Insulin Use and The Risk of Hepatocellular Carcinoma: Insights and Implications.

In recent years, the incidence of diabetes mellitus and hepatocellular carcinoma (HCC) has been increasing worldwide, in the context of an increasing prevalence of non-alcoholic fatty liver disease (NAFLD). In patients with diabetes mellitus, exogenous insulin is commonly prescribed and used in long-term settings. Recent studies suggest that insulin use may elevate the risk of HCC. A substantial body of work seeks to unpack the association between insulin use and the risk of developing HCC, although there may be conflicting evidence. Further validation is necessary to clarify the true relationship between insulin mechanisms and its hepatocarcinogenic effect. Given the burden of diabetic patients developing HCC, diabetologists and hepatologists must collaborate, particularly regarding the prevention and surveillance of HCC in diabetic patients.

Transarterial embolization with bleomycin-lipiodol emulsion: a successful minimal invasive approach for giant liver hemangioma.

Hemangiomas are most common benign liver tumor. Most patients have an excellent prognosis because of the small size and benign nature of tumor. On some occasions, giant liver hemangioma may cause symptoms and significant challenges due to its complication. We report a case of giant liver hemangioma treated with minimal invasive approach by transarterial embolization (TAE). Following three TAE sessions over a specific timeframe, the patient was successfully managed, addressing that TAE may be a useful alternative to hepatic surgery in such cases.

Stemness markers in hepatocellular carcinoma of Eastern vs. Western population: Etiology matters?

Hepatocellular carcinoma (HCC) is one of the most common cancers with a high mortality rate. HCC development is associated with its underlying etiologies, mostly caused by infection of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV), alcohol, non-alcoholic fatty liver disease, and exposure to aflatoxins. These variables, together with human genetic susceptibility, contribute to HCC molecular heterogeneity, including at the cellular level. HCC initiation, tumor recurrence, and drug resistance rates have been attributed to the presence of liver cancer stem cells (CSC). This review summarizes available data regarding whether various HCC etiologies may be associated to the appearance of CSC biomarkers. It also described the genetic variations of tumoral tissues obtained from Western and Eastern populations, in particular to the oncogenic effect of HBV in the human genome.

The validity and reliability of Indonesian version of atrial fibrillation effect on quality of life (AFEQT) questionnaire for atrial fibrillation patients.

BACKGROUND: More than 60% of patients with atrial fibrillation (AF) have a significant health-related quality of life (HRQoL) impairment. HRQoL, a patient-reported outcome (PRO), has become an important endpoint to assess treatment success in AF patients. The Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaire is an AF-specific HRQoL tool shown to be feasible, reliable, and valid, with translations in various languages. Since this questionnaire has never been translated or validated in Indonesian, we aimed to determine the validity and reliability of the Indonesian version of the AFEQT questionnaire for AF patients. RESULTS: This cross-sectional, observational study was conducted in the Integrated Cardiovascular Service Polyclinic, Cipto Mangunkusumo Hospital, Indonesia, from December 2021 to March 2022. A total of 30 participants were recruited for cross-cultural adaptation process, which consisted of translation and adaptation process, and a total of 102 participants were consecutively recruited to participate in the validation process, which consisted of validity test (construct validity) and reliability tests (internal consistency and test-retest). The retest was conducted within a 1-2-week interval after the baseline assessment, by analyzing the intraclass correlation coefficient (ICC). The construct validity was determined by multitrait scaling analysis, and the convergent and divergent validity was compared to SF-36 domains. Multitrait scaling analysis revealed that all items in the Indonesian version of the AFEQT questionnaire had a strong negative correlation towards their respective domains (r -0.639--0.960). For convergent and divergent validity, AFEQT domains had weak to strong positive correlations to all SF-36 domains (r 0.338-0.693). This questionnaire also had acceptable internal consistency (Cronbach's α for overall score: 0.947; Domains: Symptoms: 0.818, Daily Activities: 0.943, Treatment Concern: 0.894, and Treatment Satisfaction: 0.865), as well as moderate-to-good test-retest reliability (0.521-0.828). CONCLUSIONS: The Indonesian version of the AFEQT questionnaire has good validity and reliability for assessing quality of life of atrial fibrillation patients in Indonesia.

