Current Updates on Diagnosis and Management of Cholangiocarcinoma: from Surgery to Targeted Therapy.

Cholangiocarcinoma is commonly described as any malignancy arising from the lining of the bile duct and is recognized as one of the most common biliary malignancies. We conducted a literature review of current available evidences and guidelines.Based on the anatomical location of the origin of the mass, cholangiocarcinoma can be divided into intrahepatic, perihilar, and distal cholangiocarcinoma. Each of these subtypes has their own risk factors, best treatment options, and prognosis. The most common risk factors for cholangiocarcinoma also differs based on geography and population backgrounds. Histopathological biopsy remained the gold standard for cholangiocarcinoma diagnosis, however various advances has been made in diagnostic procedure, including MRCP, EUS, ERCP, EBUS, and cholangioscopy. Surgical resection is still the best treatment modality for cholangiocarcinoma, but it can only be done in few patients considering most patients were diagnosed in the unresectable state. Other treatment options includes conventional chemotherapy, locoregional therapy, systemic targeted therapy, and palliative best supportive care. Cholangiocarcinoma has an abundance of molecular targets and advances in biomolecular technologies bring further hope for future curative treatment options. Treatment options should be chosen individually based on each patient's condition and setting. Cholangiocarcinoma is still a major health problem in hepatobiliary malignancies. Multiple options are available for cholangiocarcinoma treatments.

The risk factors of SARS-CoV-2 antibody level differences in healthcare workers post vaccination in Siloam hospitals: A nationwide multicenter study.

Background: Several vaccines have been approved against COVID-19, and 5 have been used in Indonesia. Due to the decrease in antibody levels 3 to 6 months after the second dose of CoronaVac, healthcare workers received the third booster of mRNA vaccine (mRNA-1273) to increase the antibody level. This study aimed to evaluate the risk factors of anti-S-RBD IgG levels differences in healthcare workers. Methods: This study is a retrospective cohort study of 576 healthcare workers without previous SARS-CoV-2 infection who received 2 doses of CoronaVac and the third dose of mRNA-1273 6 months after the second dose. Blood samples were obtained 2nd, 6th, 12th, and 24th weeks after the second dose of CoronaVac vaccine administration, with mRNA-1273 booster on week 20. Quantitative measurements of IgG antibodies were performed with Elecsys Anti-SARS-CoV-2 S immunoassay. We identify the baseline factors predicting post-vaccination antibody titers using univariate and multivariate linear regression analysis. Results: This study comprised 576 participants aged 32 years old, 72.05% female, and 45.84% from high-risk occupation subgroups. The median antibodies titer level on the 2nd, 6th, 12th, and 24th weeks after the second vaccine dose administration were 40.99 u/mL, 42.01 u/mL, 54.78 u/mL, and 23,225 u/mL. Antibody levels trended highest in female and younger age group (20-29 years old). Conclusions: The third dose of vaccine increased the quantitative SARS-CoV-2 spike IgG antibody titers and eliminated differences in antibodies titer by gender.

Prognostic value of inflammatory markers in patients with COVID-19 in Indonesia.

BACKGROUND & AIMS: Coronavirus disease 2019 (COVID-19) has a wide clinical spectrum, ranging from asymptomatic infection to severe diseases with high mortality rate. Early identification of high-risk COVID-19 patients may be beneficial to reduce morbidity and in-hospital mortality. This study aimed to investigate whether baseline levels of inflammatory markers such as C-reactive protein (CRP) and immune-cell-based inflammatory indices, neutrophil to lymphocyte ratio (NLR), derived-NLR (d-NLR), and platelet to lymphocyte ratio (PLR) at hospital admission are associated with adverse disease outcomes in COVID-19 patients. METHODS: Clinical data from 391 hospitalized COVID-19 patients in three Siloam Hospitals in Indonesia were retrospectively collected and analysed from March 20 to October 30, 2020. RESULTS: Fifty-four (13.8%) hospitalized patients had clinical deterioration and required ICU treatment, categorizing them as severe COVID-19 cases. Older age, presence of underlying diseases, and increased inflammatory markers values at admission were significantly associated with severe cases. After adjustment of sociodemographic and comorbidities factors, CRP, NLR, and d-NLR values, but not PLRs, were identified as independent risk factors for disease severity and death in COVID-19 patients. The area under curve (AUC) of CRP, NLR, and d-NLR were 0.854, 0.848, and 0.854, respectively. The optimal cut-off points for CRP, NLR, and d-NLR for identification of COVID-19 patients with potential worse disease outcomes were 47 mg/L, 6, and 4, respectively. CONCLUSION: Initial assessment of CRP, NLR, and d-NLR values at hospital admission may be important predictors for adverse disease outcomes in COVID-19 patients.

