Factors Associated with All-Cause 30-Day Mortality in Indonesian Inpatient COVID-19 Patients at Cipto Mangunkusumo National General Hospital.

Introduction: Indonesia, as a developing country, has limited data on the factors associated with 30-day mortality in COVID-19 patients in Indonesia. As a matter of fact, study analyzing factors associated with 30-day mortality of COVID-19 infection in Indonesia has never been conducted. This study aims to fill this gap in the literature by conducting a large-scale analysis of factors associated with 30-day mortality in COVID-19 patients in Indonesia. Method: This study employed a single-center retrospective cohort observational design, and was conducted at Cipto Mangunkusumo National General Hospital between the years 2022 and 2023. Sampling was conducted using the consecutive sampling method. The study included patients aged 18 years and above who had been confirmed to have COVID-19 infection. Survival analysis was conducted using Kaplan-Meier and multivariate Cox regression analysis. Result: Our study included a total of 644 patients, with 120 patients (18.6%) expiring within 30 days. In the multivariate analysis using the backward Wald method, severe COVID-19 (HR: 7.024; 95% CI: 3.971-12.744; p value: <0.0001), moderate COVID-19 infection (HR: 1.660; 95% CI: 1.048-2.629; p value: 0.031), liver cirrhosis (HR: 3.422; 95% CI: 1.208-9.691; p value: 0.021), female sex (HR: 1.738; 95% CI: 1.187-2.545; p value: 0.004), old age (HR: 2.139; 95% CI: 1.279-3.577; p value: 0.004), high leukocyte (HR: 11.502; 95% CI: 1.523-86.874; p value: 0.018), high NLR (HR: 1.720; 95% CI: 1.049-2.819; p value: 0.032), high CRP (HR: 1.906; 95% CI: 1.092-3.329; p value: 0.023), high procalcitonin (HR: 3.281; 95% CI: 1.780-6.049; p value: 0.001), and high creatinine (HR: 1.863; 95% CI: 1.240-2.800; p value: 0.003) were associated with 30-day mortality from COVID-19 infection. Subgroup analysis excluding cancer patients showed that age, D-Dimer, CRP, and PCT were associated with 30-day mortality in COVID-19 patients, while steroid therapy is protective. Conclusions: This study finds that COVID-19 severity, liver cirrhosis, sex, age, leukocyte, NLR, CRP, creatinine, and procalcitonin were associated with COVID-19 mortality within 30 days. These findings underscore the multifactorial nature of COVID-19 infection mortality. It is important, therefore, that patients which exhibit these factors should be treated more aggressively to prevent mortality.

CXCL8, MMP1, MMP2, and FN1 Gene Expression and Tumor Extension in Nasopharyngeal Cancer Patients: A Cross-sectional Study.

BACKGROUND: There are correlations between tumor staging, lymph node involvement, and patient survival in Nasopharyngeal cancer (NPC) which is one of the most common types of cancer in Indonesia.  The inflammation process plays a role in tumor progression over the long term and this marked by increased proinflammatory cytokine and gene overexpression. This study aims to identify differentially expressed genes (DEGs) in NPC using T and N staging. METHODS: This is a cross-sectional study of NPC patients in Cipto Mangunkusumo, Jakarta, between 2018 and 2022. DEGs were identified based on the amount of mRNA detected on paraffin blocks with a 1.5- to -1.5-fold change and an adjusted p-value of <0.05. RESULTS: We included 48 subjects. The mean age of subjects was 47.75 (10.48) years, and most were male (77.1%). Non-keratinized squamous cell carcinoma was the most common histopathology type. Differences in the tumor size of the T4 and non-T4 in metastatic (33.3%) group when compared to the non-metastatic (37.5%) group were insignificant (p = 0.763). The proportion of N3 subjects in the metastatic vs non-metastatic group was different significantly (83.3% vs. 50%, p = 0.030). Gene expression analysis showed that C-X-C motif ligand 8 (CXCL8), matrix metalloproteinase-1 (MMP1), matrix metalloproteinase-1 (MMP2), and fibronectin-1 (FN1) genes of the T4 and non-T4 group to be different significantly. CONCLUSION: There was significant finding in the N3 subjects of the metastatic and non-metastatic groups. The DEGs of CXCL8, MMP1, MMP2, and FN1 were statistically significant in the T4 when compared to the non-T4 group.

