The characteristics of neurocognitive function in farmers exposed to chronic pesticides at Banjar Tengah Kelod, Kerambitan, Tabanan, Bali, Indonesia

Purpose: This study aims to evaluate the characteristics of neurocognitive function in farmers exposed to chronic pesticides.

Material and Methods: This study uses a descriptive cross-sectional design with total sampling methods. The study was conducted from 1^st January 2019 until 31^st January 2019 located in Banjar Tengah Kelod, Kerambitan sub-district, Tabanan district, Bali, Indonesia.

Results: A total of 60 samples, consisted of 36 samples (60%) were women and 24 samples (40%) were men were obtained. The median age of the study sample was 55 year-old. Most of the samples who experienced neurocognitive impairment used organophosphate pesticides (60%), followed by organochlorine (20%), carbamate (13.3%), and pyrethroid (6.7%). Organophosphate users experienced neurocognitive impairment in both memory domain (mean score of 1.5 what scoring was used?) and visuospatial executive functions (mean score of 1, what scoring system?). The mean memory function score in the organochlorine user group was the highest compared to other groups of pesticide users while the average score of visuospatial function was 1. The samples of the study using carbamate pesticides had the same average score in both domains of neurocognitive function. The mean score of memory function in pyrethroid user was 2.5 and the average score of executive visuospatial function was 1.

Conclusion: Chronic exposure to the four types of pesticides provided a picture of neurocognitive function impairment, including memory, visuospatial and executive functions. This result did not show clinical significance. The addition of sample size and analytic method studies should be considered for further research.

The effect of intraarterial heparin flushing to autism symptoms when used to treat the concomitant cerebral venous thrombosis: a case series

Introduction. There are still no definite therapeutic strategies for Autism Spectrum Disorder (ASD) other than behavioural interventions and few FDA approved behaviour control drugs. In this study, we found a co-existence medical condition of ASD & Cerebral Vein Thrombosis (CVT) in the paediatric population. Based on these findings, a new therapeutic approach, a catheter-directed anticoagulant therapy termed as IAHF (Intra Arterial Heparin Flushing) was performed on this population of patients.

Methods. This paper aims to describe a series of 10 cases of IAHF procedure performed to treat CVT on children with ASD from 2018 through 2019 at Cerebrovascular Center RSPAD Gatot Soebroto Jakarta-Indonesia. The children diagnosed with ASD by the multidisciplinary team but also had CVT findings on their brain magnetic resonance imaging studies when performed as the series of comprehensive diagnostic examination. IAHF were conducted by delivering heparin through a modified DSA technique into the occluded vessels. Subject Autism status was assessed with the Childhood Autism Rating Scale (CARS) before and one month after IAHF procedures.

Results. The measurement of CARS Score after IAHF shows a relatively positive result. Eight patients showed a decreased in total CARS Score after the procedure, while only two patients had no improvement. One subject shows a decrease of nine points, the most significant changes, and improved the status from moderate to mild autism.

Conclusion. In children who have ASD and also accompanied by CVT findings in their imaging studies, IAHF treatment showed clinical improvement of the autism symptoms.

Physical rehabilitation of middle-aged women with vegeto-vascular dystonia in Russia

Introduction: Vegeto-vascular dystonia (VSD) resembles a common condition in women nowadays. Its manifestations exert a weakening effects constellation on the central nervous system (CNS) and the bodily process. With insufficient effect from medical efforts in VSD, the level of viability of the organism inevitably decreases. The purpose of the study was to assess the possibilities of the author's version of physiological rehabilitation of women with VSD.

Materials and methods: The study involved 2 groups of women aged 27-35 years (mean age 30.8 ± 2.1 years). Each group consisted of 25 women with a diagnosis confirmed at least 3 years ago by the VSD. In the first group of women, rehabilitation was carried out according to the author's method, whereas the traditional scheme of rehabilitation is applied in second group. Rehabilitation activities lasted for 6 months, evaluated by functional tests using Student's t-test.

