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THE ASSOCIATION BETWEEN MATRIX METALLOPROTEINASE-9 (MMP-9) WITH HIGH SENSITIVE TROPONIN T (hs-TnT) IN PATIENT WITH ACUTE MYOCARDIAL INFARCTION Suyasa, I Putu Gede Eka Ariawan; Rina, Ketut; Widiana, I Gde Raka
Medicina Vol 46 No 1 (2015): Januari 2015
Publisher : Medicina

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Mechanism of acute myocardial infarction (AMI) is previously due to atherosclerotic plaque rupturewith occurs because extra-cellular matrix of plaque fibrous cap destruction or degradation by proteaseenzyme matrix metalloproteinase-9 (MMP-9), which released by macrophage cell.Increased plasmaMMP-9 is predisposition factor of atherosclerotic plaque rupture in AMI and followed by acutethrombosis inside coronary artery lumen which caused myocardial ischemic and clinical sign of AMI. Ifthe ischemic process continuous and ongoing that can caused myocardial necrosis which can increasedplasma troponin. High sensitive troponin T (hs-TnT) newly and more sensitive detection of plasmacTn-T than conventional.The aim of this study was to determined the association between plasmaMMP-9 with hs-TnT in AMI patients.This study was a cross-sectional observational which performedin 62 patients with AMI which enrolled by consecutive sampling at Sanglah Hospital Denpasar fromDecember 2011 until December 2012. MMP-9 and hs-TnT plasma level were measured 48 hours afteronset IMA. Sixty two patients AMI were involved in this study consist of 35 STEMI patients (56.5%)and 27 NSTEMI patients (43.5%), the mean plasma MMP-9 was 23.9 (SD 0.42) ng/mL and hs-TnT was464.7 (SD 39.3) ng/mL.The results of this study were positive correlation between MMP-9 and hs-TnTAMI patients (r= 0.507; Y= - 650.6 + 46.7(X1); P<0.0001); plasma MMP-9 and onset of AMI wereinfluenced to plasma hs-TnT with formulationY = - 815.0 + 46.5(X1)+ 20.7(X2); (â MMP-9=46.5(95%CI: 24.7 to 68.4); P<0.0001; â onset AMI=20.7(95%CI : 2.1 to 39.4); P=0.030) and there was more strongercorrelation betweenMMP-9 and hs-TnT in STEMI group than NSTEMI. [MEDICINA 2015;46:22-27].Mekanisme terjadinya infark miokard akut (IMA) didahului oleh proses ruptur plak aterosklerosisdan diawali dengan destruksi atau degradasi matriks ekstraseluler fibrus cap plak oleh enzim proteaseyang dihasilkan sel makrofag yaitu matrix metalloproteinase-9 (MMP-9). Kadar MMP-9 yang meningkatmerupakan faktor predisposisi terjadinya ruptur plak aterosklerosis pada IMA yang diikuti olehproses trombosis akut pada lumen arteri koroner yang menyebabkan proses iskemia miokard dangejala klinis IMA. Proses iskemia yang tidak teratasi akan mengakibatkan nekrosis miokard yangditandai meningkatnya troponin jantung. Pemeriksaan high sensitive troponin T (hs-TnT) merupakanpemeriksaan kadar troponin yang terbaru dan memiliki kemampuan lebih baik dari pemeriksaantroponin konvensional. Tujuan dari penelitian ini untuk mengetahui hubungan kadar MMP-9 denganhs-TnT plasma pada penderita IMA. Penelitian ini merupakan studi observasional potong lintangyang dilakukan pada 62 penderita IMA yang dikumpulkan secara consecutive sampling di RSUPSanglah Denpasar dari Desember 2011 sampai Desember 2012. Kadar plasma MMP-9 dan hs-TnTdiukur 48 jam setelah awitan IMA. Dari 62 sampel penelitian yang terdiri dari 35 pasien STEMI(56.5%) dan 27 pasien NSTEMI (43.5%) didapatkan rerata kadar MMP-9 plasma 23.9 (SB 0.42) ng/mL dan hs-TnT plasma 464.7 (SB 39.3) ng/mL.Hasil penelitian ini terdapat korelasi positif antaraARTIKEL ASLI JURNAL ILMIAH KEDOKTERAN • 23death in the world,1 approximately30% from all cause of death.2Acutecoronary syndrome (ACS) is one ofcoronary heart diseasemanifestation and a seriouscardiovascular emergency.3Basic pathogenesis acutemyocardial infarction isatherosclerotic plaque rupturewith following thrombus formationin coronary artery. The process ofatherosclerotic plaque rupture iscaused by protease enzymereleased from macrophage cell,such as matrix metalloproteinase-9 (MMP-9), that