COVID-19 Pandemic is Associated With Increased Prevalence of GERD and Decreased GERD-related Quality of Life: Analysis From 9800 Participants in the Indonesian GERD-Q Study.

INTRODUCTION: The prevalence of gastroesophageal reflux disease (GERD) is expected to increase during the pandemic due to unexpected, sudden lifestyle changes such as decreased physical activity and worsening mental conditions. Here, we aim to explore the difference in the prevalence of GERD and GERD-related quality of life (QoL) in Indonesia during the COVID-19 pandemic compared with before the COVID-19 pandemic. METHODS: Retrospective analysis of the Indonesian GERD Questionnaire study, a cross-sectional study utilizing an online form of the GERD Questionnaire, was done to compare the prevalence of GERD between March 2, 2018 to March 1, 2020 (prepandemic group) and March 2, 2020 to March 1, 2022 (pandemic group). The prevalence odds ratios between the 2 groups were calculated using χ 2 . RESULTS: A total of 9800 participants were included in the analysis; 1807 and 7993 were allocated to the pandemic and prepandemic groups, respectively. The prevalence of GERD in the pandemic and prepandemic groups were 67.9% and 61.8%, respectively (prevalence odds ratio: 1.31; 95% CI: 1.17-1.46). CONCLUSION: During the COVID-19 pandemic, the prevalence of GERD, heartburn, and those who reported impaired GERD-related quality of life increased. Regurgitation was the most common symptom reported by participants.

Impact of the coronavirus disease 2019 pandemic on irritable bowel syndrome.

BACKGROUND AND AIM: Gastrointestinal manifestations of the coronavirus disease 2019 (COVID-19) pandemic may mimic irritable bowel syndrome (IBS), and social distancing measures may affect IBS patients negatively. We aimed to study the impact of COVID-19 on respondents with self-reported IBS. METHODS: We conducted an anonymized survey from May to June 2020 in 33 countries. Knowledge, attitudes, and practices on personal hygiene and social distancing as well as psychological impact of COVID-19 were assessed. Statistical analysis was performed to determine differences in well-being and compliance to social distancing measures between respondents with and without self-reported IBS. Factors associated with improvement or worsening of IBS symptoms were evaluated. RESULTS: Out of 2704 respondents, 2024 (74.9%) did not have IBS, 305 (11.3%) had self-reported IBS, and 374 (13.8%) did not know what IBS was. Self-reported IBS respondents reported significantly worse emotional, social, and psychological well-being compared with non-IBS respondents and were less compliant to social distancing measures (28.2% vs 35.3%, P = 0.029); 61.6% reported no change, 26.6% reported improvement, and 11.8% reported worsening IBS symptoms. Higher proportion of respondents with no change in IBS symptoms were willing to practice social distancing indefinitely versus those who deteriorated (74.9% vs 51.4%, P = 0.016). In multivariate analysis, willingness to continue social distancing for another 2-3 weeks (vs longer period) was significantly associated with higher odds of worsening IBS. CONCLUSION: Our study showed that self-reported IBS respondents had worse well-being and compliance to social distancing measures than non-IBS respondents. Future research will focus on occupational stress and dietary changes during COVID-19 that may influence IBS.

Rome Foundation-Asian working team report: Asian functional gastrointestinal disorder symptom clusters.

OBJECTIVE: Functional gastrointestinal disorders (FGIDs) are diagnosed by the presence of a characteristic set of symptoms. However, the current criteria-based diagnostic approach is to some extent subjective and largely derived from observations in English-speaking Western patients. We aimed to identify latent symptom clusters in Asian patients with FGID. DESIGN: 1805 consecutive unselected patients with FGID who presented for primary or secondary care to 11 centres across Asia completed a cultural and linguistic adaptation of the Rome III Diagnostic Questionnaire that was translated to the local languages. Principal components factor analysis with varimax rotation was used to identify symptom clusters. RESULTS: Nine symptom clusters were identified, consisting of two oesophageal factors (F6: globus, odynophagia and dysphagia; F9: chest pain and heartburn), two gastroduodenal factors (F5: bloating, fullness, belching and flatulence; F8 regurgitation, nausea and vomiting), three bowel factors (F2: abdominal pain and diarrhoea; F3: meal-related bowel symptoms; F7: upper abdominal pain and constipation) and two anorectal factors (F1: anorectal pain and constipation; F4: diarrhoea, urgency and incontinence). CONCLUSION: We found that the broad categorisation used both in clinical practice and in the Rome system, that is, broad anatomical divisions, and certain diagnoses with long historical records, that is, IBS with diarrhoea, and chronic constipation, are still valid in our Asian societies. In addition, we found a bowel symptom cluster with meal trigger and a gas cluster that suggests a different emphasis in our populations. Future studies to compare a non-Asian cohort and to match to putative pathophysiology will help to verify our findings.

