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The Indonesian Journal of General Medicine
Published by International Medical Journal Corp. Ltd.
ISSN : -     EISSN : 3048104X     DOI : -
Core Subject : Health,
Dentistry Health Professions Medicine & Pharmacology Public Health Veterinary
ims: The Indonesian Journal of General Medicine aims to advance the field of medicine by disseminating high-quality research findings that are accessible to a broad audience of healthcare professionals, researchers, and policymakers. The journal is committed to supporting the development of medical knowledge and practice in Indonesia and globally, fostering innovative research and evidence-based clinical practices. Scope: The journal covers a wide range of topics within the general medical field, including but not limited to: Clinical studies in various medical disciplines Epidemiological research and public health issues Innovations in diagnostic techniques and treatments Reviews on current practices and emerging trends in medicine Case studies and clinical trials Health policy and medical education The Indonesian Journal of General Medicine welcomes submissions from all areas of medicine, particularly those that have significant implications for patient care, public health, and policy-making. The journal encourages submissions that offer new insights, propose novel approaches, or address challenges pertinent to the Indonesian and international medical communities.
Arjuna Subject : Kedokteran - Kedokteran (Lain-Lain)
Articles 279 Documents
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HUBUNGAN KADAR ALPHA FETOPROTEIN MATERNAL DENGAN STATUS GIZI DAN LUARAN NEONATUS (A Systematic Review of Randomized Controlled Trial and Primary Studies) Desy Indah Puspitasari
The Indonesian Journal of General Medicine Vol. 42 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/c4b3qv51

Abstract

Latar Belakang: Alpha Fetoprotein (AFP) maternal merupakan glikoprotein yang diproduksi oleh hati dan kantung yolk janin yang memiliki peran penting sebagai biomarker kehamilan. Kadar AFP maternal yang abnormal, baik elevasi maupun rendah, telah dikaitkan dengan berbagai komplikasi kehamilan dan luaran neonatus yang buruk. Status gizi ibu hamil berperan signifikan dalam regulasi sintesis AFP dan perkembangan janin. Namun, hubungan komprehensif antara kadar AFP maternal, status gizi maternal, dan luaran neonatus belum dikaji secara sistematik dalam literatur berbahasa Indonesia. Metode: Systematic review dilakukan berdasarkan guidelines PRISMA. Kriteria inklusi meliputi studi Randomized Controlled Trial (RCT), cohort studies, case-control studies, cross-sectional studies, studi observasional, prospektif, dan retrospektif yang melibatkan populasi ibu hamil dengan pengukuran AFP serum maternal dan luaran neonatus terukur. Penilaian kualitas menggunakan Newcastle-Ottawa Scale (NOS) dan Cochrane Risk of Bias Tool. Hasil: Sebanyak 15 studi primer memenuhi kriteria inklusi dengan total 400.000+ subjek. Tinjauan mencakup 10 outcome utama: (1) kadar AFP maternal ≥2,5 MoM dikaitkan dengan penurunan berat lahir rata-rata 357-371 g (p<0,001); (2) risiko kelahiran prematur meningkat 4,8 kali lipat pada AFP ≥2,5 MoM; (3) pertumbuhan janin terhambat meningkat (RR 4,0; 95% CI 2,1-7,6); (4) mortalitas perinatal meningkat (RR 4,7); (5) small for gestational age (RR 2,8; 95% CI 2,4-3,2); (6) risiko abrupsi plasenta (RR 4,8); (7) preeklamsia (RR 3,8); (8) kematian janin dalam rahim; (9) sudden infant death syndrome (SIDS); (10) palsi serebral. Status gizi maternal yang buruk (IMT rendah, anemia, defisiensi mikronutrien) berkorelasi dengan perubahan kadar AFP dan memperburuk luaran neonatus. AFP sangat rendah (<0,25 MoM) dikaitkan dengan bayi besar dan komplikasi persalinan. Kesimpulan: Kadar AFP maternal merupakan biomarker penting yang berkorelasi dengan status gizi ibu hamil dan luaran neonatus. Pemantauan AFP maternal secara terstruktur, terutama pada trimester kedua, berpotensi mengidentifikasi kehamilan risiko tinggi dan memungkinkan intervensi gizi serta perawatan prenatal yang lebih optimal. Diperlukan studi longitudinal prospektif lebih lanjut di populasi Indonesia untuk mengkonfirmasi temuan ini.
The Role of HER2-Targeted Therapy in HER2-Positive Metastatic Breast Cancer : A Systematic Review of Randomized Controlled Trials Muhamad Luthfi Asyhar; Yuke Aulia Novianti; Mia Maya Aziza; Bernita Nur Cahyani; Theresia Murniwati Situmorang; Zia Faradila; Risa Rahmadina; Charles Sanjaya
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/3gv2zv39