cause degradationand fibrous cap rupture and formthrombus with coagulation cascadeactivation. This thrombusformation will give clinicalmanifestation of ACS and increaseof troponin levels.4-7Cardiac troponin (cTn),cTnTand cTnI , is a gold standardfor detection of myocardialnecrosis.5,8 Using high sensitivecardiac troponin (hs-cTn), hs-TnTand hs-TnI, will improve earlydiagnosis of acute myocardialinfarction (AMI) significantly andhopefully will decrease falsepositive result.5,9Several studies have beendone to compare MMP-9 levelswith hs-TnT in patients with ACS.Kobayashi et al10 found MMP-9levels increased in acute phase ofACS as reflection of plaquevulnerability and hs-TnT levelsincreased in later phase. Setiantoet al11 in 2011 compared MMP-9levels MMP-9 and troponin-I (cTn-I) in ST Elevation MyocardialInfarction (STEMI) and UnstableAngina Pectoris (UAP)/ Non STElevation Myocardial Infarction(NSTEMI) with result a positivecorrelation between increase ofMMP-9 levels and cTn-I mainly inSTEMI group and stated MMP-9role in myocardial damage severitywith r=0.33 and P=0.003. Thereis no research that studycorrelation between increase ofMMP-9 levels and hs-TnT in AMIpatients.METHODSThis study was aobservational study with cross-sectional design to evaluate MMP-9 levels and hs-TnT levels in AMIpatients at emergency unit andIntensive Cardiac Care Unit(ICCU) Cardiology DepartementUdayana University MedicalSchool/ Sanglah Hospital. Thisstudy was a research tree aboutACS that has been held fromDecember 2011 until December2012 and the result became JointStudy of ACS. This study has beenapproved by Ethics Committee ofUdayana University MedicalSchool/Sanglah HospitalDenpasar. Subjects of this studywere 62 patients with AMI thatfulfilled inclusion and exclusioncriteria. The inclusion criteriawere: 1) all AMI patients age 30-80 years old and treated atemergency unit and ICCU SanglahHospital, 2) gave consent toparticipate in this study. Theexclusion criteria were : 1) valvularheart diseases (VHD), 2) congestiveheart failure (CHF), 3) acute orchronic liver disease, 4) chronickidney disease (CKD) (creatinineclearance < 60 ml/1.73 m2/min),5) chronic or acute infection, 6)sepsis, 7) malignancy, 8) treatedwith corticosteroid or nonsteroidal anti inflammatory orimmunosuppresive drugs morethan 1 weeks, and 9) stroke. Thisstudy using human MMP-9 ELISAkit and Roche Elycsys 2010 kitwhich measured 48 hours afteronset AMI.Analysis of correlationbetween MMP-9 with hs-TnTusing non-parametric analysiswith Spearman test (P<0.05).Multivariate analysis withmultiple linear regression therelationship of the functionalpredictive value MMP-9 and othersconfounding variable to plasma hs-TnT. The last we performedANCOVA analysis to determinethe difference of strengthassociation between plasma MMP-9 and hs-TnT in STEMI orNSTEMI group. Data analysisusing SPSS 17 with significantP<0.05.RESULTSA total of 62 samples wereincluded in this study. Matrixmetalloproteinase-9 (MMP-9) andhs-TnT plasma levels 48 hoursafter AMI onset were measured.The samples also got treatmentbased on ACS guideline fromPERKI 2014.12Subject characteristicsTotal 62 patients with AMIwere included, 50 males (80.6%)and 12 female (19.4%), with meanage 57.9 (SD 10.7) years. Thirtyfive patients were diagnosed withSTEMI (56.5%) and 27 patientswith NSTEMI (43.5%) with meanonset between 6.74 (SD 3.8) hours.Cholesterol levels were between110-327 mg/dL, LDL levels werebetween 56.3-244.5 mg/dL, HDLkadar MMP-9 dengan hs-TnT pada penderita IMA dengan kekuatan korelasi sedang dan secarastatistik signifikan (r= 0.507; Y= - 650.6 + 46.7(X1); P<0.0001); kadar MMP-9 plasma dan awitan IMAmempengaruhi kadar hs-TnT plasma pada penderita IMA dengan formula persamaan Y = - 815.0 +46.5(X1)+ 20.7(X2); (â MMP-9=46.5(IK 95% : 24.7 sampai 68,4); P<0.0001; â awitan IMA=20.7(IK 95%: 2.1 sampai 39.4); P=0.030). dan kekuatan hubungan kadar MMP-9 dengan hs-TnT pada kelompokSTEMI lebih besar daripada NSTEMI. [MEDICINA 2015;46:22-27].

