 to 1096 pg/mL (more than 65 pg/mL). calcium ion levels between 3.69 to 4.93 mg / dL. Total calcium levels between 7.69 to 10.25 mg / dL. Serum phosphorus levels between 3.69 to 4.93 mg/dL. Total calcium levels between 7.68 to 10.25 mg / dL. Serum phosphorus levels between 35 to 58 %. Clinically, the result of the calcium-phosporus product are important as an indicator of progression of calcification of soft tissue and vascular. Results: data processing is done by using a computer. Correlation is a method to find the relationship between two numerical variables. Pearson correlation coefficient (r) is divided into five levels, a good correlation when r> 0.80 and moderate correlation when r between 0.60 to 0.79. There is moderate correlation between LVEF Gated-SPECT by the number of hemodialysis has been done (r=-0.735, p= 0.004), but there is no 47

correlation between LVEF with parathyroid hormone levels (r=-0.032, p=0.917) and LVEF with calcium-phosphorus product (r=-0.019, p=0.95). Conclusion: from this study there was a moderate correlation between LVEF Gated-SPECT by the number of hemodialysis that has been done in patient with chronic kidney diseases. But it‟s not correlation with parathyroid hormone levels and also with the result of the calcium- phosphorus product. Further investigation with more of subjects is needed to increase its accuration. Keywords: gated-SPECT, Tc-99m tetrofosmin, routine hemodialysis, parathyroid hormone, Calcium-Phosphorus Products. 48

Artery Diameter Ratio with Chronic Obstructive Pulmonary Disease Severity Vininta Fazharyasti Ilyas, Aziza G. Icksan, Retno Wihastuti., Joedo Prihartono Abstract Chronic Obstructive Pulmonary Disease (COPD) is a pulmonary disease that has an extrapulmonary effect that can worsen the patient's condition, and is one of the major causes of morbidity and mortality in the world, but is now less widely recognized by the public. One of the morphological changes occurring in COPD is a change in pulmonary vascularization, which can lead to pulmonary hypertension. GOLD Criteria is a scoring system of the severity of COPD based on spirometry measurement. There has been no published study on the peripheral to central pulmonary artery diameter ratios in COPD patients measured on chets CT examination without the use of specialized software, and their relationship to the severity of COPD based on the GOLD criteria of spirometry examination results. Purpose. This study attempted to assess the characteristics of peripheral pulmonary artery diameter, central pulmonary artery diameter, peripheral to central pulmonary artery diameter ratio, and its relation to severity of COPD. Methods and Materials. This study is a correlative study using cross sectional design to assess the relationship between the ratio of peripheral vascular diameter ratio to central with the degree of severity of COPD from spirometry results, conducted at Gatot Subroto Central Army Hospital from February 2017 to May 2018 with a sample size of 41 subjects. Results. From this study it is found that within COPD patients, peripheral pulmonary artery diameter is 20.0±6.6 mm, central pulmonary artery diameter is 24.7±4.5 mm, and peripheral to central pulmonary artery diameter ratio is 0.81±0.19 mm. There is a tendency of greater peripheral to central pulmonary artery diameter ratio with worsening spirometry results. Another result of this study is that the ground glass opacity and emphysema have a higher degree of COPD severity. Conclusions. There is a greater tendency of peripheral pulmonary arterial to central ratios with worsening spirometry results, although it is not potential to be used as a parameter of severity of COPD. Chest CT still plays an important role in the management of COPD. 49

Six-month Survival of Patients with Malignant Distal Biliary Stricture Following Endoscopic Biliary Stent Procedure and Its Associated Factors Luki nKusumaningtyas , Dadang Makmun , Ari F. Syam , Siti Setiati Abstract Background: unresectable malignant distal biliary stricture patients require endoscopic biliary stent placement procedure. The survival rate and its associated factors in Indonesia are unknown. This study aimed to identify 6-month survival of patients with malignant distal biliary stricture following endoscopic biliary stent procedure and its associated factors. Methods: a retrospective cohort study was conducted using medical records of patients with unresectable malignant distal biliary stricture, which involved caput of pancreas, ampulla of Vater or distal cholangiocarcinoma following endoscopic biliary stent procedure between June 2015 and August 2017 at Cipto Mangunkusumo National Central General Hospital. The cumulative survival was defined by using the Kaplan- Meier curve. Bivariate and multivariate analyses were performed using Cox regression of some factors including failure of biliary stent insertion, bleeding, sepsis, comorbidities, malnutrition, and serum albumin levels. Results: out of total 120 subjects, 85 subjects died within 6 months following the stent procedure with a proportion of 180- day survival of 24% and a median survival of 81 days (CI 95%: 56–106 days). In bivariate analysis, factors of comorbidities, sepsis, malnutrition and albumin levels ≤ 3.0 g/dL had p values of < 0.25; while the subsequent multivariate analysis showed that albumin level of ≤ 3.0 g/dL had HR of 2.73 (CI 95%: 1.48 – 5.05; p = 0.001). Conclusion: the 6-month survival following endoscopic biliary stent procedure is 24% with a median survival of 81 days. Albumin level of ≤ 3.0 g/dL has a 2.73 times greater risk for 6-month mortality rate. Keywords: survival, malignant distal biliary stricture, endoscopic biliary stenting, mortality-related factors, albumin 50