Abstract

Introduction: Human epidermal growth factor receptor 2 (HER2) amplification characterises approximately 15–20% of invasive breast carcinomas and was historically associated with rapid visceral dissemination, central nervous system (CNS) tropism, and short survival. Over two decades, HER2-directed monoclonal antibodies, antibody–drug conjugates (ADCs), and tyrosine kinase inhibitors (TKIs) have progressively redefined the natural history of HER2-positive metastatic breast cancer (MBC). This systematic review was undertaken to synthesise, within a single comprehensive evidence framework, the magnitude, consistency, and safety trade-offs of HER2-targeted therapy across all treatment lines. Methods: A systematic review of randomized controlled trials (RCTs) was conducted in accordance with PRISMA 2020. Eligible studies were phase II or III RCTs enrolling adults with HER2-positive advanced or MBC receiving at least one HER2-targeted agent. Two reviewers independently screened, extracted data, appraised risk of bias using Cochrane RoB 2, and rated certainty with GRADE. Effect estimates (hazard ratios [HRs] and risk ratios [RRs]) were pooled using DerSimonian–Laird random-effects inverse-variance models. Results: Twenty-three RCTs comprising 9,808 randomized patients met eligibility. Across 18 trials, the pooled progression-free survival (PFS) HR for HER2-directed intensification versus control was 0.55 (95% CI 0.48–0.63; p<0.001; I²=79.9%). Domain-specific PFS estimates were 0.56 (95% CI 0.47–0.66) for escalation of HER2 blockade, 0.47 (95% CI 0.34–0.64) for ADC-based strategies, and 0.49 (95% CI 0.29–0.83) for next-generation TKIs versus lapatinib. Pooled overall survival (OS) across 12 trials favoured HER2-targeted intensification (HR 0.75, 95% CI 0.69–0.81; p<0.001; I²=13.0%), with domain estimates of 0.69 (95% CI 0.60–0.79) for escalation of blockade and 0.70 (95% CI 0.62–0.79) for ADC strategies. Objective response was significantly improved (pooled RR 1.41, 95% CI 1.09–1.82; p=0.008; I²=85.9%). CNS-specific endpoints, duration of response, clinical benefit rate, and time to quality-of-life deterioration were consistently improved. Tucatinib reduced intracranial progression by 52% (HR 0.48, 95% CI 0.34–0.69; p<0.001) in patients with brain metastases. Symptomatic left ventricular systolic dysfunction remained uncommon (approximately 1–2%), whereas class-specific toxicities—diarrhoea with pan-HER TKIs (grade ≥3 in 24–31%), thrombocytopenia and transaminitis with trastuzumab emtansine (grade ≥3 in 14% and 5%, respectively), interstitial lung disease in 10–15% of trastuzumab deruxtecan recipients, and ocular toxicity with trastuzumab duocarmazine—determined tolerability. Five trials were rated at low risk of bias and 18 raised some concerns, chiefly related to open-label design. Discussion: The evidence demonstrates a coherent dose-of-blockade relationship: every incremental increase in completeness or potency of HER2 pathway inhibition has translated into reproducible gains in disease control and survival. Statistical heterogeneity in PFS was substantial but explicable by line of therapy, comparator potency, and mechanism, rather than discordance in effect direction. Negative or neutral trials (margetuximab, atezolizumab added to trastuzumab emtansine, afatinib) delineate paradigm boundaries, indicating that immune-mediated or non-selective pan-ErbB approaches have not yet matched selective, payload-based, or brain-penetrant strategies. The CNS remains the decisive frontier; tucatinib-based regimens have the strongest randomized support for active brain metastases. Consistency across East Asian populations supports applicability to regional practice, though structural barriers to access and surveillance remain. Conclusion: HER2-targeted therapy produces large, consistent, and clinically meaningful improvements in PFS, OS, and response across all treatment lines in HER2-positive MBC, with a predictable and manageable toxicity profile. Sequential use of dual antibody blockade, ADCs, and brain-penetrant TKIs should be regarded as the standard therapeutic architecture. Equitable access to these agents—together with systematic cardiac and pulmonary surveillance—should be prioritised in health systems where HER2-directed therapy remains incompletely implemented. Future trials should address head-to-head comparisons beyond second line, biomarker-driven allocation, ADC sequencing, and treatment de-escalation in exceptional responders.
EFEKTIVITAS PROGRAM MANAJEMEN SKIZOFRENIA STABIL BERBASIS STEPPED CARE MODEL DI LAYANAN PRIMER TERHADAP KEPATUHAN ANTIPSIKOTIK DAN PENCEGAHAN RELAPS : A Systematic Review of Randomized Controlled Trials and Primary Studies Enrico Fermi Hutagalung; Devi Arnes
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/caybyr77