INHIBITOR IN HEMOPHILIA K Yantie, Veny; K, Ariawati
Medicina Vol 43 No 1 (2012): Januari 2012
Publisher : Medicina

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Hemophilia is an X-linked recessive disorder which is believed to affect approximately one in 5000-10.000 male birth. An inhibitor is a type of antibody. In hemophilia patients type A, B, and C are directly destroy factor VII, IX, and XI. The incidence of antibody development in hemophilia A is between 20% and 40%, hemophilia B inhibitors only 1 to 6 %. The presence of an inhibitor is usually confirmed using a specific blood test called the Bethesda inhibitor assay. The treatment of hemophilic bleeding in a person with an inhibitor can be a challenging experience. Patients hemophilia with inhibitor have poor prognostic. (MEDICINA 2012;43:31-36).

Penanganan pseudokista pankreas karena trauma Margareth, Sessy Arie; Wiargitha, I Ketut; Sudiasa, I Ketut
Medicina Vol 47 No 1 (2016): Januari 2016
Publisher : Medicina

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Kista pankreas karena trauma adalah kasus yang jarang terjadi dengan angka kejadian 5% pada kasus trauma. Gejala kista pankreas muncul tiga minggu pasca-trauma sehingga sering terjadi keterlambatan penanganan. Lebih dari 75% kista pankreas merupakan kista semu (pseudokista), dindingnya tidak dibatasi oleh epitel, melainkan jaringan ikat. Diagnosis kista pankreas ditegakkan melalui anamnesis, pemeriksaan kadar amilase, ultrasonografi (USG) abdomen, dan computed tomography (CT) scan abdomen. Penanganan konservatif dilakukan bila kista dapat beresolusi sendiri. Operasi eksisi atau drainase interna dilakukan pada kista yang kecil. Kista yang besar ditatalaksana dengan sistogastrostomi, sistojejunostomi, atau sistoduodenostomi. Drainase eksternal dilakukan bila kista ruptur atau terinfeksi. Anak lelaki usia 9 tahun datang dengan keluhan utama nyeri perut kiri atas yang menjalar ke punggung dan menetap. Hal ini terjadi setelah penderita mengalami trauma pada perut. Pada pemeriksaan fisis didapatkan perut distensi, teraba masa lunak, dan mobile pada epigastrium. Pemeriksaan laboratorium menunjukkan peningkatan kadar amilase serum. Pemeriksaan USG dan CT scan menunjukkan gambaran kista pankreas. Pada saat operasi didapatkan kista pankreas di daerah kauda pankreas dan dilakukan sistojejunostomi. Lima hari pasca-operasi penderita pulang tanpa komplikasi. Evaluasi 6 bulan pasca-operasi, penderita tampak membaik dengan kadar amilase normal. Pancreatic cyst is a rare case. The incidence rate is 5% on trauma case. The symptom persist three weeks after trauma, causing delayed management. More than 75% pancreatic cysts are pseudocysts, where the wall is not confined by epithelial cells but by connective tissue. Diagnosis can be established by history taking, amylase examination, abdominal ultrasonography, and computed tomography scan of abdomen. The management is conservative if the cyst resolutioned by itself. Cystic excision or internal drainage was done if the cyst is small. Big cysts usually treated with cystogastrostomy, cystojejunostomy, or cystoduodenostomy. External drainage was done if the cyst ruptured or infected. A 9-year-old male with chief complaint pain on the upper left abdominal area that spread to the back and persistent, occurred three weeks after abdominal trauma. On abdominal physical examination, there was abdominal distension and palpable mobile mass on epigastrium. Laboratory examination showed increased of serum amylase. Abdominal USG and CT scan showed pseudocyst pancreas. During surgery, pancreatic cysts on caudal of the pancreas was found, and cystojejunostomy was done. There was no complication five days after the operation. Six months follow up after the surgery, patient is getting better with normal serum amylase.