The Influence of Lemuru Oil (Sardinella longiceps) in The Removeling Process of The New Zealand White Rabbit Alveolaris Moved by Ortodontics Puji Hartono Abstract Orthodontic procedure may cause teeth movement. This study tries to find solutions in order during dental care, to minimize incident of inflammation, tissue damage and necrosis, and also induce rapid bone remodeling process and minimize relapse after active dental treatment after giving fish oil extracted from lemuru fish (Sardinella longiceps). Relapse is a process in which the teeth arrangement return into condition before treatment. Lemuru fish oil contains high EPA and DHA that may help bone remodeling by inhibiting activity of cytokine inflammatory, accelerate bone resorption process and bone replenishment. The purpose of this research was to investigate the effect of lemuru fish oil administration to IL (interleukin)-1, TNF (tumor necrosis factor)-α levels, expression of OPN (osteopontin) and ALP (alkaline phosphatase) in rabbit alveolar bone remodeling process after being treated orthodontically. The subjects were New Zealand White rabbit. Sample were divided into 5 groups, namely: group 1 as control group which received no fish oil or orthodontic treatment, group 2 received no fish oil but with orthodontic treatment, group 3, 4 and 5 were given fish oil doses 0.375, 0.75 and 1.50 g/kg body weight. Fish oil was administered from the first day of open coil spring mounted activated for 14 days plus the number of days of observation to-1, 3, 7 and 10 days. Blood sampling procedure was continued until the 17thday. The results indicated that the greatest distance interincisors in group 4 or smallest relapse. The mean number of osteoclasts did not change after the release of an orthodontic appliance for 4 weeks. Highest average number of osteoblasts in group 5. The highest levels of IL-1α in group 2 and the lowest in group 5. TNF-α levels was found lowest in group 1 but not significant different with groups 4 and 5. Osteopontin expression on day on day 1 to day 17 was found significantly different in all treatment groups (p = 0.000). OPN levels are highest in group 2 and lowest in group 1. Alkaline phosphatase activity on day 1 to day 17 was found significantly different in all treatment groups. Lemuru oil at a dose of 0.75 g/kg and 1.5 g/kg body weight can increase levels of ALP after 7 days. In conclusion, administration of lemuru fish oil induce rapid remodeling process of alveolar bone of teeth. In addition, the lemuru fish oil reduce dental relapse after being treated orthodontically. 51

Moreover, this fish oil able to reduce the number and activity of osteoclasts but stimulates the number and activity of osteoblasts, thus in turn increases bone formation. The level and activity of IL-1α and TNF-α can be reduce, but the expression of OPN and ALP activity can be enhanced. Keywords: Remodeling, Sardinella longiceps, Ortodontics 52

Acute Kidney Injury Prevalence and Renal Replacement Therapy in Intensive Care Unit Patients in Indonesia Jonny, Moch Hasyim, Vedora Angelia, Ayu Nursantisuryani Jahya, Lydia Permata Hilman, Venna Febrian Kusumaningrum, Nattachai Srisawat Abstract Background: Currently, there is limited data of large database of acute kidney injury (AKI) epidemiology from Southeast Asia (SEA), especially in Indonesia, the biggest countries in SEA. Therefore, we aimed to study the prevalence of AKI and the utilization of renal replacement therapy (RRT) in Indonesia. Methods: We collected demographic and clinical data from 952 ICU patients. Patients were classified into AKI and non-AKI. AKI was classified according to the Kidney Disease Improving Global Outcome (KDIGO) criteria in three stages. We then assessed the Acute Physiology and Chronic Health Evaluation (APACHE) II score of AKI and non-AKI patients. RRT modalities were listed down by the number of procedures conducted. Results: Overall incidence of AKI was 43%, distributed among three stages: 18.5 % stage 1, 33% stage 2, 48.5 % stage 3. Patients developing AKI required mechanical ventilation support more often in comparison with non-AKI. Patients with AKI had an average APACHE score of 16.5, while non-AKI patients had an average score of 9.9. Among AKI patients, 24.6% requires RRT. The most common RRT modalities was intermittent hemodialysis (69.4%), followed by slow low efficiency dialysis (22.1%), continuous renal replacement therapy (4.2%), and peritoneal dialysis (1.1%). Conclusions: This study showed that AKI was a common problem in Indonesian ICU with containing a high mortality rate. We strongly believe that identification the risk factor of AKI will provide the opportunity to develop the predictability score for AKI prevention and finally improve AKI outcome. Keywords: Acute kidney injury; Intensive care unit; Incidence; Survival; Renal replacement therapy 53

