Pre and post-extended thymectomy plasmapheresis accelerates mechanical ventilation extubation in Myasthenia Gravis patients with Thymoma

I Wayan Widyantara, Kadek Mulyantari, Ketut Sinardja

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Background: Myastenia gravis (MG) is a neuromuscular junction disorder that causes significant disability in the patient. Plasmaparesis and thymectomy are some therapeutic modalities in MG patients. Patients with MG of 10-15% had thymoma and 60% occurred thymic hyperplasia. Thymectomy may improve MG outcomes in 54-94% of patients (thymoma cases) or 21-42% of patients (cases of thymic hyperplasia). Plasmaparesis perioperatif still controversial. Case report: The 60-year-old man comes with a complaint both eyelids often close and both hands and feet experience fluctuating weakness, improved at rest. Patients with a history of DM and pulmonary TB. On the physical examination obtained eyelid twitch response and improved ptosis on ice test. Laboratory shows hyperglycemia and thrombocytopenia. Electrophysiological examination supports neuromuscular junction lesions. In thoracic and thoracic rectal images the mediastinal mass was obtained. Patients were diagnosed with myastenia gravis with suspected thyroid mediastinal mass. Treatment given mestinon 60 mg every 8 hours peroral, thymectomy plan, platelet transfusion, and plasmaparesis. Obtained a tumor with a large 10x8x7 cm with adhesions around the organ. Microscopic features support a thymoma A. Patients receive perioperative plasmaparesis 1 series (5x administration) divided, 2 preoperative and 3 postoperative times. The patient used mechanical ventilation for less than 24 hours and no residual symptoms. Conclusion: Myastenia gravis grade IIa (Osserman) with thymoma A performed extended thymectomy. Plasmaparesis given pre and post surgery showed clinical improvement and duration of short ventilator use. Good prognosis associated with mild MG degree, no myastenia crisis.

 

Keywords: myastenia gravis, thymectomy, plasmaparesis

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Preeclampsia management: different insight from hospital to hospital approach in Indonesia

Firdy Liwang, Agha Bhargah

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Introduction: The incidence of preeclampsia quite high and can cause high morbidity and mortality rates for pregnant women thereby preeclampsia is still a problem experienced worldwide. Preeclampsia in Indonesia still gives a frightening impression for both the mother and the fetus. The key to success in the treatment of preeclampsia is prevention and adequate therapy to reduce morbidity and mortality. Indonesia itself, which is an archipelagic country resulting in far apart geographical location between one central hospital to another central hospital that will cause some differences related to the treatment of preeclampsia itself.

Aim: The purpose of this review is to give an overview of the different approaches to handling preeclampsia in hospitals in Indonesia, especially Sanglah General Hospital Denpasar and Kandou General Hospital Manado.

Conclusion: There are several differences in the treatment of severe preeclampsia at Sanglah General Hospital Denpasar Bali and Prof. Dr. R.D. Kandou Hospital Manado. The differences found were ways to induce labor, use of corticosteroids, detail of MGSO4 administration, and the selection of antihypertensive drugs.

 

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Correlation of lactate levels with sequential organ failure assessment (SOFA) score in sepsis patients in H. Adam Malik Hospital Medan

Jemie Jemie, Ricke Loesnihari, Achsanuddin Hanafie

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Introduction: Lactate is an intermediate metabolic that is non-toxic and were produced by all cells. In sepsis patients, increased lactate occurs due to tissue hypoperfusion and represent a sign of tissue hypoxia. A clinical scoring system such as Sequential Organ Failure Assessment (SOFA), was commonly utilized to assess the severity of sepsis periodically based on several clinically significant organ dysfunction. The purpose of this study was to investigate the correlation of lactate levels with SOFA scores on sepsis patients treated in ICU.

Method: This is a prospective cohort study, involving 57 patients with sepsis who met the inclusion and exclusion criteria. The blood lactate levels were measured, and the SOFA scores were calculated, which then analyzed with Spearman correlation test.

Results: There was a weak but significant correlation between lactate levels and 24-hour SOFA Score (r = 0.303, p = 0.022). An intermediate correlation was obtained with 48 hours SOFA Score (r = 0.449, p = 0.000). Organ dysfunction that plays a significant role in increased lactate in this study were the central nervous system, respiratory system, liver, and kidneys.

Conclusion: There was an association between lactate levels and SOFA scores at 24^th and 48^th hour. SOFA Score can be considered as proper parameters to evaluate the deterioration of septic patients treated in the ICU.

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The difference of nitric oxide (NO) and serum creatinine (SC) levels in hemodialyzed and non-hemodialyzed chronic kidney disease patients at H. Adam Malik Hospital, Medan, Indonesia

Ruslan Dame Hotmauli Marpaung, Ratna Akbari Ganie, Alwi Thamrin Nasution

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Background: Chronic Kidney Disease is structural or functional abnormalities of the kidney that last more than 3 months, with or without decreased glomerular filtration rate (GFR) which can be exacerbated by reduced production of Nitric Oxide (NO) or increased serum creatinine level. Hemodialysis is a removal process of solute from the circulation of patients with an impaired renal function to the fluid dialysate by diffusion process through the semi-permeable membrane. This study aims to determine the difference of the Nitric Oxide (NO) and serum creatinine (SC) levels between regular hemodialysis and non-hemodialysis CKD patients.