KAJIANTEKNOLOGI PIEZO ESWL(EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY) RICHARD WOLF TYPE PIEZOLITH 3000 DIBANDINGKAN ALAT ESWL TYPE YC-9200 ESWL DAN B ULTRASOUND SYSTEM Widiana, I Gde Raka
Medicina Vol 45 No 1 (2014): Januari 2014
Publisher : Medicina

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Telah dilakukan kajian teknologi di rumah sakit umum pusat Sanglah untuk menentukan apakah intervensi ESWL baru dibandingkan ESWL lama lebih cost-effective, bila dipakai mengganti alat lamabila ditinjau dari perspektif medik, sosial dan ekonomi. Dilakukan pertemuan yang dihadiri oleh pihak terkait untuk menentukan kajian HTA pada alat ESWL baru. Pertemuan itu dihadiri oleh Ketua HTA, Direktur Medik, Kepala Bidang Pelayanan, Kepala dan Staf Divisi Urologi, dan StafDivisi Radiologi. Pertemuan itu bertujuan untuk menjawab apakah ESWL merek Richard Wolf type Piezolith 3000 dengan system In-line USG, 3000 shock per pasien buatan Jerman dapat menggantiESWL lama buatan Cina type YC-9200 ESWL dan B Ultrasound system. Dilakukan pencarian di internet pada sumber primer dan sekunder MIDLINE, COCHRANE, dan Highwire. Dengan data dari3 penelitian asli yang didapat dari pencarian, dibuat model pohon keputusan pemakaian piezolith ESWL dibandingkan ESWL lama untuk melihatkemanjuran dan keamanan dibandingkan biaya danaplikasinya pada pasien batu ginjal di rumah sakit Sanglah Denpasar, dengan menilai aspek perspektifm ekonomi dan social, dihasilkan utility benefitrelative sebesar 0.40. Dengan melakukan adjustmentterhadap asumsi umur harapan hidup pasien ( 65 tahun) dengan batu ginjal maka pemakaian ESWL baru ini menghasilkan peningkatan relatif umur harapan hidup pasien sebagai keuntungan ekonomisocial yang dikenal sebagai quality adjusted life years (QALY).Disimpulkan bahwa, ESWL piezoelectric Richard Wolf type Piezolith 3000 dengan system In-line USG, 3000 lebih cost-effective dari perspektifekonomi kesehatan dibandingkan ESWL lama dengan 3 bulan QALY gain dan denganbiaya (cost) 1,5 juta rupiah per bulan QALY gain. [MEDICINA 2014;45:9-12]

PERANAN ANTIOKSIDAN PADA OLAHRAGA Ngurah, IB
Medicina Vol 38 No 1 (2007): Januari 2007
Publisher : Medicina

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GANGGUAN PENDENGARAN REVERSIBEL PADA ANAK DENGAN MENINGITIS BAKTERI Ariati, Ni Made Yeni; Suardana, Wayan
Medicina Vol 46 No 2 (2015): Mei 2015
Publisher : Medicina