Recurrent Bilateral Staghorn Stones as A Manifestation of Normocalcemic Primary Hyperparathyroidsm Bellinda Magdalena, Susie Setyowati Abstract Background: Primary hyperparathyroidism (PHPT), most commonly caused by adenoma, is traditionally defined as hypercalcemia with elevated levels of parathyroid hormone (PTH). The classical symptoms of PHPT, marked hypercalcemia, skeletal complications and nephrolithiasis have changed dramatically to a condition that is often asymptomatic. In the past decade another form of PHPT has been increasingly recognized as normocalcemic primary hyperparathyroidism (NPHPT). Case Illustration: A 55 year old man presented with bilateral retroperitoneal pain. He had a history of recurrent staghorn stones in the past 4 years with multiple surgeries and hyperthyroidism. Physical examination showed costovertebral tenderness and positive ballottement. Abdominal CT showed bilateral staghorn calculus and bilateral hydronephrosis. Laboratory findings include elevated levels of parathyroid hormones of 99.18 pg/mL, repeatedly normal albumin-adjusted calcium levels, glomerular filtration rate of 99.94mL/min and parathyroid scintigraphy with Tc99m-MIBI SPECT showed increased radioactivity of the lower right parathyroid gland. Discussion: Asymptomatic PHPT may be first diagnosed as an „incidental‟ finding on biochemical screening, for example during the medical management of kidney stones. NPHPT is recognized as normal levels of calcium serum with elevated levels of PTH in the absence of secondary causes of HPT. In asymptomatic cases, physicians are required to monitor annual serum calcium, PTH and bone mineral density. In cases where symptoms are present such as worsening of bone density, bone fractures and kidney stones, a more aggressive surgical approach is recommended. Conclusion: This patient fit the criteria of NPHPT with symptoms of kidney stones, therefore parathyroidectomy is the recommended approach. Keywords: normocalcemic primary hyperparathyroidism 54

One Year Commemoration of Endoscopic Retrograde Cholangio- Pancreatography (ERCP) of Obstructive Jaundice in Gatot Soebroto Central Army Hospital – Jakarta Syafruddin A.R. Lelosutan, Ruswhandi Martamala Abstract Background: From August 1st 2007 to 31st 2008 in GatotSoebroto Central Army Hospital showed jaundice prevalence of 2,44% (n=445) out of 18,258 patients in Department of Internal Medicine. Endoscopic retrograde cholangio-pancreatography (ERCP) has been routine definite procedure in Gatot Soebroto Central Army Hospital – previously reffered to hepatology experts outside the hospital – due to related cases were clinicaly diagnosed better and easier by new imaging techniques less invasive visualization, MRCP and 64 slice MSCT (magnitude slice computed tomography). Objective: To assess the ERCP team performance, an observation was conducted in the last one year on obstructive jaundice indication. Method: The retrospective observation through medical record from Augst 1 st, 2007 to July 31st 2008. All cases with jaundice were recorded and classified into pre-, intra – and post – heaptic jaundice. Demography, Clinical Findings and Patophysiological diagnosis data were not reported in this observation. Billiary obstruction etiologies were then grouped and associated with the therapy group, classified based on the typr of appropriate therapy given for each obstructive jaundice etiology. Result: The Prevalence of obstructive jaundice cases in GatotSoebroto Central Army Hospital was 29,7 % or 132 cases of 445 patients with jaundice as in and aout patients. From those obstructive jaundice cases, ERCP was done in 38 patient (28,8%), while the rest underwest digestive surgery, invasive PTBD (minimal invasive percutaneous transbiliary drainage) and PTC (percutaneous transhepatic cholangio drainage) or other non invasive conservative management. Conclusion: In This observation, the prevalence pf jaundice (2,44%) in internal medicine patients and obstructive (28,7%) of all jaundice cases recorded in sub SMF Gastroentero Hepatology Departement of Internal Medicine Gatot Soebroto Central Army Hospital were significant in findings. The prevalence of obstructive jaundice in Gatot Soebroto Central Army Hospital is higher compared to data from other countries as Research Institute ;1 in Mayo Clinic Collage of Medicine, Rochester, Minnesota 5% of intra hepatic obstruction jaundice, but 70 % perihilar obstruction (Klatskin tumor) and 25% of CBD distal obstruction.2 Meanwhile national data is not yet available. The 55

