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CROSSLINK TELOPEPTIDA C-TERMINAL (CTx) SEBAGAI PETANDA AKTIVITAS SEL OSTEOKLAS PADA OSTEOPOROSIS PASCA MENOPAUSE DEFISIENSI ESTROGEN Kawiyana, I Ketut Siki
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Osteoporosis occurs due to the increase of active osteoclastic bone resorption activity. This condition favors for bonemass decreased. The examination of Crosslink Telopeptida C-Terminal (CTx)serum concentration is a good indicator to determineosteoclastic bone resorption activity. The finding of that biochemical substance in serum indicates that there is increase ofosteoclast cell activity. The aim of the study was to prove that in estrogen deficient post-menopausal women, the CTxwas higherin the osteoporosis compared than the non-osteoporosis. The study was an analytic-observational study in case-control design,which was done at Sanglah General Hospital, Denpasar. The sample size was 41 case subjects (osteoporosis) and 41 controlsubjects (non-osteoporosis) using paired case-control sample size formula. The t-paired test result were: CTx serum concentrationwas higher significantly in case compared than control (0.60 ± 0.22ng/mL vs 0.46 ± 0.16ng/mL; p = 0.004). Therefore fromthe study we may conclude that: (1) CTx was higher in the osteoporosis compared than the non-osteoporosis in estrogen deficientpost-menopausal women. (2) Osteoclastic bone resoprtion activity was higher in the osteoporosis compared than the non-osteoporosisin estrogen deficient post-menopausal women

MIELOMA MULTIPEL TIPE IgA: LAPORAN LIMA KASUS Bakta, I Made
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Five cases of IgA MM (IgA multiple myeloma) have been reported. All cases showed clinical features of MM ingeneral. Increase of immunogloblulin fraction, characteristically showed M-spike in beta region, associated with high level ofIgA in serum. Plasma cell > 10% in marrow were found, with end-organ lesions, known as CRAB (hypercalcemia, renal failure,anemia and bone lesions). Anemia and bone lesions have been found in all cases. All cases fulfiled diagnostic criteria of Kyle andGreip and International Multiple Myeloma Working Group, as well. Stage III of Durie and Salmon staging system was found inall cases. Only one case could be classified in a newer staging system, International Staging System. Case no. 5 could be classifiedas stage II. Conventional regiment with melphalan and prednison has been given to the cases. Partial remission has been achievedin case no.1, no. 4, and no. 5.It could be concluded that the clinical features of IgA MM are the same as IgG MM. In laboratory findings, M-spike wasfound in beta-region in serum protein electrophoresis (SPE) of all IgA MM cases, other than in gamma-region as in IgG MM. Thelevel of IgA in serum was also higher than IgG.