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Gangguan pendengaran sensorineural adalah jenis gangguan pendengaran dengan penyebab utamaterletak pada saraf vestibulokoklear, telinga bagian dalam atau batang otak. Meningitis bakteri atauvirus mempunyai angka insidens yang tinggi untuk menyebabkan kerusakan permanen pada labirin,terutama pada penderita yang masih muda. Dilaporkan satu kasus gangguan pendengaran yangreversibel pada anak lelaki, 6 bulan dengan diagnosis meningitis bakteri. Pada penderita dilakukandua kali pemeriksaan pendengaran yang meliputi pemeriksaan timpanometri, otoacoustic emissiondan brainstem evoked response audiometry. Dari pemeriksaan pertama disimpulkan, penderitamengalami tuli sensorineural derajat sedang kanan dan tuli sensorineural derajat ringan kiri. Padapemeriksaan kedua yang dilakukan tiga bulan kemudian diperoleh simpulan pendengaran penderitadalam batas normal. [MEDICINA 2015;46:122-5].Sensorineural hearing loss is a type of hearing loss mainly caused by impairment in thevestibulocochlear nerve, the inner ear, or central processing centers of the brain. Bacterial or viralmeningitis caused high incidence of permanent damage to the labyrinth, especially in the very youngage patients. A case of reversible hearing loss in a 6 months old baby, who was diagnosed by bacterialmeningitis has been reported. Hearing examination was performed twice including: timpanometry,otoacoustic emission, and brainstem evoked response audiometry. The first examination concludedthat the patient had moderate sensorineural hearing loss on the right ear and mild sensorineuralhearing loss on the left ear. The second examination was performed three months later and concludedbilateral normal hearing. [MEDICINA 2015;46:122-5].

THE EFFICACY OF FORK TYPE HOE AND SINGLE BLADE HOE FOR HOEING WET RICE FIELD LAND IN POH MANIS VILLAGE, DENPASAR MUNICIPALITY N, Adiputra; DP, Sutjana
Medicina Vol 40 No 1 (2009): Januari 2009
Publisher : Medicina

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Balinese farmer in doing their daily activities in agricultural work still relay on their hand tools. One of the hand tools used is the hoe. In fact there are two type of hoe, fork type and single blade hoe. The single blade hoe is very rare used for hoeing in wet rice field. Farmer chose the fork type one. Therefore, a study was conducted to compare the efficacy of those two hoes. Twenty farmers were participated voluntarily. They were divided into two groups evenly. The first group hoeing using the fork type hoe, and the second group using the single blade one. They hoeing in the same area of rice field (wet rice field) from 07.00 until 12.00. The parameter measured were resting and working heart rate, product and productivity, musculoskeletal disorders, and the deep of soil hoed. The student-t test was applied to analyses the results. The results found are: a) the working heart rate, the product and productivities were 111.1 ± 14.66 bpm; 127.74 ± 9.15 m2; 0.54 ± 0.00 and 110.2 ± 13.88 bpm; 126.88 ± 8.79 m2; 0.54 ± 0.00 for first group and second group, respectively. The MSD and the deep of soil hoed were 4.50 ± 1.97; 30.0 ± 2.54 cm and 4.45 ± 2.03; 29.64 ± 1.75 cm for both groups. There are no significant different found statistically. Therefore, it is concluded that the efficacy of single blade hoe is similar to the fork type hoe for hoeing the wet rice field in the tropic. For further study it is recommended to use these two hoes for hoeing in the dry soil.[MEDICINA 2009;40:43-6].

ORALLY LACTATE CALCIUM AND SWIMMING DECREASE OSTEOCLAST AND INCREASE OSTEOBLAST IN RADIAL PERIMENOPAUSAL MICE (MUS MUSCULUS) BONE **, Muliani
Medicina Vol 43 No 3 (2012): September 2012
Publisher : Medicina