ERCP team has shown their performance through various therapeutic intervention of biliary obstruction by ERCP. 56

Hepatocyte Inflammatory Profile in Patients with Chronic Hepatitis in Gatot Soebroto Central Army Hospital Jakarta Syafruddin A.R. Lelosutan, Ruswhandi Martamala, Untung Sudomo, Ardiana, Shinta Soraya Abtract Background: Many Cases in Hepatology need liver biopsy as a gold standard. In daily practice the art of biopsy is obtained through blind needle biopsy (BNB), even though it is recommended to perform percutaneous liver biopsy with USG guidance since an invasive procedure is more reliable and important as a gold standart. Specific in active chronic hepatitis patient or in the liver cirrhosis child A due to hepatitis B and C virus infection to be eligible to get antiviviral/immunimodulator therapy through ASKES in the last two years, it is required that histopathological result must be equal to or more than Metavir score of fibrosis 2 (F-2) through UGNB. Objective: To provide information abouth the practices of liver biopsy without ultrasound guieded in GatotSoebroto Central Army Hospital, in conjunction with increases of liver biopsy needs as a condition to give interferon theraphy to ASKES patient with chronic viral hepatitis. Method: There were 1357 chronic hepatitis patient since April 2005 until 21 March 2009. Liver Biopsy without ultrasound guided was performed 64 cases (6,2%) of them. Liver biopsy speciments were sent to RSCM and Gatot Soebroto Central Army Hospital Patholigical Anatomydeparrtment. The result was scored in Metavir score accordingly. Result: The result of blind biopsy (Blind Needle Biopsy – BNB) in five yearsobatained from histopatological examination in Anatomy Patology Instalation – Gatot Soebroto Central Army Hospital based on Metavir Score. The relation between chronic liver disease and biochemical paramester analyzed as followed 57

Endoscopy Description of Bronchial Astma Patients with Gastroesofageal Reflux Disease Symptoms Syafruddin A.R. Lelosutan, Agus Dwi Susanto, Ruswhandi Martamala Abstract Background: Research examining the results of endoscopic examination of bronchial asthma (AB) patients with symptoms of gastro esophageal reflux disease (GERD) in the Gatot Soebroto Central Army Hospital, has been conducted. Controlled cases of symptomatic GERD in patients with AB to Sub Gastroentero-Hepatology Disease Clinic in Gatot Soebroto Cebtral Army Hospital in Central Jakarta, getting further diagnostic handling with Upper GI Tract Endoscopy. This study conduct to provide more adequate and faster management in overcoming asthma attacks, as well as in anticipation of complications of AB to SCBA. Methodology: The study was retrospective by evaluating the results of endoscopic examination of Upper GI Tract Endoscopy data (People with AB) who experienced symptoms according to GERD (with criteria 4 major symptoms for GERD from Talley, 2002). Data was collected for one year from November 2008 to October 2009. The data is from referred patient from Persahabatan Hospital, Jakarta with referral diagnosis of moderate persistent bronchial Ashma. The data were sorted according to inclusion and exclusion criteria, obtained that qualified as Subjects as many as n = 32 Endoscopic examination of subjects was carried out with upper gastrointestinal endoscop, endoscope series brand Olympus EVIS GIF 130 frontview (1996) with standard procedures suitable for SCBA endoscopy in the gastrointestinal endoscopy unit in Internal Medicine Gatot Soebroto Central Jakarta Hospital. PA data results from the results of the PA examination of the subjects in the PA Lab of Persahabatan Hospital, Jakrata. Statistical tests using the T-Test p <0.05. Result: In patients with AB who experience GERD clinical symptoms according to the criteria (Talley, 2002) it turns out to be higher than the rate of events concluded by Talley, 2002. The incidence rate of mild esophagitis (NERD + ERD / Esophagitis grade AB) according to the LA classification is very high (87.5%) although no severe esophagitis (grade CD) damage was found. The frequency of symptoms of GERD in patients with AB (The four major symptoms of GERD) is more frequent than patients with non-asthma GERD with a p value <0.05. 58