Correlation between branched-chain amino acids intake and total lymphocyte count in head and neck cancer patients: a cross-sectional study.

BACKGROUND: Cellular immunity as reflected by total lymphocyte count (TLC) has been proven to be related to overall survival rate cancer patients. Lymphocyte proliferation is regulated, to some extent, by nutritional factor. Branched chain amino acid (BCAA) is documented as one of numerous nutrients that play important role in lymphocyte proliferation through its effect on protein synthesis and DNA replication. Many studies describe the correlation between BCAA and TLC in hepatic cancer patients. This study emphasized the observation of that links in head and neck cancer patients. METHODS: Eighty-five subjects were included in final analysis, aged 18-75, mostly male, with head and neck cancer who had not received treatment participated in this cross-sectional study at the Dr. Cipto Mangunkusumo General Hospital's radiation and medical haematology oncology clinic. The BCAAs intake was assessed using a semi-quantitative food frequency questionnaire. Flow cytometry method was used to quantify TLC. RESULTS: Overall, the subjects' nutritional status mostly was considered normal, with the median intake of 1505 (800-3040) kcal/day of energy and mean of 73.96 ± 23.39 g/day of protein. Moreover, subjects' average BCAA intake was 10.92 ± 0.48 g/day. Meanwhile, 17.6% of subjects were found to have low TLC level. From thorough analysis, we did not find a strong correlation between BCAA level and TLC (r = 0.235, p = 0.056). CONCLUSION: In participants with head and neck cancer who had not received chemoradiotherapy, there is no correlation between BCAA intake and TLC. The contribution of non-BCAA amino acids from dietary sources to lymphocyte proliferation requires further investigation. TRIAL REGISTRATION: Retrospectively registered, with clinical trial number NCT05226065 on February 7th 2022.

A comparative study of the COVID-19 vaccine efficacy among cancer patients: mRNA versus non-mRNA.

BACKGROUND: Cancer patients have an increased risk of a severe COVID-19 infection with higher mortality rate. This study aimed to analyze the levels of anti-SARS-CoV-2 S-RBD IgG and NAB among cancer patients who were vaccinated with COVID-19 vaccines, either with BNT162b2, mRNA-1273, AZD1222/ChAdOx1nCoV-19, or Coronavac/BBIBP-CorV vaccines. METHOD: A cross-sectional study was conducted among subjects with either solid or hematological cancers who had received two doses of either mRNA or non-mRNA vaccines within 6 months. The levels of anti-SARS-CoV-2 S-RBD IgG and NAb were analyzed using the Mindray Immunoassay Analyzer CL-900i. Statistical analysis was conducted using mean comparison and regression analysis. RESULT: The mRNA-1273 vaccine had the highest median levels of S-RBD IgG and NAb, followed by BNT162b, ChAdOx1nCoV-19, and BBIBP-CorV/Coronavac. The levels of S-RBD IgG and NAb in subjects vaccinated with mRNA vaccines were significantly higher than those of non-mRNA vaccines when grouped based on their characteristics, including age, type of cancer, chemotherapy regimen, and comorbidity (p<0.05). Furthermore, the S-RBD IgG and NAb levels between the subjects vaccinated with non-mRNA vaccines and the subjects vaccinated with mRNA vaccines were significantly different (p<0.05). However, there was no significant difference between the same types of vaccines. This study demonstrated a very strong correlation between the level of S-RBD IgG and the level of NAb (R = 0.962; p<0.001). The level of anti-SARS-CoV-2 S-RBD IgG was consistently higher compared to the level of NAb. CONCLUSIONS: Generally, mRNA vaccines produced significantly higher anti-SARS-CoV-2 S-RBD IgG and NAb levels than non-mRNA vaccines in cancer subjects.

Multiple Myeloma with Histiocytosis.

Myeloma is a disease characterized by abnormal clonal plasma cells that produces paraprotein. The coincidence of myeloma and histiocytosis is a rare clinical manifestation. This case report describes a 50-year-old female with back pain, anemia, increased globulin and hypercalcemia due to multiple myeloma. Bone marrow cytomorphology revealed an increased number of plasmocytes and histiocytosis.