The Validity and Reliability Test of the Indonesian Version of Gastroesophageal Reflux Disease Quality of Life (GERD-QOL) Questionnaire.

AIM: to obtain a valid and reliable GERD-QOL questionnaire for Indonesian application. METHODS: at the initial stage, the GERD-QOL questionnaire was first translated into Indonesian language and the translated questionnaire was subsequently translated back into the original language (back-to-back translation). The results were evaluated by the researcher team and therefore, an Indonesian version of GERD-QOL questionnaire was developed. Ninety-one patients who had been clinically diagnosed with GERD based on the Montreal criteria were interviewed using the Indonesian version of GERD-QOL questionnaire and the SF 36 questionnaire. The validity was evaluated using a method of construct validity and external validity, and reliability can be tested by the method of internal consistency and test retest. RESULTS: the Indonesian version of GERD-QOL questionnaire had a good internal consistency reliability with a Cronbach Alpha of 0.687-0.842 and a good test retest reliability with an intra-class correlation coefficient of 0.756-0.936; p<0.05). The questionnaire had also been demonstrated to have a good validity with a proven high correlation to each question of SF-36 (p<0.05). CONCLUSION: the Indonesian version of GERD-QOL questionnaire has been proven valid and reliable to evaluate the quality of life of GERD patients.

National Consensus on Management of Dyspepsia and Helicobacter pylori Infection.

Dyspepsia is one of numerous general complaints, which is commonly encountered by doctors of various disciplines. In daily practice, the complaint is not only limited for gastroenterologists. Knowledge on pathophysiology of dyspepsia have been developing continuously since a scientific investigation has been started in 1980's, which considers Helicobacter pylori as one of key factor in managing dyspepsia, either it is associated with ulcer or non-ulcer. The management of dyspepsia cannot be separated from the management of H. pylori and there is an additional new knowledge associated with definition, pathophysiology, diagnosis and treatment of both dyspepsia and H. pylori infection.This consensus document on the management of dyspepsia and H. pylori infection in Indonesia has been developed using the evidence-based medicine principles; therefore, it can be used as a reference for doctors in dealing with dyspepsia and H. pylori infection cases in their daily practice. It is expected that with the new consensus, doctors can provide greater service to their patients who have dyspepsia and H. pylori infection.

Survey of clinical practice for irritable bowel syndrome in East asian countries.

AIM: Sociocultural factors are important because their different effects on the features of irritable bowel syndrome (IBS) between countries will provide clues towards solving this problem. The aims of this study were to depict the clinical realities of IBS in East Asian countries and test the hypothesis that the diagnosis and treatment of IBS differ between countries. SUBJECTS AND METHODS: Study participants were 251 physicians involved in the clinical practice of IBS at major institutions in Japan, South Korea, China, the Philippines, Indonesia and Singapore. The questionnaire contained 45 questions focused on the clinical practice of IBS. RESULTS: Subjects in Japan, South Korea, China, Indonesia, the Philippines and Singapore accounted for 55.4, 17.9, 8.8, 8.0, 6.4 and 3.6% of the study cohort, respectively. Amongst East Asian physicians, the most important symptom was considered to be abdominal pain by 33.4%, whilst 24.3% regarded alternating diarrhea and constipation to be the most important symptoms. Total colonoscopy and histopathology use showed no difference among countries. Prescriptions given for mild (p < 0.0001), moderate (p < 0.0001), severe (p < 0.0001), intractable (p = 0.002), diarrheal (p < 0.0001) and constipating (p < 0.0001) patients with IBS significantly differed between the countries. Except for several minor points, IBS specialists showed no significant difference in their diagnosis and treatment of IBS when compared to nonspecialists. CONCLUSION: This survey provided data on the clinical treatment of IBS among East Asian countries. The results supported the hypothesis that the diagnosis and treatment of IBS differs between countries.