Therapeutic Plasma Exchange as a Bridging Therapy for the Definitive Treatment of a Patient with Graves' Disease and Methimazole-Induced Liver Injury.

Introduction: Graves' disease (GD) is an autoimmune condition affecting the thyroid gland. The aim of treating GD is to control the symptoms of hyperthyroidism and achieve long-term remission. Antithyroid drugs (ATDs) are the medications of choice among newly-diagnosed GD patients as they are easy to be delivered and cause remission in more than 50% of patients. However, ATDs increase the risk of hepatotoxicity, especially among patients with liver abnormalities. Patients who cannot tolerate ATDs should receive definitive therapy such as radioactive iodine (RAI) or surgery. In order to minimize the risk of thyroid storm during these procedures, patients should be in euthyroid condition and receive bridging therapy. Therapeutic plasma exchange (TPE), which aims to remove thyroid hormones from plasma, is one of the modalities that can be considered as a bridging therapy during the perioperative period among GD patients who cannot tolerate ATD. Case Presentation: A 35-year-old man with general weakness and thyrotoxicosis symptoms was admitted to the emergency room. Lid retraction, diffuse Goiter, and tremors were evident. Laboratory findings revealed TSH = 0.005 µIU/mL, FT4 = 7.77 ng/dL, TRAb = 9.90 IU/L, ALT = 123 U/L, total bilirubin = 23.94 µmol/L, and direct bilirubin = 10.26 µmol/L. Ultrasonographic examination showed the enlargement of the thyroid gland, and abdomen ultrasonographic evaluation showed mild hepatomegaly with mild fatty infiltration. The patient was diagnosed with GD, suspected thyroid storm, elevated liver transaminases, and fatty liver disease. The patient then received methimazole, propranolol, and glycyrrhizin. During observation, the patient developed drug-induced liver injury (DILI) evidenced by an increase in liver enzymes (ALT up to 1023 U/L) and the elevation of total bilirubin to 258.21 µmol/L, so methimazole was stopped. After discontinuing methimazole, liver injury improved. However, thyrotoxicosis symptoms returned, so the patient underwent a total thyroidectomy. In order to achieve a euthyroid status before surgery, five sessions of therapeutic plasma exchange were performed, which improved the signs and symptoms of hyperthyroidism and retained the thyroxine hormone within the normal range. Thyroidectomy was then performed successfully without serious complications (e.g., thyroid storm, etc.). Conclusions: Therapeutic plasma exchange is a safe and effective bridging therapy for GD patients who require thyroidectomy but cannot tolerate ATDs.

Performance of EncephalApp Stroop Test in Cirrhotic Patients for Evaluating Covert Hepatic Encephalopathy.

BACKGROUND: Covert hepatic encephalopathy (HE) is the mildest HE spectrum that is difficult to detect, but associated with significant decrease in quality of life. Currently, there is no gold standard to detect covert HE. EncephalApp Stroop Test as a newer diagnostic tool is easier, faster and its ease of availability in various health institutions is expected to be applied in Indonesia for covert HE detection. This study aimed to validate and test the reliability and diagnostic ability of EncephalApp Stroop Test to diagnose covert HE, compared to the Psychometric Hepatic Encephalopathy Score (PHES) and critical flicker frequency (CFF). METHODS: This study is a cross-sectional test, conducted from August to September 2018, targeted at patient with cirrhosis in Jakarta, to obtain Area Under The Curve (AUC), sensitivity, specificity, cut-off point, predictive value, likelihood ratio, and post-test probability of the EncephalApp Stroop Test, compared to PHES and CFF. The Validity and reliability tests were done before diagnostic study. Translation of the EncephalApp Stroop Test were first carried out using WHO protocol. All patients first underwent a Mini Mental State Examination and Ishihara Test to rule out color blindness. RESULTS: Thirty subjects participated in validity and reliability tests, and eighty in diagnostic tests. The translated application showed excellent internal consistency (Chronbach's Alpha of 0.942) and correlation coefficient of 0.82. The diagnostic study showed OnTime + OffTime as the best parameter (AUC: 0.897 (95% CI: 82.9% - 96.5%); sensitivity: 88.6%; specificity: 80%; positive predictive value (PPV): 0.77; negative predictive value (NPV): 0.9; positive likelihood ratio (LK+): 4.4; negative likelihood ratio (LK-): 1.4; positive post-test probability: 0,775; negative post-test probability: 0,1; and cut-off point ≥ 188.8 seconds. CONCLUSION: The EncephalApp Stroop Test is valid and reliable, with good AUC value, sensitivity, specificity, PPV, NPV and likelihood ratio in diagnosing covert hepatic encephalopathy in patients with cirrhosis in Indonesia.