Results: The author's complex of rehabilitation measures proved to be very effective in first group, including a rational diet, therapeutic gymnastics, electrostimulation, massage and hydrotherapy. The complex of rehabilitation measures developed by the authors was able to provide the most complete restoration of the physical condition of women with VSD by achieving a balance between the activator and inhibitory processes in CNS also the optimal tone of their vessels.

Conclusion: The study proved that the author's version of rehabilitation of women with VSD was capable of completely eliminating somatic manifestations accompanying vegetative vascular dystonia and increasing the adaptive capabilities of the body in daily life.

Physiological peculiarities of thrombocyte activity of candidates into masters of sports in athletics of preadult age

Introduction: Physiologically, platelets are an important component of homeostasis of the whole body and blood system. However, not everything is clear with platelet activity of young healthy persons who have systematic exercises, particularly masters of sports’ candidate. Its in vitro and in vivo should be studied further.

Aim: The aims of this investigation are to find out the abnormalities of thrombocyte activity of master of sports’ candidate in athletics of young age and compare them with thrombocyte level of young people who avoided exercises during their lifetime.  Through modulation of their activity, they increase capillaries' perfusion and thereby metabolism in tissues.

Materials and methods: In our investigation group we took 125 candidates into masters of sports in athletics of preadult age regularly exercising and participating in competitions of different levels. Control group was consisted of 141 healthy youths having avoided exercises during their lifetime. Biochemical, hematological and statistical methods are applied.

Results: Athlete were found to have stable normal functional platelet activity. For subjects between 18 and 22 years, their platelets aggregation was on low level and had no reliable variations related to their stable low sensitivity to inductors. Decreased platelet activity causes conservation in athletes' blood of some quantity of circulating thrombocyte aggregates. It makes positive impact on microcirculation in organs of athlete having regular athletic exercises. Avoidance of exercise in young age promotes gradual rise of thrombocyte activity. Masters of sports’ in athletics candidate who had intensive muscle activities are characterized by persistence of stable low platelet activity. It provides low quantity of active platelets and their circulating aggregates in blood. Those young persons, who avoided exercises, are noted to have elevated platelet activity with a tendency increased aggregate formation.

Conclusion: Masters of sports in athletics’ candidate doing intensive muscle activity are characterized by preservation of stable not high platelet activity caused by low content of active platelets and their circulating aggregates. Avoiding exercises in young people are noted to have caused the increase of platelet activity with a tendency to cause platelet aggregation.

Clinical and plain x-ray findings of spinal metastases: a retrospective study of pathologically-confirmed cases

Background: Malignancy of breast, prostate, and lung contribute to metastatic bone disease, and the metastases are mostly located in the spine. Spinal metastases may involve the spinal cord, leptomeninges, epidural space and also the bone itself. Therefore, proper imaging is needed in early detection and diagnosis of spinal metastasis. This study aimed to perform the clinical and plain x-ray findings in patients with spinal metastasis.   

Method: A retrospective study was conducted on 28 spine pathological fracture patients with neurologic deficits who underwent surgical intervention in Sanglah General Hospital during a year. We evaluated the present symptoms, neurological status (Frankel score), pathological reports by plain x-ray findings, metastases cell type by histological assessment, and extension of mass expansion on MRI. A total of 20 cases that met the inclusion criteria were evaluated.

Result: Most patients suffer from pathologic fracture on thoracic spine level, followed by lumbosacral level and none on cervical spine level. The compressive fracture was a major finding on plain x-ray. The extradural lesions account for most of the MRI findings, followed by intradural/extramedullary and intramedullary lesion. Primary tumours that lead to bone metastases in this serial-cases are prostate, breast, cervix, kidney and lung cancer, respectively.

Conclusion: Thoracic spine is the most common spinal metastases manifestation. Conventional plain x-ray is the most initial modality to evaluate systemic neoplasia patients with spinal pain, although it is not a sensitive indicator to identify the presence and extent of metastatic involvement.