KORELASI ANTARA DERAJAT GASTRITIS DAN RASIO PEPSINOGEN I/II PADA PENDERITA GASTRITIS KRONIS Dary, I Wayan; Wibawa, I Dewa Nyoman
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Chronic gastritis is a histopathological entity characterized by chronic inflammation of the stomach mucosa. Chronicgastritis tend to damage stomach mucosa and be atrophy sequence to change gastric physiology. Pepsinogen (PG) can be used asÔserologic biopsy,Õ as clinical application for evaluating gastric inflammations. The different cellular origins of PG I and PG II areimportant because alteration in their serum concentration can be correlated with some histological gastric anomalies. To determinethe correlation between grade of gastritis and PG I/II ratio (PGR) in chronic gastritis patients, we conducted an analyticcross sectional study in 64 gastritis patients whom enrolled consecutively. Gastric mucosal of dyspeptic patients who had uppergastrointestinal endoscopy biopsy 2 at anthrum and 2 at corpus were examined histologically using the Updated Sydney System(USS) by two pathologists independently, and also the serum examined for PG I, PG II, and IgG H. pylori. Degree of gastritis wascounted with the USS method. Pepsinogen examination used ELISA method, however IgG H. pylori examanition usedimmunochromatographic test (ICT) method with local reagen. H. pylori positive if serologically H. pylori positive and or histologicallyH. pylori positive. Interobserver agreement for histopatology abnormalities were examined by using kappa test. Thedifference PGR and severity of gastritis between subjectswith H. pylori positive and H. pylori negative were identified by usingMann-Whitney U test. Correlation between the severity of gastritis and PGR was identified by using spearmanÕs test and theeffect of total USS score and H. pylori to PGR was identified by using dummy regression, also to know the effect of PGR and H.pylorito total USS score was identified by using dummy regression. Pvalue of less than 0.05 was considered statistically significant.There were 64 chronic gastritis whom mean age 45.9 ± 15.5 year, consisted of 44 male and 20 female. The level of PG I218.70 (53,90 Ð 530.00) mg/L, PG II 15.72 (2.84 Ð 59.25) mg/L, dan PGR 12.66 (28.97 Ð 5.80). Interobserver agreement of gastrichistologic examanation shown moderate to substantial criteria (k = 0.590 Ð 0.795) with polymorphonuclear activity k = 0.795,glandular atrophy k = 0.591, density of H. pylori k = 0.727, chronic inflammation k = 0.629, and intestinal metaplasia k = 0.778.The frequency of abnormalities gastric mucosa as infected H. pylori 28.1%, inflammation 100.0%, polymorphonuclear activity22.8%, atrophy 37.5%, and intestinal metaplasia 6.2%. Total USS score from 1 to 9 and most of them had score 1 and 2 withfrequency 17 (26,6%) and 15 (24,4%) respectively. Subjects with H. pyloriinfection had lower PGR than uninfected subjects(11.2 ± 4.3 mg/L vs 15.0 ± 5.1 mg/L, p = 0.001; Mann-Whitney U test), and also subjects with H. pyloriinfection had higherseverity of gastritis than uninfected subjects either degree of inflammation, activity polymorphonuclear, and atrophy (p = 0.000,p = 0.004, p = 0.041 respectively; Mann-Whitney Utest). There was significant inversed correlation between total USS score andPGR (r = -0.470, p < 0.0001; SpearmanÕs tes). Significant effect of total USS score and positivity H. pylori to PGR (F = 7.015, p = 0.002; dummy regression), but only coefficient of total USS score significantly (t = -2.030, p = 0.047), however positvity H.pylori didnÕt influence PGR significatly (t = -1.199, p = 0.235). Total USS score influences PGR as much as 15,4% (adjusted R2= 0.154, F = 12.504, p = 0.001; linier regression) with regression coefficient -0,933 (t = -3.536, p = 0.001). H. pylori serology andPGR can be used to determine total USS score significantly (F = 9.498, p < 0.0001; dummy regression) and both of regressioncoefficient were significant (t = -3.417, p = 0.001; t = 2.360, p = 0.021 respectively; dummy regression) how ever can be madeÔserologic biopsyÕ with formula Ôtotal USS score = 6.786-0.169.PGRÕ for H. pylori positive subjects and Ôtotal USS score = 5.258Ð 0.169.PGRÕ for H. pylori negative subjects. In conclusion that there was a significant inversed correlation between total USSscore and PGR, formula Ôserologic biopsyÕ to determine total USS score were Ôtotal USS score = 6.786 Ð 0.169.PGRÕ for H. pyloripositive subjects and Ôtotal USS score = 5.258 Ð 0.169.PGRÕ for H. pylori negative subjects.

PATOFISIOLOGI DAN PENATALAKSANAAN NEFROPATI RADIOKONTRAS Sanjaya, Surya; Suwitra, Ketut
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Contrast induced nephropaty (CIN) was recognized as one of the leading causes of acute renal failure in patient withrenal insufficiency, diabetes mellitus, volume depletion and low cardiac out put. The incidence of CIN is estimated to be 1 Ð 2%in the general population, but the relative risk is greatly increased in diabetics, the elderly, and those with intrinsic renal disease,congestive heart failure, and dehydration. CIN is defined by an increase in creatinine 0.5 mg/dL or 25% from baseline that occurs2 Ð 3 days after contrast administration. A reduction in renal perfusion caused by a direct effect ofcontrastmedia on the kidneyand toxic effects on the tubularcells are generally accepted as the main factors in the pathophysiologyof contrastmedium inducednephropathy. Pathological changes induced by contrastmedium are epithelialcell vacuolization, interstitial inflammation andcellular necrosissuggest a direct toxic effect of contrastmedia on renal tubularepithelial cells. Several measures have beenrecommended to prevent contrastinduced nephropathy,which include: volume expansion, hydrationwith intravenous administrationof normal saline, infusion of mannitol, theophylline, dopamine,acetylcysteine, use of iso-osmolar non-ionic contrastmediainsteadof low-osmolarnon-ionic or high-osmolar ionic contrast,haemofiltration rapidly after contrast administration, injectionofsmall volume of contrast medium, gadolinium based contrastmedia