Risk factors of severe hypoglycemia among patients with type 2 diabetes mellitus in outpatient clinic of tertiary hospital in Indonesia.

This study aimed to describe risk factors of severe hypoglycemia in type 2 diabetes mellitus (T2DM) patients in a tertiary care hospital in Indonesia. This study was a retrospective cohort study in the Endocrinology Outpatient Clinic of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia. All subjects more than 18 years old who had been visiting the clinic for at least a year were included. Subjects were interviewed whether they had any severe hypoglycemia events within the past year, while data on risk factor variables of severe hypoglycemia was taken from medical records one year before data collection. We recruited 291 subjects, among whom 25.4% suffered at least one episode of severe hypoglycemia within one year. History of severe hypoglycemia (OR 5.864, p ≤ 0.001), eGFR less than 60 mL/min/1.73m2 (OR 1.976, p = 0.028), and insulin use (OR 2.257, p = 0.021) were associated with increased risk of severe hypoglycemia. In conclusion, history of previous severe hypoglycemia, eGFR less than 60 mL/min/1.73m2, and insulin use were associated with severe hypoglycemia.

Relationship between anal swab PCR for SARS-CoV-2 with gastrointestinal clinical manifestations and severity of COVID-19 infection in Indonesia.

Introduction: Coronavirus disease 2019 (COVID-19) cases caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Indonesia remain high. The virus can bind with ACE2 receptor which is not only found in the lungs, but also in the digestive tract. Thus, it allows SARS-CoV-2 infection in the gastrointestinal tract, gastrointestinal manifestations, and detection of viral RNA on anal swab using polymerase chain reaction (PCR). There hasn't been similar study about the role of anal swab in Indonesia yet. Therefore, this study aims to determine the relationship between SARS-COV-2 anal swab PCR with gastrointestinal clinical manifestations, and the severity of COVID-19 in Indonesia. Methods: This is an analytical study with cross-sectional design. Samples were obtained from hospitalized COVID-19 patients from July 2020 to January 2021. Demographic data, clinical manifestations, severity, and SARS-CoV-2 anal swabs PCR were collected using case report form. Results: A total of136 patients were analyzed. 52 patients (38.2%) had positive SARS-CoV-2 anal swabs PCR and 84 patients (61.8%) had negative results. The most common gastrointestinal clinical manifestations were nausea and vomiting in 69 patients (50.7%), anorexia in 62 patients (45.6%), and abdominal pain in 31 patients (22.8%). There were 114 patients (83,8%) classified as mild-moderate symptoms and 22 patients (16,2%) classified as severe-critical symptoms. There was a statistically significant relationship between the gastrointestinal tract SARS-CoV-2 infection and gastrointestinal clinical manifestations (P=0.031). There was no statistically significant relationship between the gastrointestinal SARS-CoV-2 infection and the severity of COVID-19 infection (P = 0.844). Conclusions: This study showed there is a significant relationship between SARS-CoV-2 anal swab PCR with gastrointestinal clinical manifestations. There is no significant relationship between anal swab PCR with the severity of COVID-19 infection.