The Effect of Ketogenic Diet in Seizure Control and Improving Children Cognitive Functions with Lennox Gastaut Syndrome Wisvici Y Samin, Indah K Murni, Endy Paryanto P Abstract Introduction: Twenty-four percent (24%) of epilepsy patients experience drug resistant seizures. Drug resistant epilepsy is common in encephalopathy epilepsy or epilepsy syndrome. One of the encephalopathy epilepsy syndromes is lennox gastaut syndrome. Patients suffering from lennox gastaut syndrome can be treated with a ketogenic diet if seizures cannot be controlled with anti-epileptic drugs (OAE) alone. The role of ketogenic diets in epilepsy has been studied for a long time and several studies have shown a beneficial effect of the ketogenic diet on seizure control and cognitive improvement of patients. Objectives: The general objective of this observation is to reduce the risk of death of standard LGS patients with a ketogenic diet and improve general children's health such as monitoring nutritional status, immunization and monitoring the side effects of anti-epileptic drugs. Knowing the efficacy of the ketogenic diet on seizure control in patients suffering from lennox gastaut syndrome, the effect of the ketogenic diet on cognitive development of children, evaluation of seizure control, pain suffered by children during observation. Monitoring the side effects of the ketogenic diet on children's health. These include monitoring with routine blood tests, serum fat profile, electrolyte levels, ECG records and monitoring the nutritional status of patients. Methods: The method of observation is a direct observation of the influence of predictor factors on variables and outcomes in patients. Observations and measurements are carried out periodically, with time series. Results: There is an improvement in cognitive function with the added value of adaptive quotient (AQ) 29 to 30 and adaptive behavior which is assessed by vineland adaptive behavioral scale (VABS). Seizure control has not been achieved until the end of monitoring, but the patient has not experienced an atonic fall and there has been a decrease in the frequency and duration of the seizures. Inatentive and hyperactive behavior also improved compared to before the intervention which was assessed with 59

abbreviated conners score (1813). There has never been a rehospitalization due to seizures or epilepticus status. A side effect of the ketogenic diet found in patients is dyslipidemia at the end of the monitoring period. In addition, there is a change in nutritional status to overweight and stunted. Keywords: Lennox gastaut syndrome, ketogenic diet, cognitive function, seizure control 60

Pattern of Heart Failure in Children with Left to Right Shunt Congenital Heart Disease in Sardjito Hospital Yogyakarta Wisvici Y Samin, Indah K Murni, Endy Paryanto P Abstract Introduction: Children who suffered from congenital heart disease (CHD) with left-to-right shunts could develop complications such as heart failure and pulmonary hypertension which increase the risk of death. Delay in diagnosis could lead to uncorrected shunt and finally cause the overload and low cardiac output. The magnitude of the shunt and the type of lesion from left-to-right CHD are major determinant of the time needed for developing heart failure. The evidence of positive correlation of heart failure with type of left-to-right shunts CHD in children is still lacking in the field of clinical research, especially in developing countries. The purpose of this study is to find the pattern of heart failure in each type of CHD with left-to-right shunts in RSUP dr. Sardjito. Methods: We conducted a cross sectional study with consecutive recruitment of 40 patients (24 male and 16 female) at the pediatric cardiology clinic at Dr. Sardjito hospital in April-May 2018. The diagnosis was established based on trans-thoracic echocardiography. Sign and symptom of heart failure was recognized based on Ross criteria for heart failure in children. Descriptive analysis was made to compare the frequency of heart failure on each type CHD with left to right shunt. Results: There were 20 (50%) children who presented with the sign and symptom of heart failure despite undergoing treatment. The percentage of heart failure was highest in children diagnosed with PDA (80%). Following were VSD (40%) and ASD (33%). VSD was the most common CHD with 20 (50%) out of 40 children in this study. Discussion: Heart failure in children with CHD was most common in children with PDA. Children who had PDA will have two phase of shunt from the aorta to pulmonary artery. Those shunt will cause the volume overload of the right chamber, thus reduce the left chamber (cardiac) output in general and activated the neurohormonal counter-regulatory mechanism to anticipate the low output syndrome. The compensatory mechanism will produce heart failure clinical sign and symprom. The distribution of type of shunt in CHD was similar to the previously documented data. Keywords: Heart failure, congenital heart disease, left to right shunt 61