Diagnostic Value of Neutrophil Lymphocyte Ratio and D-Dimer as Biological Markers of Deep Vein Thrombosis in Patients Presenting with Unilateral Limb Edema.

INTRODUCTION: Patients with deep vein thrombosis (DVT) pose high morbidity and mortality risk thus needing fast and accurate diagnosis. Wells clinical prediction scores with D-dimer testing are traditionally used to rule out patients with low probability of DVT. However, D-dimer testing has a few limitations regarding its relatively low specificity. Neutrophil-lymphocyte ratio (NLR), a marker of inflammation, was found to increase in DVT. Hence, we aimed to evaluate the role of NLR for DVT diagnosis. METHODS: Data were collected from medical records of patients with suspected DVT at Cipto Mangunkusumo National General Hospital during January-December 2014. Diagnosis of DVT was conducted using lower limb ultrasonography. Diagnostic values for NLR, D-dimer, and NLR + D-dimer were determined by receiver operating characteristic (ROC) analysis to obtain area under the curve (AUC), sensitivity, specificity, negative predictive value, and positive predictive values. Sensitivity and specificity analyses of NLR and D-dimer were also conducted based on Wells score and divided into groups of low and high probability of DVT. RESULTS: The AUC values for NLR, D-dimer, and NLR + D-dimer were 72.6%, 70.4%, and 76.1%, respectively. The optimal cut-off value determined for NLR was 5.12 with sensitivity of 67.7%, specificity of 67.9%, PPV of 68.85%, and NPV of 64.91% in differentiating subjects with and without DVT. This study also found that D-dimer had sensitivity of 69.4%, specificity of 71.4%, PPV of 72.88%, and NPV of 67.8%. Meanwhile, the NLR + D-dimer combination had sensitivity of 66.1% and specificity of 72.6%. Multivariate analysis showed that NLR (OR: 2.636; 95% CI: 1.144-6.076; p: 0.023) and D-dimer (OR: 4.175; 95% CI: 1.810-9.633; p: 0.001) were associated with DVT. CONCLUSION: NLR value has wider AUC than D-Dimer and is relatively easier to obtain and does not require specific assay, thus enabling rapid evaluation of symptomatic patients suspected of having DVT. Adding NLR to D-dimer increased AUC to detect DVT. Therefore, NLR could serve as a complementary diagnostic tool for D-dimer to exclude DVT, especially in low clinical probability patients.

Diffuse Large B-Cell Lymphoma and Job's Syndrome: A Case Report.

Job's syndrome or hyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency. Characterized by recurrent pulmonary and skin infections with elevated IgE serum level, this syndrome has been considered a risk factor for lymphoma. Although the majority of cases were diagnosed in childhood, there are still a few cases that were diagnosed in adulthood. It is necessary to recognize these two conditions since the treatment for lymphoma patients with HIES should be adjusted and needs a thorough care. Here we present a case of diffuse large B cell lymphoma in a patient with symptoms of HIES diagnosed during chemotherapy.

The Difference in the Cyclin D1 Expression in Advanced Stage Nasopharyngeal Cancer based on Treatment Response: A Retrospective Cohort Study.

BACKGROUND: nasopharyngeal cancer (NPC) is the most common type of head and neck cancer in Indonesia (28.4%). Reports showed that 18.9% of cases came with advanced stage. Chemotherapy play important role in advanced stage. However, patients with the same stage of the disease may have different treatment response, likely due to the different tumor biological characteristics. Cyclin D1 is a protein involved in the cell cycle, which will stimulate proliferation. This study aimed to examine the proportion of cyclin D1 in NPC and its association with treatment response. METHODS: a retrospective cohort study was conducted on advanced NPC patients that underwent chemotherapy at Cipto Mangunkusumo Hospital from 2015 until 2018. Cyclin D1 immunohistochemistry staining was done by antigen retrieval methods using the cyclin D1 NovocastraTM monoclonal antibody. The cyclin D1 expression was evaluated with h-score. Treatment response was reviewed based on the RECIST 1.1 criteria. RESULTS: fifteen subjects (48.4%) had a positive expression of cyclin D1. Higher proportion of cyclin D1 positive was found in responsive group compare with non-responsive group (66.7% vs. 33.3%, p = 0.032). Statistically significant difference in mean h-score was observed between the subjects who responded and those who did not respond (116.24 SD57.80 vs. 77.97 SD45.27, p = 0.048). CONCLUSION: this study suggests that a higher expression of cyclin D1 is associated with a good treatment response in NPC patients.