Comparison Between Neutrophil-Lymphocyte Ratio and Systemic Immune-Inflammation Index as Predictors of One-Year Survival in Patients with Untreated Advanced Hepatocellular Carcinoma.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) generally only come for treatment when cancer has reached an advanced stage, with very limited treatment options. There has not been an accurate predictor marker to be able to identify which group of patients may have better survival. This study wanted to analyze the role of the inflammatory status indices as predictors of 1-year survival in patients with advanced HCC who did not undergo therapy. METHODS: This study has a retrospective cohort design using secondary data on subjects with advanced HCC who did not undergo therapy at Cipto Mangunkusumo Hospital and Dharmais Hospital. The neutrophil-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) were evaluated for their role as predictors of 1-year survival based on the area under receiving operator curve (AUROC). The best optimal cut-off for NLR and SII was decided based on the Youden index, followed by survival analysis based on those cut-offs. Confounding factors were analyzed with multivariate cox regression analysis. RESULTS: A total of 196 subjects were included in the data analysis. One-year survival was 6.6%, with a median survival of 56 days (95% CI: 46-67). The NLR had a discriminatory ability based on AUROC of 0.667 (95% CI: 0.536-0.798; p = 0.044), with the optimal cut-off point to differentiate survival was 3.7513. The SII has a discriminatory ability based on AUROC of 0.766 (95% CI: 0.643-0.889; p = 0.001), with the optimal cut-off point to distinguish survival was 954.4782. SII had superiority in discriminatory ability (p = 0.0415). CONCLUSIONS: The discriminatory ability based on AUROC of SII was better than that of NLR in predicting 1-year survival in patients with advanced HCC who did not undergo therapy.

National Consensus on Portal Hypertension Management in Indonesia.

Portal hypertension is a clinical syndrome that consists of hypersplenism, ascites, gastroesophageal varices, and encephalopathy. This condition is marked by increased portal pressure gradient and may occur with or without liver cirrhosis. To date, portal hypertension remains as the leading cause of severe complications and death of a patient with chronic liver disease, especially liver cirrhosis. Therefore, thorough understanding about management of portal hypertension is strongly required, especially considering that many complications of portal hypertension require early diagnosis and treatment to improve the prognosis of the patients. Additionally, although hepatic venous pressure gradient (HVPG) measurement has become a gold standard procedure for measuring portal pressure in the last twenty years, utilization of this method in Indonesia has been hindered by reluctance of the patients due to its invasiveness, high cost, and limited availability. This consensus is developed with evidence-based medicine principles to provide a guideline for portal hypertension management for general practitioners, specialists, and consultants, to achieve better clinical outcomes of portal hypertension in Indonesia.  Keywords: portal hypertension, liver cirrhosis, chronic liver disease.

The Validity and Reliability of the Indonesian Version of the Chronic Liver Disease Questionnaire (CLDQ) in Measuring Quality of Life in Patients with Liver Cirrhosis.

BACKGROUND: Liver cirrhosis remains the major cause of liver-related morbidity and mortality around the world. Cirrhosis also negatively affects health-related quality of life. Quality of life evaluation in cirrhosis treatment is often overlooked, despite its importance compared to traditional outcome. One of the specific tools to measure quality of life in cirrhosis patient is the Chronic Liver Disease Questionnaire (CLDQ). Although this tool has been widely used in many countries, no studies have been conducted on its validity and reliability in the Indonesian language. This study aimed to assess the validity and reliability of the Indonesian version of CLDQ using appropriate methods. METHODS: This is a cross-sectional study conducted at Hepatobiliary outpatient clinic in Dr. Cipto Mangunkusumo National General Hospital (RSCM), from April-May 2021. The CLDQ was first translated into the Indonesian language and subsequent pretest was performed on 10 people, resulting in the final Indonesian version of the CLDQ. The final version was later tested in the main study with larger number of subjects (52 people). Validity was assessed using construct and external validity tests, while reliability was tested using internal consistency and test-retest methods. RESULTS: The Indonesian version of CLDQ had a good construct validity (r 0.613-0.917), moderate external validity (54.1%), strong correlations between CLDQ and SF-36, good internal consistency (Cronbach-Alpha ≥ 0.7), and good test-retest reliability (ICC > 0.7). CONCLUSION: The Indonesian version of CLDQ is valid and reliable in measuring the quality of life of liver cirrhosis patients in Indonesia.