Candesartan as a tentative treatment for COVID-19: A prospective non-randomized open-label study.

BACKGROUND: This study aimed to investigate whether the addition of candesartan to the standard care regimen improved the outcome in patients with coronavirus 2019 (COVID-19). METHODS: A prospective non-randomized open-label study was undertaken from May to August 2020 on 75 subjects (aged 18-70 years) hospitalized in Siloam Kelapa Dua Hospital. Uni- and multi-variable Cox regression analyses were performed to obtain hazard ratios (HRs). The primary outcomes were: (1) length of hospital stay; (2) time to negative swab; and (3) radiological outcome (time to improvement on chest X ray). RESULTS: None of the 75 patients with COVID-19 required intensive care. All patients were angiotensin-receptor-blocker naïve. In comparison with the control group, the candesartan group had a significantly shorter hospital stay [adjusted HR 2.47, 95% confidence interval (CI) 1.16-5.29] after adjusting for a wide range of confounders, and no increased risk of intensive care. In the non-obese subgroup, the candesartan group had a shorter time to negative swab (unadjusted HR 2.11, 95% CI 1.02-4.36; adjusted HR 2.40, 95% CI 1.08-5.09) and shorter time to improvement in chest x ray (adjusted HR 2.82, 95% CI 1.13-7.03) compared with the control group. CONCLUSION: Candesartan significantly reduces the length of hospital stay after adjustment for covariates. All primary outcomes improved significantly in the non-obese subgroup receiving candesartan.

Prevalence and Profile of Fibrosis in Diabetic Patients with Non-alcoholic Fatty Liver Disease and the Associated Factors.

BACKGROUND: the risk of Non-Alcoholic Fatty Liver Disease (NAFLD) is increasing in patients with type-2 diabetes. Prevalence and factors related to the increased risk of NAFLD in diabetic patients in Indonesia has never been studied before. Data regarding the profile of fibrosis in the population has also been unknown. This study aimed to identify the difference on the profile of diabetic patients with and without NAFLD as well as the degree of fibrosis. METHODS: the study was conducted using a cross-sectional method in type-2 diabetic patients who were treated at the outpatient clinic of endocrinology and metabolic division in Cipto Mangunkusumo Hospital. Sampling was done consecutively. Collected data comprised of age, duration of diabetes, body mass index (BMI), waist circumference, HDL, triglyceride, and HbA1C levels. Abdominal ultrasonography was conducted for all patients to determine the presence of NAFLD. Patients with NAFLD were subsequently underwent transient elastography in order to assess their degree of liver fibrosis. Chi-square or Fisher's-Exact tests were used for bivariate analysis and logistic regression was used for multivariate analysis. RESULTS: as many as 186 patients were analyzed in the study and 84 patients (45.2%) were demonstrated to have NAFLD. Transient elastography examinations were carried out in 68 patients and 17 patients (25.0%) were found with severe fibrosis. Univariate analysis showed significant differences on BMI (PR=1.878; 95%CI= 1.296-2.721; p<0.001) and waist circumference (PR=2.368; 95%CI= 1.117-5.017; p=0.018) between patients with and without NAFLD. However, the multivariate test showed that BMI was the only factor that had a significance difference between both groups (OR=2.989; 95%CI=1.625-5.499; p<0.001). CONCLUSION: prevalence of NAFLD among type-2 diabetic patients in Cipto Mangunkusumo Hospital has reached 45.2% and 25.0% among them had severe fibrosis. BMI is the only factor found to be associated with the occurrence of NAFLD.