HUBUNGAN ANTARA PERUBAHAN VOLUME DARAH RELATIF DENGAN EPISODE HIPOTENSI INTRADIALITIK SELAMA HEMODIALISIS PADA GAGAL GINJAL KRONIK Agustriadi, Ommy; Suwitra, Ketut; Raka Widiana, Gde; Sudhana, Wayan; Sidharta Loekman, Jodi; Kandarini, Yenny
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Intradialytic hypotension (IDH) is a common complication in chronic hemodialysis (HD) patients, in turn would increase morbidity and mortality. Relative blood volume changes during HD play a role in IDH episode. Those changes can be assessed by total plasma protein measurement before and after HD. To determine relationship between relative blood volume changes (assessed by percentage of total plasma protein changes during HD) and IDH episode during HD in chronic renal failure, an analytical cross-sectional study was perferomed in 51 patients (28 males and 23 females, age 47.8 ±11.6 years) underwent chronic HD at Hemodialysis Unit of Sanglah Hospital Denpasar. Data were collected during single HD session. Blood pressure was measured every 30 minutes and relative blood volume changes assessed by measuring percentage of total plasma protein changes during HD. Among them, IDH episode experienced in 10 (19.6%) patients. Logistic regression analysis revealed a strong and significant relationship between relative blood volume changes and IDH episode during HD in chronic renal failure (Beta = 0.29; OR = 1.35; CI 95%: 1.1 - 1.6; p < 0.01) and it was found that every 1% changes in relative blood volume, would increase risk of hypotension episode by 35%. This relationship was still strong and significant (Beta = 0.46; OR = 1.58; CI 95%: 1.11 -2.25; p = 0.01) after adjusted by hemoglobin levels, intradialytic body weight changes, use of antihypertensive medi¬cations and diabetes melitus. Using ROC curve, found that optimal cut of point of intradialytic total plasma protein changes to predict an IDH episode during HD was 5.56% with 90.0% sensitivity and 80.5% specificity (95% CI: 0.83-0.99; p < 0.01). Our data revealed a strong and significant relationship between intradialytic relative blood volume changes assessed by intradialytic total plasma protein changes and IDH episode during HD in chronic renal failure.

PENGARUH INSULIN TERHADAP FUNGSI KARDIOVASKULAR Ridwan, Muhammad; Gotera, Wira
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Insulin is an anabolic hormone responsible for regulation of glucose metabolism and signals for storage and usage ofmany fundamental nutrients such as glucose, amino acids, and fatty acids. Its effects on cardiovascular function, reveal widerearly-known insulin actions, are based on the balance between its NO-dependent vasodilator action and endothelin-1-dependentvasocontriction action regulated by signals through phosphatidylinositole 3-kinase (PI3K) and mitogen-activated protein kinase(MAPK)-dependent pathways on vascular endothelial cells. On insulin resistance setting, signal perturbances of PI3K pathwayand enhanced signals through MAPK pathway are conditions underlying link between metabolic disorders and cardiovasculardiseases. Insulin also has antiinflammatory effects by suppressing expression of ICAM-1, MCP-1, NF-kB, MMP-9 and CRP. Onthe heart, insulin increases contractility and plays important roles in maximazing heart glucose uptake particularly in stress states.In addition, insulin plays a role in physiologic heart growth through Akt pathway. However, chronic exposure of insulin isassociated with ventricular disfunction. In term of cardiovascular function, insulin is known to increase peripheral blood flow danto decrease peripheral resistance, so that results in enhanced cardiac output without significant changes in blood pressure.Not only can improved insulin action repair glucose metabolism, but also improve risks underlying atherosclerosis andcardiovascular complications of diabetes. In 2007, European Cardiac Society (ESC) has recommended intensive insulin usage totightly control blood glucose in order to improve adult critically ill and heart surgery patient mortality and morbidity