Undifferentiated Nasopharyngeal Carcinoma Presenting with Shoulder Mass.

Nasopharyngeal cancer (NPC) is the most common cancer among head and neck cancer that usually presented with unilateral neck mass. Unusual symptoms of NPC can lead us to diagnosis misleading and delayed definitive treatment. We present a case of NPC with bone metastasis in the shoulder. A 33-year-old female presented with right shoulder mass caused by undifferentiated carcinoma of unknown primary, based on biopsy of shoulder mass. After four months, she was complaining painless neck swelling, headache, and hearing impairment in the left ear. Bone MRI showed malignant bone tumour in the right humerus. Neck CT scan showed mass in the nasopharyngeal and bilateral lymphadenopathy. Biopsy in nasopharyngeal revealed undifferentiated carcinoma of nasopharyngeal cancer (WHO-3 type A). The patient was diagnosed as NPC stage IVb and thus was treated with palliative chemotherapy. After three cycles of cisplatin docetaxel, patient condition improved.

Tranexamic acid in the management of upper gastrointestinal bleeding: an evidence-based case report.

AIM: to review the effectiveness of tranexamic acid therapy which has been proposed to reduce bleeding and in turn lower mortality rate. METHODS: following literature searching based on our clinical question on Cochrane Library, PubMed, Clinical Key, EBSCO, Science Direct and Proquest, one systematic review that includes seven randomized controlled trials is obtained. The article meets validity and relevance criteria. RESULTS: the systematic review found that there is no any clear evidence between intervention and control groups in term of mortality. CONCLUSION: the use of tranexamic acid to reduce mortality in patients with upper gastrointestinal bleeding is not recommended.

DRESS and Ischemic Stroke.

DRESS (drug rash eosinophilia and systemic symptoms) is a life threatening condition characterized by skin rash, fever, leucocytosis with eosinophilia or atypical lymphocytosis, lymphadenopathy, and internal organ involvement. This case report would like to describe an interesting case of DRESS coincidence with ischemic stroke. A 38 year old woman had been admitted with skin rash and fever since four days before. Four weeks before admission she received antibiotic and multivitamin for one week. The patient looked ill, with body temperature 38.0°C. Marked physical findings were cervical lymphadenopathy and hepatomegaly. Dermatological examination finding was generalized exanthema. Laboratory evaluation showed leucocytosis, eosinophilia, and increased level of ALT and AST. During hospitalization the patient also suffered from ischemic stroke. Treatments administered in this patient were oxygen, adequate intravenous fluid, parenteral nutrition, methyl prednisolone, cethirizin bid, ranitidin bid, and antibiotic. The antibiotic treatment in this case was performed with graded challenge or test dosing.

Diagnosis and management of acromegaly: giant invasive adenoma.

Acromegaly is a rare disorder caused by excessive growth hormone. Majority of acromegaly are due to pituitary adenoma. It is estimated that 5% of pituitary adenoma become invasive and may grow to gigantic sizes (>4 cm in diameter). We would like to describe a man with giant invasive adenoma. We describe the case of 52-year-old man with acromegaly. The patient was presented to medical care because of hemichorea. He also had visual field defect, uncontrolled diabetes, and dyslipidemia. Hormonal profile showed increment of GH 2-hour after a standard 75-g oral glucose load and of high IGF-1 level with low level of FSH and LH. The next was performed by pituitary imaging. Magnetic resonance imaging showed a macroadenoma with diameter 2.3x3.5x6.6 cm3 that fills the sella tursica, and enlarges into suprasella, genu of corpus collosum, and invades third ventricle. This report describes a rare case of acromegalic patient with giant invasive adenoma. This could be a demonstrative case and lesson for diagnosis and manage acromegalic patient.