Seroprevalence and Socio-demographic Factors of Helicobacter pylori Infection in Patients with Dyspepsia in Kalibaru Primary Health Care North Jakarta.

AIM: to identify the seroprevalence and its association with socio-demographic factors of Helicobacter pylori infection. METHODS: a cross-sectional study was performed in 111 patients with dyspepsia (according to ROME III) who got treatment at Kalibaru Primary Health Care, North Jakarta from January to February 2015. Patients aged over 18 years and no history of gastrectomy were interviewed and 3 cc venous blood was drawn. Bioramps Laboratories's Immunochromatography Diagnostic Test (Bio M Pylori) was used to diagnose patient with Helicobacter pylori infection. Chi Square were used to analyzed socio-demographic and T test were used to analyze age. Variables with p<0.25 were analyzed by logistic regression. RESULTS: seroprevalence of Helicobacter pylori of 111 dyspepsia patients who got treatment in Kalibaru Primary Health Care in this study was 22.5% (95% CI 14.8%-30.2%). There is no relation between age and Helicobacter pylori infection (p=0.270). Higher socio-economic class was related to lower risk Helicobacter pylori infection (OR 0.2; 95% CI 0.02-1.71). Higher crowding index was related to higher risk Helicobacter pylori infection (OR 1.2; 95% CI 0.37-4.49). Lower clean water index was related to higher risk Helicobacter pylori infection (OR 1.5; 95% CI 0.57-4.04). Lower sanitation status was related to higher risk Helicobacter pylori infection (OR 2.5; 95% CI 1.01-6.19). CONCLUSION: seroprevalence of Helicobacter pylori infection in patient with dyspepsia in Kalibaru village was 22.5%. There is an association between sanitation and Helicobacter pylori infection.

The role of per oral cholangiopancreatoscopy (POCPS) in complicated pancreaticobiliary disease.

A fifty-five year old female patient presented with jaundice, subfebrile fever and dark yellow urine since one month before admission. She lost weight 10 kilograms during one month. One day before admission to Ciptomangunkusumo General Hospital, she complained of worsened abdominal pain at right upper quadrant urging her to come to the emergency room. An abdominal examination revealed Murphy sign, mild hepatomegaly and deeply icteric sclera. Serum bilirubin was 21.8 mg/dl, alkaline phosphatase and gamma-glutamyltransferase levels were significantly elevated (1090 IU/L and 560 IU/L consecutively) while the transaminases were moderately high (ALT 80 U/L). The C-reactive protein was 555 mg/L. An abdominal ultrasound examination revealed dilatation of right and left intrahepatic bile duct and presence of common hepatic duct stone. Subsequent magnetic resonance imaging/magnetic cholangiopancreatography (MRI/MRCP) revealed intrahepatic bile duct dilatation, multiple CBD stone and benign stricture at common hepatic duct causing right and left intrahepatic bile duct obstruction.We assessed the patient as acute cholangitis and obstructive jaundice suspected to be caused by biliary duct stone then we performed endoscopic retrograde cholangiopancreatography (ERCP), we revealing stenosis at distal CBD, multiple CBD stone, giant stone in CHD and dilatation of bilateral IHBD. We performed CBD stone extraction then inserted biliary stent for drainage. Then we planned to do second ERCP with SpyGlassTM for giant stone extraction. After the first ERCP, the clinical condition of the patient improved and the bilirubin decreased to 10 mg/dL. In the next two weeks we performed a second ERCP to extract the giant stone with SpyGlass TM. However, after we inserted SpyGlassTM into the biliary duct, what we found were not as we expected before. We revealed that there was a mass in biliary duct and there was no CBD stone. We did the biopsy and inserted a new plastic stent (after removed the older one) to the common biliary duct. Surprisingly, the result of histopathology also supports our findings, which was the adenocarcinoma at common bile duct.