Association of serum interleukin-10 (IL-10) with the severity of acne vulgaris

Background: Acne vulgaris is a common inflammatory disorder in pilosebaceous gland units, which affected more than 90% of teenagers, and half of them settled until adulthood. Inflammation is one of the four critical factors in the pathogenesis of acne vulgaris, and it could be a primary process or secondary to Propionibacterium acnes. The immune system has a various anti-inflammatory mechanism to counter-balance inflammatory mediators. One of the potent cytokines that play a role in regulating the inflammatory state is Interleukin-10 (IL-10). This study conducted to determine the association of serum IL-10 with the severity of acne vulgaris.

Methods: This is a cross-sectional analytic study involving 33 subjects with acne vulgaris and 31 normal-healthy volunteers as a control. Both groups had their serum IL-10 measured. Acne vulgaris severity was assessed with Lehmann criteria. Anova was used to determine the statistical difference of IL-10 among different groups of acne severity. This study has been approved by the Ethical Committee Faculty of Medicine, Universitas Sumatera Utara.

Results: The mean serum IL-10 of normal-healthy and acne vulgaris subjects were 5,79 ± 1,23 pg/ml and 5,25 ± 1,55 pg/ml, respectively. Mann-Whitney test showed a significant difference (p=0,029). The mean IL-10 serum levels according to acne vulgaris severity were 6,63 ± 1,94 pg/ml in the mild category; 4,89 ± 0,95 pg/ml in the moderate category and 4,38 ± 0,61 pg/ml in the severe group. ANOVA showed significant difference with p=0,001.

A network meta-analysis on comparative efficacy of statins focusing for prevention of contrast-induced acute kidney injury in chronic kidney disease patients undergoing percutaneus coronary intervention

Background: The use of interventional diagnostic and therapeutic procedures required intravascular iodinated contrast are performed in millions of patients worldwide and are steadily increasing the risks of contrast-induced acute kidney injury (CI-AKI). Statins are primarily used in cardiovascular medicine for their lipid-lowering effects but they possess remarkable pleiotropic effects such as improving endothelial function as well as decreasing oxidative stress and inflammation. A network meta-analysis was carried out to evaluate the effect of different statins in prevention of CI-AKI and also to investigate which type and dose of statins maybe the best choice specifically in CKD patients who have higher risk. 

Methods: We performed a pairwise and network meta analysis of 14 randomized studies (9847 patients) comparing a total of 6 different statins: rosuvastatin high dose, atorvastatin high dose, simvastatin high dose, rosuvastatin regular dose, atorvastatin regular dose, pravastatin regular dose versus each other and versus placebo in CKD patients undergoing PCI with iodinated contrast for prevention of CIAKI. Google Scholar, Pubmed, Science Direct databases were searched up to May 2019. The data were pooled using STATA, and R version statistics calculating odds ratios (ORs) with 95% confidence intervals.

Results: Statin loading before contrast administration was associated with a significantly reduced risk of CI-AKI in patients with CKD undergoing cardiac catheterization (pooled OR= 0.51; P=0.0001). Regular dose pravastatin comprised the best effect size for a reduction in CIAKI risk (OR = 0.32, 95% CI 0.14-0.72, p=0.006). Regular dose pravastatin and high dose atorvastatin were ranked as the highest probability to be the best treatment (Pbest) with 44% and 31% respectively for effect on CIAKI prevention.

Conclusion: Preloading with statins is associated with significantly reduced risk of CI-AKI in patients with CKD undergoing cardiac catheterization. Regular dose pravastatin and high dose atorvastatin have the highest probability to be the most effective prevention strategy.

The erection conundrum: risk factors for erectile dysfunction among middle-aged and elderly men in Lamongan, East Java, Indonesia

Background: The most common sexual problem affecting the general population of men is Erectile Dysfunction (ED) with a global estimated number of over 100 million. It affects the biological, psychological, and social aspect of life which can cause frustration, depression, and anxiety. Unfortunately, the attention towards the disease in Indonesia is often overlooked as evidenced by the lack of studies regarding the prevalence and risk factors for the disease. This study aims to evaluate possible risk factors of Erectile Dysfunction among elderly males in Lamongan, East Java.