One Year Survival of Extrahepatic Cholangiocarcinoma Patients Who Did Not Undergo Curative Resection and Paliative Chemotherapy and Its Associated Factors.

BACKGROUND: Extrahepatic cholangiocarcinoma is rare but fatal. Patients who come are usually already in the advanced stage that can not undergo curative resection and chemotherapy also seems to be very rarely done. The survival rate and its associated factors in Indonesia are unknown. This study aimed to identify 1-year survival of patients with extrahepatic cholangiocarcinoma without curative resection and palliative chemotherapy and its associated factors. METHODS: This is a cross-sectional study using medical records of extrahepatic cholangiocarcinoma (perihilar and distal) inpatient and outpatient patients at Cipto Mangunkusumo Hospital, Jakarta from January 2015 to March 2020, reviewed retrospectively. The following factors were analyzed in terms of mortality: metastasis, sepsis, hypoalbuminemia, serum bilirubin level, serum CA 19-9 level, billiary drainage, neutrophyl lympocyte ratio (NLR) and comorbid factors. RESULTS: 115 out of 144 patients were enrolled in this study with male proportion of 50.4%, and proportion of patients aged 65 years or above was 71.3%. 1 year survival rate was 10 % and median survival was 3 months (CI 95% 2.388-3.612)Multivariate analysis showed that only sepsis, unsuccessful or no prior biliary drainage and total bilirubin >19.8 mg/dl were independent predictors of mortality. CONCLUSION: 1 year survival of extrahepatic cholangiocarcinoma without curative resection and paliative chemotherapy was 10 %.Sepsis, unsuccessful or no prior bilirary drainage, and total biirubin >19.8 mg/dl  are factors significantly associated with shortened survival in malignant obstructive jaundice patients.

Diagnostic Value of Neutrophil to Lymphocyte Ratio in Non-Alcoholic Fatty Liver Disease Evaluated Using Transient Elastography (TE) with Controlled Attenuated Parameter (CAP).

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a chronic inflammatory disease with excessive fat accumulation in the liver. Transient elastography (TE) with controlled attenuation parameter (CAP) is a device and method to examine the degree of fibrosis and steatosis. However, this device is not widely available across Indonesia. Neutrophil and lymphocyte ratio (NLR) is a simple marker for inflammation, which has a potency to predict disease outcome. This study aims to know the diagnostic value of NLR as the indicator of steatosis and fibrosis severity. METHODS: This was a cross-sectional study with consecutive sample collection. We used secondary data from medical records, starting from 2016 to 2018. A descriptive and data analysis, including correlation test, multivariate linear regression, t-test, receiver operating curve (ROC) and area under the curve (AUC) were done to find out the outcome of the study. Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) Version 20.0 (SPSS Inc, Chicago, Illinois). A P value <0.05 was considered as statistically significant. RESULTS: Out of 106 subjects, 62.3% patients were women with the mean of age 57.29 years old and 77.4% had metabolic syndrome. Most patients had moderate to severe steatosis degree (66%) with the mean of TE mean 6.14 (2.8-18.2) kPa. There was a positive correlation between CAP and TE compared with NLR with r = 0.648 (p < 0.001) and r = 0.621 (p < 0.001), respectively. The use of RNL to assess moderate-severe steatosis has a cutoff point of 1.775 with sensitivity, specificity, PPV and NPV, respectively, at 81.5%, 80.6%, 89.1%, and 69.1%; cutoff point 2.150 to assess significant fibrosis with sensitivity, specificity, PPV and NPV of 92.3%, 87.5%, 70.6%, and 97.2%, respectively. CONCLUSION: NLR has a positive and significant correlation with the degree of steatosis and fibrosis with high sensitivity and specificity as evaluated by TE/CAP.