A systematic review with meta-analysis: Efficacy and safety of potassium-competitive acid blocker compared with proton pump inhibitor in the maintenance of healed erosive esophagitis.

Introduction: Proton pump inhibitor (PPI) is the mainstay therapy for the maintenance of healed erosive esophagitis (EE). It is unknown whether potassium-competitive acid blockers (PCABs) are more efficacious and safer than PPIs. Methods: Only randomized controlled trials (RCTs) comparing PCABs to PPIs in the maintenance of healing rates of endoscopically proven healed EE and indexed in MEDLINE, EMBASE, and CENTRAL until 3 February 2024, were included. A fixed-effects model meta-analysis was performed to pool primary efficacy outcome (maintenance of healing rates at week 24) and safety data (any treatment-emergent adverse event or TEAE). The risk of bias was assessed using Cochrane's Risk of Bias 2 (RoB2) tool. Results: Four RCTs with a total of 2554 patients were eligible for inclusion. All trials were of low risk of bias. Compared to lansoprazole 15 mg, the maintenance rates of healed EE at week 24 were significantly higher with vonoprazan 10 mg (RR 1.13; 95% CI 1.07-1.19) and vonoprazan 20 mg (RR 1.15; 95% CI 1.10-1.21). Likewise, compared to lansoprazole 15 mg, any TEAEs were significantly greater with vonoprazan 20 mg (RR 1.10; 95% CI 1.01-1.20) but not vonoprazan 10 mg. Conclusion: Vonoprazan 10 and 20 mg were superior to lansoprazole 15 mg in the maintenance of the healing of EE. Any TEAEs were greater with vonoprazan 20 mg.

Safety and efficacy of lansoprazole injection in upper gastrointestinal bleeding: a postmarketing surveillance conducted in Indonesia.

AIM: to assess the safety and effectiveness of lansoprazole injection (Prosogan®) in patients with upper gastrointestinal bleeding due to peptic ulcers or erosive gastritis. METHODS: this study was a multicenter observational postmarketing study of lansoprazole (Prosogan®) injection. Patients with upper gastrointestinal bleeding due to peptic ulcers or erosive gastritis were given intravenous lansoprazole for a maximum of 7 days or until the bleeding stopped and the patients were able to take oral doses of lansoprazole. Primary outcome of the study was cessation of bleeding. Some laboratory parameters were also measured. RESULTS: among a total of 204 patients evaluable for safety, there was no adverse event reported during the study. A total of 200 patients were eligible for efficacy evaluation, 125 patients (62.5%) were males. Among these patients, upper GI bleeding stopped in 20 patients (10.0%) on day 1, in 71 patients (35.5%) on day 2, 75 patients (37.5%) on day 3, 24 patients (12.0%) on day 4, and 7 patients (3.5%) on day 5, making a cumulative of 197 patients (98.5%) on day 5. The hemostatic effect was rated as 'excellent' if the bleeding stopped within 3 days, and 'good' if the bleeding stopped within 5 days. Thus, the results were 'excellent' in 166 patients (83.0%) and 'good' in 31 patients (15.5%). These results were not different between males and females, between age below 60 years and 60 years and above, and between baseline Hb below 10 g/dL and 10 g/dL and above. CONCLUSION: the results of this observational postmarketing study in 200 patients with upper gastrointestinal bleeding due to peptic ulcers or erosive gastritis demonstrated that intravenous lansoprazole twice a day was well tolerated and highly effective.

Needs assessment of basic gastrointestinal endoscopy training: A qualitative study in Indonesia.