Diagnostic Value of NT-proBNP for Diagnosing Pulmonary Hypertension in Left to Right Shunt Congenital Heart Disease Wisvici Yosua Samin, Indah Kartika Murni, Endy Paryanto Prawirohartono Abstract Background: Pulmonary hypertension (PH) related to congenital heart disease (CHD) is accountable for 30.3% case in all PH in children. Delayed diagnosis and therapy are the main cause of high mortality. Limited access to echocardiography is the main reason of delayed diagnosis in developing countries. Biologic marker has a potential to become good diagnostic marker due to its availability, economic value, objectivity and being not invasive. NT-proBNP is produced by ventricle myocardium as a response to strain and ischemia. It is ideal to estimate ventricle myocardium dysfunction. Ventricle dysfunction is happened in early stage of pulmonary hypertension in children. Hence, NT-proBNP is proposed to be a comparable diagnostic test to echocardiography. Objectives: To define the optimal cut off NT-proBNP in ROC curve and test the diagnostic performance of NT-proBNP Method: Eligible left to right shunt CHD patient was recruited consecutively according to eligibility criteria. The diagnostic study has a cross-sectional design, in which all patients will have an echocardiogram with measured tricuspid regurgitation velocity before blood withdrawal for NT-proBNP measurement. NT-proBNP level will be plot in a ROC curve and sensitivity, specificity, likelihood ratio, confirming and excluding power has been measured. Results: Forty patients were recruited with mean age of 2.74 years of age. Twenty (50%) patients have VSD and 10 (25%) have PDA. Area under the curve from ROC curve for NT- proBNP is 0,721 with optimal cut off value of 0,721. Diagnostic test results were, sensitivity 54.5%, specificity 89.7%, likelihood ratio 5.3, confirming power 5.3 and excluding power 2.0. Confirming power of 5.3 is weak to diagnose PH- CHD in children. Finally, NT-proBNP is not able to out-perform echocardiography as a reference diagnostic test for PH-CHD. Keywords: Pulmonary hypertension, congenital heart disease, left to right shunt, NT-proBNP 62

Sleep Problems in 0-36 Months Old Indonesian Children with Atopic Dermatitis Irwanto, Hapsari W. Ningtiar, Taufiq Hidayat, Azwin M. Putera, Zahrah Hikmah, Anang Endaryanto Abstract Background : Atopic dermatitis (AD) is a chronic, relapsing, highly pruritic skin condition that develops in early childhood. Sleep problems are common in AD children and lead to impaired quality of life, disturbance of neurocognitive function and behavior. Objective : The aim of this study was to assess the prevalence of sleep problems in 0-36 months old Indonesian children with AD. Methods : Children aged 0-36 months were enrolled, divided into two groups, AD and control. Sleep problems and AD were assessed using Brief Infant Sleep Questionnaire (BISQ) and Severity Scoring of Atopic Dermatitis Index (SCORAD). Chi-square test was performed to compare the outcome. Results : There were 35 children participating in each group. In children with sleep problems, 85.7% were diagnosed with AD and 11.4% were non-AD. Nocturnal sleep duration, night waking, nocturnal wakefulness, sleep onset time, method of falling asleep and parental con- sideration of sleep problems occur more often within AD group. Severity of AD also significantly contributes to sleep problems in AD group. Conclusion : in this study showed that sleep problems are more prevalent in children with AD. 63

Determinant Factors of The Degree of Depression in Beta Major Thalassemia Children Hapsari Widya Ningtiar, Ahmad Suryawan, Irwanto, IDG Ugrasena Abstract Background : Thalassemia is a chronic disease with long-term treatment that increases the potential for impact on physical, cognitive, and psychological conditions. About 80% of patients with major thalassemia have at least one psychiatric disorder, depression is one of the most frequently reported, especially in prepubertal and puberty periods. Objective : The aim of this study is to evaluate determinant factors of depression in beta mayor thalassemia children. Methods : This was a cross-sectional study on patients aged 9 to 17 years at hematology outpatient clinic in Dr. Soetomo General Hospital from September to Desember 2018. Level of depression determinded by Children Depression Inventory (CDI) questionnaire. The data were collected and analyzed using using the IBM SPSS Statistics version 21. It is statistically significant with p<0.05. Results : Forty-five participants were included in this study, 15 participants with mild depression and 30 participants without depression. Gender (p=0.462), age of diagnosis (p=0.385), frequency of tranfussion (p=0.065), family history of depression (p=0,350), physical change (p=0.711), duration of illness (p=0.674) have no significant value as a determinant factor while complication (p=0.049) and serum cortisol level (p=0.037) had significant value as determinant factors of depression in Beta Major Thalassemia children. Conclusion : Mild depression is more common in thalassemia patients who experience complications and had high serum cortisol levels. Keywords : Beta Major Thalassemia; Level of depression; Children Depression Inventory(CDI). 64