Overall Survival of Hepatocellular Carcinoma Patients Underwent Radiofrequency Ablation (RFA) Treatment: a Retrospective Cohort Study from Two Referral Hospitals in Indonesia.

BACKGROUND: Radiofrequency ablation (RFA) is one of the curative modality therapies commonly used for the early stage of HCC management. Although numerous studies have reported the outcome of RFA around the world, the data regarding the usage of RFA for the early and intermediate stage of HCC remains limited. Hence, the study aimed to report the survival rate of the early and intermediate stage HCC patients who underwent RFA in two tertiary referral hospitals in Jakarta, Indonesia. METHODS: A retrospective cohort study was conducted in Cipto Mangunkusumo and Medistra multicenter hospital in Jakarta, Indonesia. The patients with HCC BCLC A and B who underwent RFA treatments between January 2015 to December 2017 were recruited for the study. Baseline characteristics of patients were collected from the medical record. Survival analysis was calculated using the Kaplan Meier. p value result was obtained from the log-rank test. Sub-analysis of factors associated with the survival was also included in this study. RESULTS: There were 62 patients enrolled in this study (32.3% were BCLC A and 67.7% were BCLC B). Forty-six out of 62 patients (74.2%) were reported to have RFA as their first line of treatment, while 12 (25.8%) were reported to have a combination of RFA and other therapy modalities. All these patients were follow-up with an average duration of 27 months. The survival rate of liver cancer due to HCC for 12 and 36 months in patients who received RFA was 82.3% and 57.8%, respectively. Moreover, BCLC staging of liver cancer and response after RFA was significantly associated with survival. CONCLUSION: RFA still can be used as initial modality therapy nor combination with another therapy for the early and intermediate stage of HCC. BCLC staging and response after RFA had shown to be the independent factors related to survival.

Diagnostic Performance of Mac-2-Binding Protein Glycosylation Isomer (M2BPGi), compared to Transient Elastography to Assess Liver Stiffness in Treatment Naïve Chronic Hepatitis C Patients.

BACKGROUND: Liver fibrosis is an essential factor in the management of Hepatitis C virus infection. Its assessment is crucial in decision-making regarding the therapeutic decisions, and the patients' follow up. However, the established liver measurement methods have several limitations. Therefore, this study aims to assess the role of Mac-2-Binding Protein Glycosylation Isomer (M2BPGi) as a novel biomarker to measure liver stiffness in treatment naïve Chronic Hepatitis C Indonesian patients. METHODS: This study used a cross-sectional design to determine the correlation between serum M2BPGi and the degree of liver stiffness, Transient Elastrography, and differences in serum M2BPGi levels in chronic hepatitis C patients. Serum M2BPGi level and Transient Elastography results were evaluated in 56 Chronic Hepatitis C patients and 48 healthy controls. Pearson correlation analysis was conducted to find the correlation between the level of M2BPGi and Transient Elastography result. ROC analysis was conducted to find the optimum cut-off to assess fibrosis's degree among Chronic Hepatitis C Patients. RESULTS: The level of serum M2BPGi and Transient Elastography result was strongly correlated with the median level of serum M2BPGi. It was also significantly higher among Chronic Hepatitis C Patients than among healthy controls (r: 0.708, p<0.001; 0.590 COI vs. 4.130 COI, p<0.001). Among the Chronic Hepatitis C patients, the median serum of M2BPGi increased according to the degree of liver fibrosis: 1.500 COI (F0-F1), 2.985 COI (F2-F3) and 8.785 COI (≥F4). The optimum cut-off value for diagnosing significant fibrosis (F2-F3) was 1.820 COI (AUC: 90.8%) and for diagnosing cirrhosis (≥F4) was 3.770 COI (AUC: 89.3%). CONCLUSION: Serum M2BPGi was a reliable diagnostic tool for identifying liver fibrosis in Indonesian patients with Chronic Hepatitis C.