Background and Aim: Gastointestinal endoscopy is a complex practical skill, and training and experience are required to ensure the accuracy and safety of the procedures. Therefore, proper endoscopy training is needed to provide highly skilled endoscopists. This study explores the learning experience and assesses the need for endoscopy training in Indonesia from an endoscopy trainee's point of view. Limitations from the current training model and the trainees' suggestions hopefully will become a foundation for the future endoscopy training model in Indonesia. Methods: A total of 132 current endoscopy trainees and graduates of endoscopy training from various centers in Indonesia completed an online qualitative survey regarding their endoscopy training experience, their satisfaction with the current training method, barriers to achieving competency, and their suggestions for future training. Data were subjected to descriptive and qualitative analysis using content analysis. Results: We found variations in the trainee's learning experience regarding the training supervision, feedback, and assessment methods. The most common endoscopy training methods were observation and direct practice with supervision. There was only a low proportion of simulator use (25%). The most found concept in barriers to achieving competency was "insufficient number of patients." Meanwhile, the most found concept in suggestions for future training methods was "increasing the variety of cases and procedures." Conclusion: Our findings suggest that there are still variations in endoscopy training methods in Indonesia. Therefore, we propose to design a standardized endoscopy training program to ensure the competence of endoscopy trainees and better care for endoscopic patients. Simulators might be used to increase the trainees' competence in settings with low numbers of patients or cases.

The effectiveness of endoscopic retrograde cholangiopancreatography in the management of patients with jaundice at Cipto Mangunkusumo Hospital, Jakarta.

AIM: to evaluate endoscopic retrograde cholangiopancreatography (ERCP) benefits in treating patients with clinical appearance of yellowish discoloration. METHODS: a descriptive retrospective cross-sectional study was performed on 122 patients at Cipto Mangunkusumo Hospital from January 2008 to December 2010. The main complained was yellowish discoloration of the skin. ERCPs were performed as appropriate, and then the distribution of disease entity, results of procedure and complications were noted. RESULTS: subjects of this study consist of 63 males (52%) and 59 females (48%), 7 patients have undergone ERCP 2 times. Data showed 63 cases (51%) were indicated by stone and 52 cases (43%) by tumor/mass and 7 cases by infection (6%). Ten out of 122 cases (7%) showed normal results. Difficult canulation was encountered in 23 cases (18%) as access to the CBD could not be obtained. From 53 cases with stone, the extraction was successful in 43 (81%) including while 12 procedures with high grade of difficult ERCP left stone remnants (23%), and the remaining 10 procedures entailed stones retention (19%). Radioopaque stones found in 2 cases (4%) and radioluscent in 51 cases (96%). Stent placement was done in CBD (30 cases, 83%), pancreatic duct (4 cases, 11%), and extraneous CBD (2 cases, 5%). Complications found 3 cases (2%) migration stent outside CBD in 2 cases, 1 case with crand radioluscentin 51 acked basket. CONCLUSION: ERCP procedure is really helpful in assisting clinicians to diagnose and manage therapeutic measures, especially in pancreaticobilliar tract disorder, while performing stone extraction and stent placement.

The value of fecal tumor M2 pyruvate kinase as a diagnostic tool for colorectal cancer screening.

AIM: to evaluate the performance of fecal tumor M2 pyruvate kinase (M2PK) as a diagnostic biomarker for colorectal cancer (CRC) screening in high-risk or symptomatic populations. METHODS: consecutive patients (N=328) who were referred for elective colonoscopy were prospectively enrolled. One walnut-sized stool sample was collected from each patient for analysis of tumor M2PK content using an ELISA kit. No dietary restrictions were applied. The clinical pathologists who conducted the M2PK analyses were blinded to the patients' confirmed diagnoses. Levels of fecal tumor M2PK were compared with histopathological results from colorectal biopsies. RESULTS: of the 328 patients who underwent colonoscopy examinations, 197 (60.1%) were men and 131 (39.9%) were women. Based on histopathological examination, 83 (25.3%) patients had normal bowel histology, 42 (12.8%) patients had CRC, 67 (20.4%) patients had adenoma, 19 (5.8%) patients had inflammatory bowel disease, three (0.9%) patients had amoebic colitis, and 114 (34.8%) patients had infective colitis. The cutoff level for tumor M2PK concentration was defined as 4.00 U/mL. The sensitivity, specificity, positive predictive value, and negative predictive value of the M2PK test were 71.4%, 71.0%, 73.5%, and 94.4%, respectively. There was a significant association between CRC and fecal tumor M2PK level (P<0.001). The M2PK test detected 16 tumors among 67 (23.9%) cases of adenoma, eight tumors among 19 (42.1%) cases of inflammatory bowel disease, 35 tumors among 114 (30.7%) cases of infective colitis, and two tumors among three (66.7%) cases of amoebic colitis. CONCLUSION: the fecal tumor M2PK test has good sensitivity and specificity for CRC detection, especially in high-risk or symptomatic populations.