The CDC PNU-1 Criteria for Diagnosis of Ventilator - Associated Pneumonia Hapsari Widya Ningtiar, Dwi Putri Lestari, Neurinda Permata Kusumastuti, Arina Setyaningtyas, Retno Asih Setyoningrum, Ira Dharmawati, Abdul Latief Azis Abstract Background: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in the pediatric intensive care unit (PICU), with mortality rates of up to 50%. Post- mortem pulmonary examination is considered to be the gold standard for diagnosisof VAP,butisimpossiblefor routine application.Thesen- sitivity and specificity of Clinical Pulmonary Infection Score (CPIS) are considered to be similar to the those of the gold standard, but the Centers for Disease Control and Prevention PNU-1 (CDC PNU-1) is simpler and not invasive, compared to the CPIS. Objective: To evaluate the level of agreement between CDC PNU-1 and CPIS criteria in diagnosing VAP. Methods: This cross-sectional study was conducted in the PICU at Dr. Soetomo Hospital, Surabaya from June to October 2018. Subjects were children aged 1 month–18 years who had been intubated for more than 48 hours. The VAP diagnoses were made by CDC PNU-1 and CPIS criteria. The level of agreement between the two methods was evaluated by Cohen‟s Kappa test using SPSS Statistics Base 21.0 software. Results: Thirty-six subjects were evaluated using CDC PNU-1 and CPIS criteria. Subjects‟ mean age was 3.5 (SD 4.7) years. Amongst 19 patients with VAP, 14 were diagnosed by CPIS criteria and 17 were diagnosed by CDC PNU-1 criteria. The level of agreement between the CDC PNU-1 and CPIS criteria was good (Kappa 0.61; 95%CI 0.31 to 0.83). The CDC PNU- 1 had sensitivity 0.85, specificity 0.77, positive predictive value (PPV) 0.70, and negative predictive value (NPV) 0.89. Conclusion: The CDC PNU-1 criteria has a good level of agreement with CPIS criteria in diagnosing VAP. 65

Study to Evaluate The Efficacy and Safety of EASYEF® in Acute Wound (Split-Thickness Skin Graft Donor Site) Anastasia Dessy Harsono Plastic Surgery RSPAD Gatot Soebroto in collaboration with Daewoong Pharmaceutical Co., Ltd as sponsor Abstract Acute injuries refer to injuries such as trauma, surgical wounds, and burns. The use of split thickness skin graft (STSG) is one of the reconstruction techniques that has an important role in the treatment of burns, trauma wounds, and acute wounds. EASYEF®, an epidermal growth factor manufactured by Daewoong Pharmaceutical Co., Ltd. is proven to cause epithelial cell proliferation thus used in this study to determine the effect on acute wound such as trauma, surgical wounds and burns. Total of 10 subjects were divided into 2 groups who received EASYEF® spray (50 mcg) or tulle gauze with moist gauze as primary dressing, and who received EASYEF® spray (50 mcg) and tulle gauze or tulle gauze with moist gauze as primary dressing. During 14 days of study treatment, efficacy and safety was evaluated through visual observation and verbal evaluation. Wound healing at the site of the donor split-thickness skin graft is determined by the time of exudate reduction, time for pain relief, and re- epithelialization. Significant differences were shown in Cohort 2, EASYEF® spray + tulle gauze and tulle gauze. Clinical adverse events during the course of the trial, signs of infection in the skin graft donor and systemic adverse event were observed. A total of 13 adverse events were reported in 10 subjects. Most of the adverse events reported were pain and were definitely not related to EASYEF® spray. Keywords: acute wound, EASYEF® spray, epidermal growth factor, skin donor, split-thickness skin graft 66

Survivor Characteristics of Congenital Malformations of The Gastrointestinal Tract Post Surgical Correction in Army Central Hospital Jakarta Marissa Anggraeni, Diana Chaidir, Carina E. Jacobs, Catur S. Sutisna, Irhamni, Windhi Kresnawati, Yenny Kumalawati, Yenny Abstract Background : Congenital Malformations of the Gastrointestinal Tract (CMGIT) usually manifest in the neonatal period, with symptoms and signs of gastrointestinal tract obstruction and could be life-threatening. Survival rate of MCMGIT post correction varies among countries between 77,9%- 87%, whereas in Army Central Hospital remain low at 58,62%. Material : This Descriptive Retrospective study was carried out in NICU during the period of October 2017 to March 2018. All The CMGIT babies operated in this hospital during this period were included. Results : of the twenty nine cases of CMGIT admitted to NICU for surgical correction, there were 17 survivors. All the patients were referral patients. The study shows that there is no significant difference between survivor and non-survivor groups in vital sign and complete blood count on admission, APGAR score, albumin level, length of stay, and time of surgery (elective vs cito). In survivor groups, colostomy was the most frequent type of surgery (76% of cases) whereas non-survivor groups predominated with resection-anastomoses operation (86% of cases). There are several significant difference between the two groups (survivor vs non-survivor): the proportion of full term babies (88% vs 58%), referral age (7 vs 14 days), septicemia (41% vs 67%), and the need of ventilator (5,8% vs 91,6%). Conclusion : Most of the survivors from CMGIT post surgical correction were full term babies. They were referred before 7 days old. They had no resection-anastomoses operation, and had no comorbid conditions such as septicemia and were on ventilator support. 67