Methods: A cross-sectional study was conducted at Outpatient and Inpatient Section of Nephrology Division, Internal Medicine Department, H. Adam Malik Hospital, Medan during July-August 2017 among 27 respondents who undergone regular Hemodialisa (HD) and 27 respondents in non-Hemodialisa (non-HD) group. The patients that fulfill the inclusion criteria of the study were enrolled. Nitric Oxide examination was carried out by using Chemwell analyzer with a double-antibody sandwich method using Enzyme method -Linked Immunosorbent Assay (ELISA).

Results: There was no significant difference of NO-levels between HD groups (1476.14± 1431.1 µM) with non HD (1123.06 ± 1150.83 µM) (P= 0.250). However, there was a significant difference of creatinine level between HD groups (11.8±3.26 pg/mL) with a non-HD group (5.71±5.03 pg/mL) (P = 0.000).

Conclusion: No significant difference of NO levels were found in HD patients and non-HD CKD patients. However, a current study exhibits a significant relationship between SC levels of CKD patients between both groups.

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Long-term visual deprivation inhibit the visual lobe neocortex cytoarchitecture increment in 42 days male rats (Rattus norvegicus): a stereological study

Gede Wirata, I Nyoman Mangku Karmaya, I Made Muliarta

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Background: The inhibition of nerve impulse transmission between the onset of the nervus opticus pathway and the terminal of radiatio opticus can reduce cortical reflex so that visual deprivation appears. Visual deprivation at the level of the neocortex can change the structure itself if it occurs over a critical period of neuron development in the neocortex layer in infants. Strategies to measure the quality and quantity of neocortex cytoarchitecture of visual lobe require unbiased stereological methods.

Aim: This study aimed at proving long-term visual deprivation can reduce the visual lobe neocortex cytoarchitecture.

Methods: This research was an experimental study with post test only control group design from 2018 till 2019. The sample was 30 male 42-day-old rats (Rattus norvegicus) about 60-80 g in weight regarding the inclusion criteria. This study involved six random groups divided into control groups, monocular deprivation, and binocular deprivation where each group was further divided into groups that experienced treatment for 7 and 14 days.

Results: There was a difference in mean volume of visual lobe neocortex between groups P1 and P2 compared to P0 (7) or P0 (14) (p <0.05). The P1 group (14) had a lower average than the P1 group (7) (p <0.05); (2) There was a difference in the mean of pyramidal visual lobe neocortex cell density between groups P1 and P2 against group P0 (7) or P0 (14) (p <0.05). There was no significant difference in the 14-days deprivation group against 7-days, both monocular and binocular; (3) there was a difference in the total number of visual lobe neocortex pyramidal cells between groups P1 and P2 compared to groups P0 (7) or P0 (14) (p <0.05). Group P1 (14) has a lower average cell number than group P1 (7); (4) The group P0 (14) has the highest neocortex volume, density, and pyramidal cells total number compared to groups P0 (7), P1, and P2. The CE value is 0.2, which is the optimal estimated strength used.

Conclusion: Visual deprivation for more than seven days has been shown to reduce mean difference neocortex volume, cell density, and the pyramidal cells number of visual lobe neocortex against either 7 days or 14 days group.

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Vulvovaginitis gonococcal in a child: A case report

I Gusti Ayu Agung Elis Indira, Putu Ayu Elvina, Made Dwi Puspawati, Anak Agung Gde Putra Wiguna

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Background: Gonococcal or gonorrhea infection is one of the most common sexually transmitted infections (STIs). This infection is caused by Neisseria gonorrhoeae, a Gram-negative aerobic diplococcus. Gonorrhea is transmitted primarily through sexual intercourse, especially in the sexually active age, between 15-29 years. Gonococcal vaginitis is the most common form of gonorrhea in children. The infection in children generally indicates the existence of sexual contacts that require proper management. Although infrequent, nonsexual gonorrhea transmission, either from vomit, physical contact or autoinoculation may occur in children.

Case: A vulvovaginitis was found in 7-year-old Balinese girl. She was diagnosed with gonococcal infection based on the anamnesis, physical examination and laboratory examination from vagina discharge with gram stain and culture. She was treated with oral Cefixime 200 mg tablet in a single dose and obtained clinical and laboratory improvement within the period of observation for eight days. Further examination and management of the patient's parents are also performed.

Discussion: Oral cefixime is preferred for children because the route of administration is not traumatic, and have a lower price with equally good effectiveness compared to injections. There were no signs of sexual violence, and no gonococcal infection was found in the family. It is suggested that it was transmitted from nonsexual contact from the patient’s friend; however, the source of infection need to be further investigated.

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