Case series in Indonesia: B.1.617.2 (delta) variant of SARS-CoV-2 infection after a second dose of vaccine.

BACKGROUND: The B.1.617.2 (delta) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first discovered in Maharashtra in late 2020 and has rapidly expanded across India and worldwide. It took only 2 mo for this variant to spread in Indonesia, making the country the new epicenter of the delta variant as of July 2021. Despite efforts made by accelerating massive rollouts of current vaccines to protect against infection, cases of fully-vaccinated people infected with the delta variant have been reported. AIM: To describe the demographic statistics and clinical presentation of the delta variant infection after the second dose of vaccine in Indonesia. METHODS: A retrospective, single-centre case series of the general consecutive population that worked or studied at Faculty of Medicine, Universitas Indonesia with confirmed Delta Variant Infection after a second dose of vaccine from 24 June and 25 June 2021. Cases were collected retrospectively based on a combination of author recall, reverse transcription-polymerase chain reaction (RT-PCR), and whole genome sequencing results from the Clinical Microbiology Laboratory, Faculty of Medicine, Universitas Indonesia. RESULTS: Between 24 June and 25 June 2021, 15 subjects were confirmed with the B.1.617.2 (delta) variant infection after a second dose of the vaccine. Fourteen subjects were vaccinated with CoronaVac (Sinovac) and one subject with ChAdOx1 nCoV-19 (Oxford-AstraZeneca). All of the subjects remained in home isolation, with fever being the most common symptom at the onset of illness (n = 10, 66.67%). The mean duration of symptoms was 7.73 d (± 5.444). The mean time that elapsed from the first positive swab to a negative RT-PCR test for SARS-CoV-2 was 17.93 d (± 6.3464). The median time that elapsed from the second dose of vaccine to the first positive swab was 87 d (interquartile range: 86-128). CONCLUSION: Although this case shows that after two doses of vaccine, subjects are still susceptible to the delta variant infection, currently available vaccines remain the most effective protection. They reduce clinical manifestations of COVID-19, decrease recovery time from the first positive swab to negative swab, and lower the probability of hospitalization and mortality rate compared to unvaccinated individuals.

Genomic profiles of Indonesian colorectal cancer patients.

Background: Colorectal cancer (CRC) is one of the most commonly diagnosed cancers worldwide and genetic mutation plays a vital role in CRC development. A previous study has suggested that genetic alterations among Indonesian patients with CRC might differ from those known in developed countries. This study aimed to describe the genomic profiles of Indonesian patients with CRC. Methods: A total of 13 patients were recruited for this study from May to July 2019. Tissue samples were collected, and genomic DNA was extracted from the samples. AmpliSeq for Illumina Cancer HotSpot Panel v2 Next-generation sequencing was used for DNA sequencing and a genome analysis toolkit was used for local realignment around the discovered variants. Results: A total of 45 genes comprising 391 single nucleotide variants (SNVs) with a depth >10 were observed. The genes with the most variants were STK11, SMAD4, EGFR, and ERBB4 and the genes with the most non-synonymous variants were SMAD4, TP53, FGFR3, CDKN2A, and STK11. Genes and SNVs in at least 90% of all samples consisted of 43 genes comprising 286 variants. Genes with the most non-synonymous SNVs were EGFR, SMO, FGFR3, TP53, STK11, CDKN2A. Genes related to the chromosomal instability pathway, such as TP53, SMAD4, KRAS, and APC, are also found in the analysis. Conclusions: Our findings showed that all patients with CRC in this study had genetic mutations in the chromosomal instability pathway. Analysis of genetic mutation of Indonesian patients with CRC might be crucial for advanced targeted therapy and for better clinical outcomes.

Pandemic inequity in a megacity: a multilevel analysis of individual, community and healthcare vulnerability risks for COVID-19 mortality in Jakarta, Indonesia.