The value of anal swab RT-PCR for COVID-19 diagnosis in adult Indonesian patients.

OBJECTIVE: This study will test the performance of the anal swab PCR test when compared with the nasopharyngeal swab PCR test as a diagnostic tool for COVID-19. DESIGN: An observational descriptive study which included hospitalised suspected, or probable cases of hopitalised COVID-19 patients, conducted in Dr. Cipto Mangunkusumo National Hospital, Ciputra Hospital, Mitra Keluarga Depok Hospital and Mitra Keluarga Kelapa Gading Hospital, Indonesia. Epidemiological, clinical, laboratory and radiology data were obtained. Nasopharyngeal and anal swabs specimens were collected for SARS-CoV-2 RNA detection. RESULTS: We analysed 136 subjects as part of this study. The clinical spectrum of COVID-19 manifesation in this study was typical of hospitalised patients, with 25% classified as mild cases, 14.7% in severe condition and 12.5% of subjects classified as having acute respiratory distress syndrome. When compared with nasopharyngeal swab as the standard specimen for reverse transcription polymerase chain reaction (RT-PCR) detection of SARS-CoV-2 antigen, the sensitivity and specificity of the anal swab was 36.7% and 93.8%, respectively. The positive and negative predictive value were 97.8% and 16.5 %, respectively. The performance of the anal swab remained similar when only the subgroup of patients with gastrointestinal symptoms (n=92, 67.6%) was analysed (sensitivity 40% and specificity 91.7%). Out of all the subjects included in analysis, 67.6% had gastrointestinal symptoms. Similarly, 73.3% of patients in the anal swab-positive group had gastrointestinal symptoms. The two most common gastrointestinal symptoms in the subjects' population were nausea and anorexia. CONCLUSION: Anal swab specimen has low sensitivity (36.7%) but high specificity (93.8%) for detecting SARS-CoV-2 antigen by RT-PCR. Only one additional positive result was found by anal swab among the nasopharyngeal swab-negative group. Anal swab may not be needed as an additional test at the beginning of a patient's diagnostic investigation and nasopharyngeal swab RT-PCR remains as the standard diagnostic test for COVID-19.

Effects of Extracardiac Factors in Signal-Averaged Electrocardiography-measured Late Potentials from Early Anterior Myocardial Infarction in Intensive Cardiac Care Unit.

BACKGROUND: one modality that can predict ventricular arrhythmias after myocardial infarction (MI), particularly anterior MI, is signal-averaged electrocardiogram (SA-ECG), through the detection of late potentials (LP) which is a substrate for ventricular arrhythmias. Extracardiac factors, which are also risk factors for MI, such as hypertension, diabetes, dyslipidemia, and obesity, are apparently associated with post-MI ventricular arrhythmias, which in turn may be correlated with LP. This study aims to determine the effect of extracardiac risk factors on LP incidence in anterior MI patients treated in the intensive cardiac care unit (ICCU). METHODS: this was a cross-sectional study in which 80 subjects with anterior MI during the period of December 2018-2019 underwent SA-ECG examination. The medical history and extracardiac risk factors were recapitulated, and then the SA-ECG data was taken from either direct examination or ICCU patients' database in that period. This study used multivariate analysis with logistic regression test. RESULTS: the most common factors found were hypertension (70.00%), followed by dyslipidemia (56.25%), diabetes (46.25%), and obesity (38.75%). Obesity and dyslipidemia are extracardiac factors with the two biggest roles in the prevalence of LP. However, from additional analysis, we found that diabetes with acute hyperglycemia also had immense influence on the occurrence of LP. The OR for diabetes with acute hyperglycemia, obesity, and dyslipidemia were 4.806 (IK95% 0.522-44.232), 4.291 (IK95% 0.469-39.299), and 3.237 (IK95% 0.560-18.707). However, the association is not statistically significant. CONCLUSION: patients with anterior MI who suffer from diabetes with hyperglycemia in admission, obesity, and dyslipidemia have a potentially higher LP prevalence, despite statistical insignificance. To increase the prognostic value of SA-ECG, serial examinations are needed during hospitalization.