Abstract

Pendahuluan: Skizofrenia merupakan gangguan psikiatri berat dengan prevalensi global 0,32% dan tingkat ketidakpatuhan antipsikotik 30-70% yang berkontribusi pada tingginya angka relaps. Stepped care model (SCM) menawarkan kerangka layanan bertingkat yang mengintegrasikan manajemen pasien skizofrenia stabil di fasilitas kesehatan primer. Penelitian ini bertujuan mengevaluasi efektivitas program manajemen skizofrenia stabil berbasis SCM di layanan primer terhadap kepatuhan antipsikotik dan pencegahan relaps. Metode: Systematic review mengikuti pedoman PRISMA 2020. Kriteria inklusi mencakup RCT, cohort study, case-control, dan cross-sectional study pada pasien skizofrenia fase stabil. Penilaian risiko bias menggunakan Cochrane RoB 2.0 dan Newcastle-Ottawa Scale. Hasil: Dari 1.847 artikel, 18 studi memenuhi kriteria inklusi (7 RCT, 8 cohort, 2 cross-sectional, 1 case-control) dengan total 261.892 partisipan. Kepatuhan antipsikotik meningkat 11-27% pada kelompok intervensi SCM. Long-acting injectable (LAI) antipsikotik menunjukkan superioritas dalam pencegahan relaps (HR 0,46-0,79) dan penurunan rehospitalisasi 20-49%. Intervensi digital dan dukungan tenaga kesehatan komunitas meningkatkan kepatuhan secara signifikan (AMD 0,11; 95% CI 0,04-0,19; p=0,004). Psikoedukasi digital berbasis narasi meningkatkan kepatuhan (MD 1,27; 95% CI 0,30-2,24; p=0,02) dan sikap terhadap medikasi (MD 3,41; 95% CI 1,18-5,65; p=0,002). Diskusi: Bukti secara konsisten mendukung superioritas pendekatan SCM terintegrasi yang menggabungkan LAI antipsikotik, pemantauan digital, dukungan tenaga komunitas, dan psikoedukasi dibandingkan perawatan konvensional. Konteks layanan primer di negara berpenghasilan rendah-menengah menunjukkan intervensi berbasis komunitas dapat mengadaptasi pendekatan ini secara efektif. Kesimpulan: Program manajemen skizofrenia stabil berbasis SCM di layanan primer terbukti efektif meningkatkan kepatuhan antipsikotik dan mencegah relaps. Implementasi di Puskesmas Indonesia memerlukan adaptasi kontekstual, pelatihan tenaga kesehatan primer, dan sistem pemantauan terstandar.
The Impact of Nutrition on the Prevention of Complications (Encephalopathy, Ascites) in Patients with Liver Cirrhosis : A Systematic Review of Randomized Controlled Trials and Primary Studies Nabilla Ladyan Finasisca; Ryandri Yovanda
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/6vfqgg95