INTRODUCTION: Worldwide, the 33 recognised megacities comprise approximately 7% of the global population, yet account for 20% COVID-19 deaths. The specific inequities and other factors within megacities that affect vulnerability to COVID-19 mortality remain poorly defined. We assessed individual, community-level and healthcare factors associated with COVID-19-related mortality in a megacity of Jakarta, Indonesia, during two epidemic waves spanning 2 March 2020 to 31 August 2021. METHODS: This retrospective cohort included residents of Jakarta, Indonesia, with PCR-confirmed COVID-19. We extracted demographic, clinical, outcome (recovered or died), vaccine coverage data and disease prevalence from Jakarta Health Office surveillance records, and collected subdistrict level sociodemographics data from various official sources. We used multilevel logistic regression to examine individual, community and subdistrict-level healthcare factors and their associations with COVID-19 mortality. RESULTS: Of 705 503 cases with a definitive outcome by 31 August 2021, 694 706 (98.5%) recovered and 10 797 (1.5%) died. The median age was 36 years (IQR 24-50), 13.2% (93 459) were <18 years and 51.6% were female. The subdistrict level accounted for 1.5% of variance in mortality (p<0.0001). Mortality ranged from 0.9 to 1.8% by subdistrict. Individual-level factors associated with death were older age, male sex, comorbidities and age <5 years during the first wave (adjusted OR (aOR)) 1.56, 95% CI 1.04 to 2.35; reference: age 20-29 years). Community-level factors associated with death were poverty (aOR for the poorer quarter 1.35, 95% CI 1.17 to 1.55; reference: wealthiest quarter) and high population density (aOR for the highest density 1.34, 95% CI 1.14 to 2.58; reference: the lowest). Healthcare factor associated with death was low vaccine coverage (aOR for the lowest coverage 1.25, 95% CI 1.13 to 1.38; reference: the highest). CONCLUSION: In addition to individual risk factors, living in areas with high poverty and density, and low healthcare performance further increase the vulnerability of communities to COVID-19-associated death in urban low-resource settings.

Side effects of endoscopic variceal ligation by using Indonesian Endoscopic Ligator versus Endoscopic Variceal Sclerotherapy.

AIM: to investigate the side effects and survival of endoscopic variceal ligation by using Indonesian Endoscopic Ligator versus Endoscopic Variceal Sclerotherapy. METHODS: we studied the medical records and endoscopy reports of patients who underwent endoscopic variceal ligation (EVL) or endoscopic sclerotherapy (EST) from January 2003 until December 2006. EST was done using ethoxysclerol injection; and ligation was done using a home-made Indonesian endoscopic ligating device. Patient characteristics, side effects of EVL and EST, as well as survival and length of stay were collected. Data of side effects was analyzed by chi-square test. RESULTS: there were no statistically significant differences of patients characteristics among both groups. The side effects in EVL group (29.2%) were less frequent than the EST group (60.9%) (p = 0.009). The death side effect in the EVL group (1.0%) was less frequent than in the EST group (21.7%) (p<0.001). The four-year survival in patients who had EVL and EST were 91.7% and 16.7%, respectively (p<0.001). CONCLUSION: EVL had fewer side effects than EST in the treatment of esophageal varices bleeding. Death in the EVL group was lower than in the EST group.

Gastric ulcers induced by systemic hypoxia.

AIM: to assess the effect of systemic hypoxia on gastric mucosa and the activation of stress-responsive transcription factors induced by hypoxia. METHODS: in this experimental study, rats were allocated to control and experimental groups. The experimental group was divided into subgroups and subjected to hypoxia conditions for 1, 7, 14 or 21 days. Afterwards, histopathological evaluation and study of the protein expression of the gastric mucosa were performed. RESULTS: the results showed that longer exposure to hypoxic conditions leads to more severe gastric ulceration. Twenty-four hours after induction, 60% of rats had developed gastric ulcers. Seven days after induction, 80% of rats developed gastric ulcers. In the 14-day and 21-day hypoxia conditions, epithelialization (a sign of gastric ulcer healing) was observed. Evaluation of the average ulcer depth on the day of treatment showed that the greatest depth was on day 7, and the shallowest was on day 21 of treatment. Western blot analyses demonstrated that systemic hypoxia resulted in the expression of heat shock factor (HSF) and heat shock protein 70 (HSP-70), which were highest on day 7 and then regressed gradually. In control, HSF-1 and HSP-70 were not detected by Western blot analysis in the control group (normoxia). CONCLUSION: in this study, systemic hypoxia caused gastric ulcers, and during the time of exposure to hypoxia, an adaptation process in the form of gastric epithelialization occurred in the rats. This development of gastric lesions was in line with the expression pattern of HSF-1 HIF-1 and HSP-70.