Methods: This is a quantitative study with an analytical observational design, performed using a case-control approach. Respondents consisted of male inpatients as well as outpatients aged 40 years or more in Ngimbang General Hospital evaluated using the International Index of Erectile Function (IIEF) questionnaire. The patient’s comorbid data are taken from the Medical Record to ensure proper diagnosis. The acquired data are then analysed using the ordinal logistic regression method.

Results: A total of 174 men were evaluated. There are 62 people with no ED (35.6%), 39 people with mild ED (22.4%), 35 people with mild to moderate ED (20.1%), 16 people with moderate ED (9.2%), and 22 people with severe ED (12.6%). Significant risk factors are older age (OR: 1.29; CI: 1.23-1.37), Diabetes (OR: 6.56; CI: 2.77-15.56), and hypertension (OR: 5.19; CI: 2.27-11.88) (all, p < 0.05); whereas dyslipidemia and smoking habit are insignificant (p>0.05).

Conclusion: Age, diabetes, and hypertension are significant risk factors for Erectile Dysfunction.

High incidence of varicocele among young men in Public Police Hospital Denpasar, Bali, Indonesia: a descriptive study

Background: Varicocele is a progressive disease which possibly starts from puberty. When left untreated, it could progress and causes complications such as infertility. Determination on the representative national incidence and characteristic of varicocele has been a hard challenge due to the lack of data on varicocele epidemiological studies, especially in Bali. This study aims to know the characteristic of varicocele patients undergoing varicocelectomy in Bhayangkara Denpasar Hospital from January 2017 to December 2018. 

Methods: This research is a descriptive retrospective study with cross sectional approach. The population of the study consists of patients who were diagnosed with varicocele and underwent varicocelectomy in Bhayangkara Denpasar Hospital from January 2017 to December 2018. Total sampling method was used. Research data were retrieved by taking the patient’s entire medical record with varicocele in Bhayangkara Denpasar Hospital from January 2017 to December 2018.

Results: Ninty five samples were diagnosed with varicocele and underwent varicocelectomy. The highest percentage among age groups is 15 to 24 years (89.5%), with normal stature (94%), normal weight (86%), asymptomatic (90.5%), left unilateral varicocele (86.%), grade III varicocele (82,1%) and without comorbid (93.8%). The samples underwent varicocelectomy with Ivanissevich procedure (72.8%), operation time of ≤ 60 minutes (95.8%) and length of stay of ≤ 2 days (95.8%).

Conclusion: The high incidence of varicocele in young adulthood is due to a majority of the samples being young police recruitment participants who were accidentally diagnosed during general medical check-up. Early screening on varicocele in the age group of 15 to 24 years is recommended to consider the need of sperm analysis examination and further deciding on the treatment options. One of the options is surgery.

Comparing the effect of Angiotensin-Converting Enzyme Inhibitors versus Angiotensin Receptor Blockers in heart failure patients with type 2 diabetes mellitus: a systematic review

Abstract:

Introduction: Heart failure is a prevalent world wide. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are widely prescribed. The aim of this study was to determine the effect of the two drugs in heart failure patients with type 2 diabetes mellitus.

Methods: This meta-analysis was performed on research articles on the drugs of heart failure patients in PubMed, ProQuest and EBSCO database published between 2008-2018. Pooled odds ratio (OR) are calculated using fixed and random effects models. Data were processed using Review Manager 5.3 (RevMan 5.3).

Results: From total 209 articles, 10 studies met the criteria for systematic review. Meta-analysis result showed that there were no difference effect of angiotensin-converting enzyme inhibitors versus angiotensin receptor blockers in heart failure patients with type 2 diabetes mellitus (RR = 1.73 [95% CI 0.88-3.40], p=0.11). Heterogeneity test for studies (Pheterogeneity = <0.00001) showed variation of heterogeneous research. There is no publication bias on this study Egger’s test (p = 0.334) and Begg’s test (p = 0.180).