Clinical significance of isolated gastric varices in liver cirrhotic patients: A single-referral-centre retrospective cohort study.

INTRODUCTION: Gastric varices (GVs) occur in 10-30% of liver cirrhotic patients, with a mortality rate of up to 45%. Rupture of isolated GVs (IGVs) is less prevalent but often results in more severe hemorrhage and a higher risk of mortality than rupture of esophageal varices (EVs). However, there is no clear consensus yet about the optimal management for incidentally discovered IGVs. OBJECTIVE: To determine the clinical significance of IGVs in liver cirrhotic patients. METHODS: This was a retrospective cohort endoscopy database study within a 2-year period (2016-2017). All study subjects were liver cirrhotic patients with OVs or GVs. The exclusion criteria were noncirrhotic portal hypertension, presence of malignancy, absence of varices, and incomplete data. Statistical analysis was performed using IBM SPSS 23. RESULTS: A total of 153 patients were included in this study. IGVs were found in 13 (8.49%) patients, whereas OVs were found in 112 (73.20%) patients and gastro-OVs were found in 28 (18.30%) patients. Child-Pugh class C (CP C) score was the strongest independent risk factor for variceal bleeding in bivariate analysis (hazard ratio [HR]: 10.21, 95% confidence interval [CI]: 4.15-25.12, P = 0.001) and multivariate analysis (HR: 12.49, 95% CI: 4.95-31.54, P 0.001); however, the presence of IGVs was not an independent risk factor. CP C score was also the only significant risk factor associated with 1-year mortality in liver cirrhotic patients on multivariate analysis (HR: 26.77, 95% CI: 6.01-119.34, P 0.001). CONCLUSION: The presence of IGVs has no clinical significance in the occurrence of 1-year rebleeding and in patient survival.

Diagnostic performance of APRI and FIB-4 for confirming cirrhosis in Indonesian HIV/HCV co-infected patients.

BACKGROUND: After successful of antiretroviral therapy, highly effective direct acting antiviral (DAA) make HCV elimination reasonable in HIV/HCV co-infected patients. However, in achieving this target, there are still barriers to start DAA treatment, particularly in the area of liver fibrosis assessment that determine the duration of therapy. We aimed to assess the diagnostic performance of APRI and FIB-4 for diagnosing cirrhosis in HIV/HCV co-infected patients using hepatic transient elastography (TE) as gold standard. METHOD: This is a retrospective study on HIV/HCV co-infected patients who concomitantly performed hepatic TE measurement, APRI, and FIB-4 evaluation before HCV treatment initiation at a tertiary hospital in Jakarta from 2014 to 2019. Sensitivity, specificity and diagnostic accuracy of indirect biomarkers for liver stiffness measurement (LSM) ≥ 12.5 kPa was determined by receiver operator characteristics curves. RESULTS: 223 HIV/HCV co-infected patients on stable antiretroviral therapy were included, of whom 91.5% were male with mean age of 37 (SD 5) years. Only 28.7% of patients were classified as cirrhosis (F4). Using TE as gold standard (≥12.5 kPa), the low threshold of APRI (1) had specificity 95%, sensitivity 48.4%, correctly classified 81.6% of patients, with moderate performance, AUC at 0.72 (95% CI 0.63-0.80). The optimal cut-off of FIB-4 was 1.66 [specificity 92.5%, sensitivity 53.1%, AUC at 0.73 (95% CI 0.65-0.81)] and correctly classified 81.1% of the patients. CONCLUSION: APRI score ≥ 1 and FIB-4 score ≥ 1.66 had moderate performance with high specificity in diagnosing cirrhosis. These biochemical markers could be used while TE is not available.