Abstract

Introduction: Liver cirrhosis (LC) is an advanced stage of hepatic fibrosis with estimated annual mortality exceeding 1.3 million deaths globally. Hepatic encephalopathy (HE) and ascites represent the most clinically consequential complications, dramatically impairing patients' quality of life and substantially increasing mortality risk. Malnutrition, present in 20–80% of cirrhotic patients, has been increasingly recognized as both a consequence and a determinant of these complications. Nutritional interventions—including branched-chain amino acid (BCAA) supplementation, zinc repletion, protein optimization, late evening snacks (LES), and probiotic administration—may constitute modifiable strategies for complication prevention. This systematic review aimed to comprehensively evaluate the impact of nutritional interventions on the prevention of HE and ascites in patients with LC. Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. Eligible studies included randomized controlled trials (RCTs), cohort studies, case-control studies, cross-sectional studies, and observational studies involving adult patients (≥18 years) with diagnosed liver cirrhosis, reporting nutritional interventions and outcomes related to HE, ascites, or associated biomarkers. Risk of bias was assessed using the Cochrane RoB 2.0 tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies. Results: Twenty-three primary studies (15 RCTs and 8 observational studies) encompassing 8,214 patients were included. Nutritional therapy significantly reversed minimal hepatic encephalopathy (MHE) in 71.1% of treated patients versus 22.8% controls (P=0.001). BCAA supplementation improved event-free survival (HR 0.67; 95%CI 0.49–0.93; P=0.015). Probiotics reduced overt HE development (HR 2.1 for controls versus probiotic group; P<0.05). Late evening snacking improved total body protein stores significantly over 12 months (P=0.003). Zinc supplementation reduced serum ammonia and improved Child-Pugh scores (P=0.01 and P=0.04, respectively). L-ornithine L-aspartate (LOLA) combined with standard therapy reduced 28-day mortality (16.4% versus 41.8%; P=0.001). Zinc deficiency independently predicted new or worsening ascites (HR 2.8; 95%CI 1.6–14.1; P=0.021). Discussion: The evidence synthesized confirms that targeted nutritional interventions meaningfully modulate the pathophysiological pathways underlying HE and ascites in LC. Multiple mechanisms are implicated: BCAA supplementation restores Fischer's ratio and reduces hyperammonemia; zinc repletion corrects metalloenzyme deficiencies essential for urea-cycle function; probiotics reduce gut-derived ammonia production and bacterial translocation; LES mitigates accelerated starvation metabolism; and adequate protein intake prevents sarcopenia. Sodium restriction with concurrent adequate caloric intake remains a cornerstone for ascites management, although poor adherence represents a clinically significant challenge. Conclusion: Multi-modal nutritional interventions—encompassing protein optimization (1.2–1.5 g/kg/day), BCAA supplementation, zinc repletion, probiotic administration, LES, and individualized caloric delivery—exert clinically significant protective effects against HE and ascites in patients with LC. Integration of formal nutritional assessment and individualized clinical nutrition strategies into multidisciplinary cirrhosis management pathways is strongly recommended. Further large-scale, multicenter RCTs with standardized nutritional protocols are needed to establish definitive guidelines.
Thyrotoxic Cardiomyopathy as the Cause of Congestive Heart Failure in a 32-Year-Old Woman: A Case Report Muhammad Arif Dwitama; Elsa Nabila Yumeza
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/axzkt295