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Calcium and moderate intensity swimming exercise can increase bone density. The aim of this research is to see the effect of orally calcium consumption and swimming activity to decrease osteoclast and increase osteoblast in radial perimenopausal mice (Mus musculus) bone. Pretest and pos#est control group design was used in this research. Research subject used 15-16 aged mice (Mus musculus) which divided into 4 groups (each group consisted of 13 mice), that was control, lactate calcium, swimming and lactate calcium and swimming. Treatment was given 90 days. This study showed a significant difference of the mean of the pos#est osteoblast between control and experimental groups (P<0.05). There was no significant difference between lactate calcium and swimming groups (P>0.05). Enhancement of osteoblast mean in combination group was greater than the other experimental groups. There was a significant difference of the mean of the pos#est osteoclast between control and experimental groups (P<0.05), without significant difference between lactate calcium, swimming groups and combination of lactate calcium and swimming group (P>0.05). Conclusion: either lactate calcium or swimming decreases osteoclast and increases osteoblast of the mice but the osteoblast enhancement will be bigger when they are given together at once

seorang penderita tuberkulosis diseminata dengan komplikasi penyakit ginjal kronis Koncoro, Hendra; Kandarini, Yenny; Sudhana, Wayan; Widiana, I Gde Raka
Medicina Vol 47 No 3 (2016): September 2016
Publisher : Medicina

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Tuberkulosis diseminata dapat melibatkan berbagai organ dan secara klinis timbul dengan bermacam-macam tanda dan gejala.Penyakit ginjal kronis merupakan salah satu komplikasi yang disebabkan oleh penyebaran hematogenik Mycobacterium tuberculosis ke traktus urogenital. Diagnosis dini dan inisiasi terapi yang tepat merupakan hal penting dalam pencegahan komplikasi lanjut penyakit ini. Dilaporkan sebuah kasus dengan tuberkulosis diseminata yang memperlihatkan keterlibatan paru dan organ ekstra-paru. Kasus ini memperlihatkan tuberkulosis paru, serviks, dan urogenital yang dikonfirmasi dengan pewarnaan sputum basil tahan asam, biopsi serviks, dan biopsi buli buli. Pewarnaan sputum basil tahan asam menunjukkan hasil 3+, sedangkan biopsi serviks dan buli buli menunjukkan radang kronik granulomatosa dengan multinucleated giant cell tipe Langhans. Kadar blood urea nitrogen (BUN) 11 mg/dL dan kreatinin serum 2,58 mg/ dL dengan hidronefrosis ringan kiri pada saat dirawat. Setelah diagnosis ditegakkan, pasien diterapi dengan obat anti-tuberkulosis dan membaik dengan kadar BUN 13,55 mg/ dL dan kreatinin serum 0,9 mg/ dL setelah satu bulan terapi.[MEDICINA.2016;50(3)63-70]

ADENOKARSINOMA DUKTAL PANKREAS Widityasari, Diah; Dewi, IGA Sri Mahendra
Medicina Vol 45 No 3 (2014): September 2014
Publisher : Medicina

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Kanker pankreas merupakan penyebab tersering keempat dari kematian akibat kanker dan mengenaiusia dekade enam sampai delapan di negara maju, tetapi jarang terjadi di Indonesia. Kasus inidibahas karena mengenai usia lebih muda. Penderita laki-laki usia 37 tahun datang dengan keluhanmata berwarna kuning dan gatal-gatal seluruh tubuh. Pemeriksaan laboratorium didapatkan kadarbilirubin direct 12,51 mg/dL, bilirubin indirect 9,74 mg/dL, bilirubin total 22,25 mg/dL, SGOT 77,10 U/L, SGPT 115,40 U/L dan CA19-9 > 500.00 u/L. Ultrasonography dan computerized tomography scanningmenunjukkan pembesaran kaput pankreas, obstruksi intra dan ekstrahepatik. Pemeriksaan makros-kopis, berupa tumor kaput pankreas ukuran 3x2,5x1 cm, putih kekuningan, padat kenyal, batas tidaktegas, meluas ke duodenum. Mikroskopis, tumor terdiri dari struktur kelenjar dan glandular irregularinfiltratif di antara parenkim pankreas, produksi musin berkurang, inti pleomorfik sedang, anak intiprominen, mitosis 9/10LPB. Tampak stroma desmoplastik dan invasi perineural. Pemeriksaanhistokimia PAS dan imunohistokimia CK7 dan CK19 positif. Pasien didiagnosis adenokarsinomaduktal grade II berdasarkan temuan klinis, laboratorium, radiologis, makroskopis, mikroskopis yangkhas serta pemeriksaan histokimia dan imunohistokimia. [MEDICINA 2014;45:188-192].

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