HUBUNGAN ANTARA KONSENTRASI ASAM URAT SERUM DENGAN RESISTENSI INSULIN PADA PENDUDUK SUKU BALI ASLI DI DUSUN TENGANAN PEGRINGSINGAN KARANGASEM Ngurah Wises, Ida Bagus; Suastika, Ketut
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Elevated serum uric acid concentrations are commonly seen in association with individual cardiovascular risk factorsuch as hypertriglyseridemia, hypertension, obesity, and hyperglycemia, a cluster that, when found together in the same person,characterizes the so-called metabolic syndrome. The original conceptualization of this syndrome was on the basis of resistance tothe actions of insulin. The reduction of endothelial nitric oxide bioavailability and the production of reactive oxygen species byuric acid may be the mechanism for insulin resistance. Otherwise insulin has a physiological action on renal tubules by stimulatingreabsorption of sodium and urate, resulting an increase in serum uric acid levels. In this condition, HOMA-IR was the modelwhich is a convenient means of evaluating insulin resistance.To know the association between serum uric acid concentration and insulin resistance, a cross sectional analytic studywas conducted on Balinese in Tenganan region between Desember 2007 and January 2008. The study involved 80 participantsage of 18-65 years old, agree to participate by informed consent. Serum concentration of insulin was measured by immunoassaymethod, plasma glucosa, serum uric acid, HDL-cholesterol, trigycerides, serum creatinin, were determined by enzymatic procedureafter overnight fast. Descriptive statistic analysis on numeric data presented as mean ± SD, nominal and ordinal data inproportion. Inferential statistic analysis with bivariate KendallÕs tau correlation and simple logistic regression was performed andmultiple logistic regression was used to know the independency of its association.Of 80 eligible samples, 39 (49%) men, and 41 (51%) women, mean age was 41.73 ± 12.41 yo, mean of waist circumferencewas 77.99 ± 10.91 cm, mean of serum uric acid concentration was 5.49 ± 1.38 mg/dL, mean of plasma glucosa was 92.04± 8.79 mg/dL, median of insulin was 2.70 (2.00 Ð 17.90) mIU/mL, median of HOMA-IR was 0.685 (0.38-4.10), mean of HDLcholesterol was 59.19 ± 14.01 mg/dL, and median of triglycerides was 122.50 (48 Ð 369) mg/dL. In univariate analysis, theinsulin resistance were positively correlated with serum uric acid, waist circumference, and triglycerides (r= 0.234; P = 0.003),(r = 0.269; P = 0.001), and (r = 0.153; P = 0.046) respectively and negatively with HDL cholesterol (r = -0.297; P = 0.009). Inmultivariate analysis with multiple logistic regression both the 2nd tertile of uric acid (4,7 Ð 6,6 mg/dL) and waist circumferencewere independently associated with the insulin resistance (PR 3.97; IK 95% : 1.273 Ð 12.386; P = 0.018), and (PR 5.79; IK 95%: 1.417 Ð 23.650; P = 0.014) respectively. Conclusion: There is association between serum uric acid concentration and insulinresistance, and both the 2nd tertile of uric acid and waist circumference are independently and significantly associated with insulinresistance.

OSTEOPOROSIS PATOGENESIS DIAGNOSIS DAN PENANGANAN TERKINI Kawiyana, I Ketut Sik
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Osteoporosis is a bone metabolic disease, which is characterized by decreased bone mass due to reduced bone matrixand mineral, accompanied by micro architecture derangement of the bone tissue. Hence, in this disorder the bone has the tendencyto fracture due to low bone quality. Cell which responsible for bone formation is osteoblast, whereas osteoclast is responsible forbone resorption. In osteoporosis, bone turn over is abnormalwhichbone resorption is greater than bone formation. Thereforedirect factors for osteoporosis are number and activity of osteoclast in resorbing bone, and they are influenced by mediators andthe mediators depends on estrogen level. Number and activity of osteoclast cell are greater than number and activity of osteoblastcell in osteoporosis. This imbalance causes decreasing bone mass. The pathogenesis of osteoporosis has been discussed by showingthe recent theories related to increase of osteoclast cellÕs differentiation and activity due to: estrogen hormon deficiency,cytokine factor and axial loading. Several means in diagnosing the risks for osteoporosis and itÕs current managements based onitÕs pathogenesis have been mentioned too.

WISATAWAN ASING DENGAN PENYAKIT INFEKSI SALURAN NAFAS YANG DIRAWAT DI RSUP SANGLAH - DENPASAR - BALI Ngurah Ra, Ida Bagus; Sajinadiyasa, I Gede Ketut
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Each year 1 billion passengers travel by air, and over 50 million people from industrialized countries visit the developingworld and Bali is one of their choice. Travelers may be exposed to variety of pathogens and risk, and 20 to 70 percent of peoplereport some health problems while traveling. After diarrhea, respiratory infection is the most common illness affecting travelers.The aim of the study was to now characteristic foreign patients with respiratory infections hospitalized at Sanglah GeneralHospital. We have done retrospectif study to medical record of foreign patients hospitalized at Sanglah General Hospital onJanuary 2004 Ð June 2008.We had 17 patients with 13 (76.47%) Pneumonia and 4(23.53%) COPD with acute exacerbation, 13man and 4 woman, the mean of age 55.33 years old and more patients ³ 60 years old. Country of origin of patients mostlyAustralia, US, Germany, Nederland. Patients outcome; improve 14 (82.4%) and die 3 (17.6%), mean length of stay 4.35 days.Two die patients more than 60 years old and one below than 60 years but with coronary heart disease. The conclusion of this studyis respiratory infection who hospitalized at Sanglah General Hospital are dominated by pneumonia and eldery, possibility ofinfected respiratory disease seem higher in longer flight

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Kota denpasar,

Bali

INDONESIA