Abstract

Introduction : Thyrotoxic cardiomyopathy represents a potentially reversible form of cardiomyopathy precipitated by prolonged or severe excess of thyroid hormones, leading to high-output cardiac failure, arrhythmias, and ultimately myocardial dysfunction. Its occurrence in young women without prior cardiovascular comorbidities remains a clinically underrecognized emergency. This case report aims to highlight the pathophysiological interplay between thyroid hormone excess and acute congestive heart failure (CHF) in a young female patient presenting to a secondary-level hospital in Indonesia. Case Illustration : A 32-year-old female with no prior medical history presented with a three-week history of progressive dyspnea on exertion, orthopnea, epigastric discomfort, and fatigue. On admission, she was found to have a ventricular rate of 240 beats per minute, oxygen saturation of 95% on room air, diffuse pulmonary crackles, and a palpable thyroid enlargement. The Wayne Index was 19. Thyroid function tests revealed a markedly elevated free thyroxine (FT4) of 61 pmol/L and suppressed thyroid-stimulating hormone (TSH) of 0.10 mIU/L. Electrocardiography demonstrated ventricular rate of 210 bpm with subsequent confirmation of atrial fibrillation with rapid ventricular response (AF RVR). Chest radiography demonstrated cardiomegaly with pulmonary edema and bilateral pleural effusion. She was managed in the Intensive Care Unit with antithyroid therapy (thiamazole 2×20 mg), intravenous amiodarone infusion per protocol, furosemide, propranolol, and supportive care. Following 10 days of comprehensive management, she achieved clinical remission with normalized heart rate, resolution of dyspnea, and hemodynamic stability, and was successfully discharged. Discussion : Thyroid hormone excess exerts direct chronotropic, inotropic, and lusitropic effects on the myocardium via genomic and non-genomic mechanisms, including upregulation of alpha-myosin heavy chain, sarcoplasmic reticulum Ca²⁺-ATPase (SERCA2a), and downregulation of phospholamban. These effects, coupled with peripheral vasodilation and neurohormonal activation, establish the substrate for high-output heart failure, atrial fibrillation, and eventually systolic dysfunction — the hallmarks of thyrotoxic cardiomyopathy. Early diagnosis using validated scoring tools (Burch-Wartofsky Point Scale, Wayne Index) and prompt multimodal therapy are critical to prevent multiorgan failure. Conclusion : This case underscores the importance of thyroid function evaluation in young patients presenting with new-onset atrial fibrillation and heart failure, particularly in the absence of conventional cardiovascular risk factors. Thyrotoxic cardiomyopathy is a reversible condition when diagnosed promptly and treated with antithyroid agents, appropriate rate control, and diuresis.
HUBUNGAN INFEKSI SALMONELLA TYPHI DENGAN KOMPLIKASI INTESTINAL DAN SISTEMIK : A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS Mochammad Ivan Kurniawan; Dicky Kresnadi Rahmanto
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/pp737n58

Abstract

Pendahuluan: Demam tifoid akibat Salmonella enterica serovar Typhi masih menjadi beban kesehatan global signifikan dengan potensi komplikasi intestinal (perforasi ileum, perdarahan enterik) dan sistemik (ensefalopati, syok, hepatitis, miokarditis). Tinjauan sistematis ini bertujuan mensintesis bukti uji acak terkendali (RCT) mengenai hubungan infeksi S. Typhi dengan komplikasi serta modifikasi risiko melalui intervensi antimikroba, kortikosteroid adjuvan, dan vaksinasi. Metode: Penelusuran dilakukan mengikuti PRISMA 2020. Kriteria inklusi menggunakan kerangka PICOS: populasi tifoid terkonfirmasi kultur atau berisiko di endemis; intervensi antimikroba, kortikosteroid, atau vaksin; komparator aktif/plasebo; luaran komplikasi intestinal dan sistemik. Risiko bias dinilai dengan Cochrane RoB 2, kepastian bukti dengan GRADE. Hasil: Sebanyak 21 RCT (>315.000 partisipan) diinklusikan. Deksametason dosis tinggi menurunkan mortalitas tifoid berat dari 55,6% menjadi 10,0% (p=0,003). Gatifloksasin superior terhadap sefiksim (HR 0,084; p<0,0001) namun inferior terhadap seftriakson pada galur resisten fluorokuinolon (HR 0,24; p=0,01). Vaksin konjugat tifoid memberikan efikasi 78,3-85% konsisten di Nepal, Malawi, dan Bangladesh. Komplikasi berat tidak terdeteksi sebagai luaran bermakna pada RCT terapi rawat jalan karena insidens rendah. Diskusi: Resistensi antimikroba telah mengubah lanskap terapi; fluorokuinolon tidak direkomendasikan di wilayah resistensi tinggi. Vaksinasi konjugat merupakan intervensi pencegahan komplikasi dengan bukti terkuat. Kesimpulan: Vaksin konjugat tifoid dan deksametason pada tifoid berat memiliki bukti acak terbaik. Terapi antimikroba harus dipandu pola kerentanan lokal. Diperlukan RCT kontemporer dengan luaran komplikasi primer.
Review of Computer-Aided Detection (CAD) Software for Tuberculosis on Chest X-Rays : A Systematic Review of Randomized Controlled Trial and Primary Studies Catur Nila Pratiwi; Wildan Priscillah; Eka Yusi Athiyyah
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/j44p8k35