Introducing the tolerogenic macrophage therapy as an alternative approach to manage systemic lupus erythematosus: a case series

Introduction: Systemic Lupus Erythematosus (SLE) has been quite an enigma in medicine. The possibility of the host own defense mechanism attacking itself is still quite difficult to understand. Patients who suffer from this disease tend to have a problem in their qualities of life, especially as the majority affect female in their productive ages. Conservative therapy to manage this disease is widely developed and implemented. Since the known therapies have several side effects and limitation, a need to develop a new strategy that can re-establish the “tolerance” mechanism of our immune system is increasingly needed. Immunotherapy is already a promising field in the strategy against autoimmune cases. In our facility, we developed immunotherapy called ToM (Tolerogenic Macrophage) which similar to Mreg (Regulatory Macrophage) in order to utilise the “tolerance” ability of this immune apparatus.

Case: In this study, we present 2 cases of female patients who suffer from SLE, which underwent ToM Therapy in our Cellcure facility in RSPAD Gatot Soebroto Jakarta-Indonesia. After the procedure the patient was monitored one month and one year. Clinical and control parameter such as ANA (IF) and ANA profile was examined again in both patients to measure the effect of this therapy. The ANA titer and the titer of specific antibodies such as dsDNA, Nucleosomes and Histones results show significant reduction, accompanied by the improvement of the symptoms.

Conclusion: ToM Therapy seems to have a good efficacy as immunotherapy for SLE. Further study needed to establish this approach.

Type IA urethral duplication: a case report

Background: Urethral duplication is a rare congenital malformation mainly affecting men and boys. Although a number of theories have been proposed to describe this condition, the actual mechanism of this disorder is still not clear. The most frequent anomaly occurs in the sagittal plane, in which the duplicated urethra is in either dorsal or ventral position in relation to the orthotopic urethra. The therapeutic management of these conditions is complicated and depends on the presence of symptoms as well as the type of anomaly.

Case Description: We present a case of urethral duplication in a 2 years old male child. The malformation was characterised by the presence of the meatus in the dorsal penoscrotal and accompanied by the sign of infection in it. Urethrography showed contrast stopped filling 2 cm from the meatus in the dorsal penoscrotal with a total dead-end impression as an accessory urethra and there was no abnormalities in the principal urethra looked from the contrast filled the penile urethra, bulbous urethra, prostatic urethra, and bladder. That was the form of Effmann Type IA urethral duplication. The dorsal accessory urethra was excised entirely without complication and he remains symptom-free eight months after surgery.

Conclusion: In summary, urethral duplication is a rare clinical condition. It has many variants that were classified by Effman. Management depends on the anatomy of the duplication involved and the patient’s clinical symptoms.

PKB XXVII Ilmu Penyakit Dalam: Comprehensive Management in Internal Medicine

Foreword

Internal Medicine is quickly developing in all lines, from basic theories, pathophysiology, diagnostic procedures and therapy. The challenges of new cases and the re-emergence of re-emerging diseases in the era of globalization, modernization and industrialization require clinicians to constantly renew their knowledge and expertise and possess global standard quality to improve medical services. Information on medical science and technology is now easily accessible to anyone, produce an increasingly critical society and bring up challenges for clinicians.

The advancement of Indonesian doctors must be supported by access to regional, national and international scientific communication in the form of scientific forums that present the latest research information and results, as well as a forum for discussion with experts in addition to establishing family bond for doctors.

Pendidikan Kedokteran Berkelanjutan (PKB) Internal Medicine Department, Faculty of Medicine of Udayana University / Sanglah Hospital 2019 is a scientific activity in Internal Medicine topics held annually. In the series of activities of PKB XXVII in Internal Medicine Faculty of Medicine Universitas Udayana / Sanglah Hospital 2019, the update in the field of Internal Medicine will be presented in the form of training (workshops), symposiums, and expert discussions hence the opportunities for interaction between participants and experts are optimal. Development in the field of research is also a concern and we give appreciation in the form of opportunities to compete in oral papers and posters.

Dr. I Wayan Losen Adnyana, SpPD-KHOM

Chairman