Survival, stent patency, and cost-effectiveness of plastic biliary stent versus metal biliary stent for palliation in malignant biliary obstruction in a developing country tertiary hospital.

BACKGROUND AND AIM: Patients with advanced malignant obstructive jaundice often require biliary drainage. Resources restraint makes clinicians need to outweigh effectiveness of each biliary stents and their costs. Hence, a cost-effectiveness analysis is necessary. METHODS: A retrospective cohort study was done on malignant biliary obstruction patients undergoing palliative biliary stenting between January 2015 and December 2018. We evaluated 180-day survival rate using log-rank test and stent patency duration using Mann-Whitney U test. Effectiveness was defined as stent patency, while cost was calculated using hospital perspective using decision tree model and reported as incremental cost-effectiveness ratio. RESULTS: A total of 81 men and 83 women were enrolled in this study. One hundred and eighty days survival rate was 35.9% (median 76 days, 95% confidence interval [CI] 50-102 days) and 33.3% (median 55 days, 95% CI 32-78 days), while average stent patency was 123 (8) days versus 149 (13) days for plastic and metal stent groups, respectively (P > 0.05). Metal stent could save Indonesian Rupiah (IDR) 1 217 750 to get additional 26 days of patency. CONCLUSION: There were no differences in survival and stent patency between the two groups. Metal biliary stent is more cost-effective than plastic stent for palliation in malignant biliary obstruction.

Colorectal cancer patients in a tertiary hospital in Indonesia: Prevalence of the younger population and associated factors.

BACKGROUND: An increasing trend in colorectal cancer (CRC) occurring at younger ages has been observed worldwide, even though incidence is declining in the general population. Most currently available guidelines still recommend CRC screening for older populations, despite an alarming rise in early-onset CRC incidence. Risk stratification is necessary to further determine the population most at risk for early-onset CRC. However, epidemiological data on related clinical characteristics and potential risk factors, especially in developing countries, have not been widely reported. AIM: To investigate the prevalence, demographics, clinicopathologic features, and associated factors of young-onset CRC patients in a tertiary hospital in Indonesia. METHODS: Patients undergoing colonoscopy examination between 2008 and 2019, yielding a diagnosis of CRC were identified from medical records. The subjects were classified into two groups according to their age at diagnosis, namely early-onset (18-49 years old) and late-onset (≥ 50-years-old). Demographic data, characteristics, and risk factors of both onset age groups were evaluated using the chi-square and Fisher's exact test. RESULTS: Among 495 CRC patients confirmed by histopathology, 205 (41.4%) were classified as early-onset and 290 (58.6%) as late-onset. Most subjects in the early-onset CRC group were male (53.7%), with 89.8% displaying adenocarcinoma histopathology. A majority (78%) of the early-onset CRC patients had left-sided tumors, with the rectum (41%) and rectosigmoid (17.6%) being the most common sites. Abdominal pain was the most frequent symptom in the early-onset CRC patients (55.6%), which was significantly higher than that in the late-onset CRC patients (43.8%, P < 0.05). Early-onset CRC cases were more likely to be underweight (34.6% vs 20.0%, P < 0.001) compared to late-onset CRC cases. The proportion of subjects with suspected hereditary nonpolyposis colorectal cancer (HNPCC) was also higher in the early-onset CRC group than in the late-onset age group (9.3% vs 4.1%, P < 0.05). However, no difference was observed in the parental or family histories of CRC cases. CONCLUSION: Early-onset CRC patients were more likely to have abdominal pain, underweight status, and HNPCC suspicion than late-onset CRC patients.