Abstract

Introduction: Tuberculosis (TB) remains a leading global infectious disease and major public health challenge, particularly in low- and middle-income countries. Computer-aided detection (CAD) software utilizing artificial intelligence (AI) and deep learning algorithms has emerged as a promising tool to augment chest radiograph (CXR) interpretation for pulmonary TB screening and triage. This systematic review aims to comprehensively evaluate the diagnostic performance, clinical utility, cost-effectiveness, and implementation characteristics of commercially available CAD software for TB detection on CXRs across diverse clinical and epidemiological settings. Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. Eligible study designs included randomized controlled trials (RCTs), prospective and retrospective cohort studies, case-control studies, and cross-sectional studies evaluating at least one commercially available CAD software for pulmonary TB detection on digital CXRs with microbiological reference standards. Risk of bias was assessed using QUADAS-2 and Cochrane RoB 2.0. Results: Seventeen primary studies encompassing over 130,000 participants across Africa, Asia, Europe, Oceania, and Latin America were included. Evaluated CAD products included CAD4TB (versions 5-7), qXR (versions 2-3.2), Lunit INSIGHT CXR (versions 3.1-4.9), JF CXR-1/2, and InferRead DR. Area under the receiver operating characteristic curve (AUROC) values ranged from 0.70 (paediatric populations) to 0.92 (unselected adult populations). At 90% sensitivity, specificity ranged from 22.2% (prior TB history populations) to 84% (prison settings). Multiple CAD products met WHO Target Product Profile (TPP) minimum thresholds (≥90% sensitivity and ≥70% specificity) in symptomatic adult populations. CAD outperformed human radiologists in several large-scale studies. Performance was consistently lower in people living with HIV, elderly individuals, persons with previous TB, and paediatric patients. Discussion: Accumulating evidence substantiates that AI-based CAD systems are accurate, scalable, and cost-effective tools for pulmonary TB screening. However, heterogeneity in performance across software versions, geographic populations, and patient subgroups underscores the necessity for local threshold calibration and version-specific validation. Integration of CAD into national TB programs requires addressing economic, regulatory, and data governance challenges. Conclusion: CAD software demonstrates substantial diagnostic accuracy for pulmonary TB on CXRs and holds considerable promise for scaling up TB case finding. Standardized evaluation frameworks, population-specific threshold optimization, and equitable access are prerequisite conditions for maximizing the public health impact of CAD-CXR systems globally.
Focal and Generalized Seizure Characteristics in Uremic and Hepatic Metabolic Encephalopathy : A Systematic Review of Randomized Controlled Trials and Primary Studies David William Brian Iskandar
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/xz3m6x47

Abstract

Introduction: Metabolic encephalopathy arising from uremic and hepatic dysfunction represents a significant neurological emergency, manifesting across a spectrum from subtle cognitive impairment to overt convulsive status epilepticus. Seizures in this context are mechanistically distinct from idiopathic epilepsy, driven by accumulation of uremic toxins, hyperammonemia, astrocytic edema, disturbances in neurotransmission, and blood-brain barrier dysfunction. Despite the clinical importance of recognizing focal versus generalized seizure characteristics in these two paradigmatic forms of metabolic encephalopathy, a comprehensive synthesis of primary study evidence remains lacking. This systematic review aimed to characterize and compare focal and generalized seizure manifestations in uremic encephalopathy (UE) and hepatic encephalopathy (HE), evaluate EEG patterns, neuroimaging correlates, and clinical outcomes. Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. Eligible studies included randomized controlled trials, cohort studies, case-control studies, cross-sectional studies, and observational studies reporting seizure characteristics in human subjects with confirmed uremic or hepatic metabolic encephalopathy. Risk of bias was assessed using the Newcastle-Ottawa Scale and Joanna Briggs Institute tools. Results: Fifteen primary studies (cumulative n >1,900,000 patients) were included. Seizures occurred in approximately 10% of patients with end-stage kidney disease. Generalized tonic-clonic seizures predominate in both UE and HE, while focal seizures are documented particularly in HE secondary to portosystemic shunting. EEG findings include triphasic waves (OR=8.10 for liver insufficiency), generalized background slowing, and periodic lateralized epileptiform discharges. Cirrhosis was independently associated with status epilepticus (HR=1.9, 95% CI=1.3–2.8) but not isolated seizures. Nonconvulsive status epilepticus carries mortality rates of 37–52% in critically ill metabolic encephalopathy patients. Lentiform fork sign on MRI characterizes uremic encephalopathy seizures with basal ganglia involvement. EEG parameters inversely correlate with ammonia levels, MELD score, and cognitive performance scores in hepatic encephalopathy. Discussion: The pathophysiology of seizures in UE involves NKCC1-mediated depolarization of EGABA secondary to astrocyte potassium buffering failure, NMDA receptor activation by acute ammonia, and retention of multiple uremic toxins. In HE, ammonia-induced astrocytic swelling, GABAergic dysregulation, and peripheral neuroinflammation collectively lower the seizure threshold. Focal seizures in HE are distinctively associated with portosystemic shunting (TIPS), while generalized seizures dominate both conditions. Treatment requires addressing the underlying metabolic derangement alongside judicious antiseizure medication selection, given altered pharmacokinetics in renal and hepatic dysfunction. Conclusion: Seizures in uremic and hepatic metabolic encephalopathy are predominantly generalized tonic-clonic, though focal manifestations occur particularly with portosystemic shunting. EEG—especially triphasic waves—and MRI provide complementary diagnostic information. Mortality is significantly associated with seizure occurrence and nonconvulsive status epilepticus in both conditions. Standardized prospective studies with larger cohorts are urgently needed to establish evidence-based antiseizure medication treatment guidelines specific to these populations.
Does Sleep Quality affect The Occurrence and Detection of Subclinical Arrhythmiasin Young Adults when Measured using Wearable ECG Devices? : A Systematic Review Erlin Prawita Sari; M Ramazali; Gita Noor Azizah; Aan Try Maryani
The Indonesian Journal of General Medicine Vol. 43 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/sadxdw75