Clinical and Hemodynamic Effect of Endothelin Receptor Antagonists on Eisenmenger Syndrome Patients Emir Yonas, Raymond Pranata, Muhammad Yamin, Nuvi Nusarintowati, Siti Elkana Nauli, Hafil Budianto Abdulgani, Bambang Budi Siswanto Abstract Introduction : Endothelin receptor antagonists (ERAs) are widely accepted as a specific treatment for pulmonary arterial hypertension. Unfortunately, consensus and recommendation are lacking for the treatment of patients that suffers from pulmonary arterial hypertension and congenital heart disease, including Eisenmenger syndrome. Objective : This meta‐analysis aimed to compare the effect of ERA on patients with Eisenmenger syndrome. Methods : Electronic search on PubMed (MEDLINE), EBSCO, EuropePMC, Clinicaltrials.gov, and google scholar was done. Studies involving the use of ERAs on Eisenmenger syndrome patients were included. There were 18 studies included. The primary outcome of interest 6‐min walking test distance before and after exposure to ERA. Results : There were 517 patients with Eisenmenger syndrome. The subjects had Eisenmenger syndrome secondary to congenital heart disorders, with WHO functional Class ranging from Class I–IV. The follow‐ up ranges from a mean of 4–60 months. Seventeen studies reported a statistically significant difference between pretreatment and the posttreatment result of 6‐min walking test distance. Pooled mean difference comparing pre and posttreatment values yielded an increase of 55.24 m (42.15, 68.33) P < 0.001; moderate heterogeneity I2 51% P = 0.008. Pooled mean pulmonary vascular resistance index difference comparing pre and posttreatment values yielded a decrease of 4.76 woods unit (−6.86, −2.66), P < 0.001 favoring posttreatment; low heterogeneity I2 0%, P = 0.82. Pooled mean mean pulmonary arterial pressure difference comparing pre and posttreatment values yielded a decrease of 5.40 mmHg (−7.53, −3.28), P < 0.001 favoring posttreatment, low heterogeneity I2 0%, P = 0.65. Conclusion : Implementation of ERA in Eisenmenger improves 6‐mi walking distance and pulmonary vascular pressure indices. Earlier 68

administration of ERA might be beneficial, further studies are needed to assess mortality benefit of this agent. Keywords : adult, congenital heart disease, eisenmenger syndrome, endothelin receptor antagonist 69

Cartilage Regeneration on Donor Site Defect with One Sided Perichondrial Auricular Cartilage Graft : An Experimental Rabbit Model Nurardhilah Vityadewi, Kristaninta Bangun Abstract Background: Auricular cartilage considered a source for cartilage graft with favorable aesthetic result and most frequently used in augmented rhinoplasty. Rhinoplasty becomes an increasingly popular procedure and also the number of revision increases. Most revision procedures require grafting and auricular cartilage is typically precious site for secondary rhinoplasty. Since the donor site is limited, search for the source and optimization of the donor site of graft material is necessary. The availability of the cartilage amount after harvesting very limited to be a structural support of the ear. It is our goal to investigate the possibility of reharvesting cartilage from the utilized donor site without any risk of distorting the ear morphology. The aim of this study was to evaluate the healing process of the donor site, include the cartilage regeneration of the donor site in experimental animal model. Methods: We conducted an experimental study in 6 white, healthy, New Zealand rabbits for the investigation of the cartilage regeneration from donor defect with one side perichondrium. Cartilage defects size 0,5 x 3 cm2 were created on the rabbits‟ ear. Two experimental groups with 12 ears in each group were created: Group 1 (with one side perichondrium) and group 2 (without perichondrium). Macroscopic and microscopic evaluations were done on the 4th weeks. Results: Microscopic evaluation revealed the immature cartilage formed in 4th week observation of the donor defect with one side perichondrium (p < 0,005). The macroscopic evaluation of the thickness and secondary wound contraction of the donor defect area have no significant results within two groups. Conclusion: The donor defect with one side perichondrium showed new cartilage formation within area of the perichondrium. This findings showed 70

the regeneration of cartilage was developed at the donor defects with one side perichondrium in 4th week. Keywords: auricular cartilage graft, donor defect, cartilage regeneration, cartilage healing 71