Abstract

Introduction: Poor sleep quality is prevalent among young adults (18–39 years) and is linked to adverse cardiovascular outcomes. Wearable ECG devices offer a novel opportunity to assess both sleep and subclinical arrhythmias in real-world settings. However, the direct relationship between sleep quality and subclinical arrhythmia occurrence in healthy young adults remains unclear. This systematic review evaluates whether sleep quality affects the occurrence and detection of subclinical arrhythmias in young adults using wearable ECG devices. Methods: A systematic screening of literature was performed based on predefined criteria: population (young adults 18–39 years), sleep quality measurement (validated instruments), ECG technology (wearable devices), arrhythmia type (subclinical/asymptomatic), temporal linkage (concurrent sleep and ECG recording), and absence of cardiovascular disease, arrhythmogenic medications, shift work, or diagnosed sleep disorders. Results: From a large pool, multiple studies demonstrated that poor sleep quality (short duration, fragmentation, irregularity, deprivation) consistently shifted autonomic cardiac regulation toward sympathetic dominance and reduced parasympathetic (vagal) tone, as indexed by heart rate variability (HRV). For example, after 48-hour sleep deprivation, the LF/HF ratio increased significantly (3.02 vs. 2.48, p<0.001) (3). Sleep restriction to 4 hours/night for 5 nights increased resting heart rate from 60 to 63 bpm and LF/HF from 4.6 to 6.0 (1). Sleep irregularity reduction from 57 to 31 minutes improved resting heart rate (65 to 62 bpm, p=0.005) and increased RMSSD (34 to 42 ms, p=0.009) (2). In young adults with circadian disruption, sleeping <6 hours increased ventricular ectopic events (12). Epidemiological data showed frequent nighttime awakening was associated with a 33% increased risk of atrial fibrillation (HR 1.33, 95% CI 1.17–1.51, p<0.001) (6). Wearable devices achieved 85–95% sensitivity for AF detection (8), and the Zio patch showed 88.8% sensitivity for sleep detection versus polysomnography (10). Discussion: The evidence robustly supports that poor sleep quality impairs autonomic cardiac regulation in young adults via sympathetic activation and vagal withdrawal. This autonomic shift is a known arrhythmogenic substrate. Wearable technologies are now capable of simultaneously monitoring sleep quality and detecting subclinical arrhythmias. The critical remaining gap is the direct demonstration that sleep quality variation modulates the frequency, timing, or detectability of subclinical arrhythmic events in naturalistic settings. Conclusion: Poor sleep quality significantly alters autonomic cardiac function in young adults toward a pro-arrhythmic state. Wearable ECG devices are technically capable of assessing both parameters. Future purpose-designed studies combining longitudinal wearable cardiac monitoring with validated sleep assessment in young adult cohorts are needed to directly link sleep quality to subclinical arrhythmia detection.

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