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"Latar belakang: Chief resident merupakan bagian penting dalam proses pendidikan di program studi pendidikan dokter spesialis (PPDS). Salah satu kompetensi chief resident adalah membimbing residen juniornya, namun kompetensi ini jarang diajarkan secara formal. Telah dilakukan program pelatihan Resident as Teacher dengan durasi 5 jam untuk 20 chief resident di PPDS Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia. Penelitian ini bertujuan mengevaluasi efek pelatihan tersebut terhadap kemampuan membimbing chief resident.dengan menggunakan metode Kirkpatrick tingkat 1 hingga 3. Metode: Penelitian kualitatif dengan dengan rancangan fenomenologi. Rancangan fenomenologi ini berupa deskripsi perspektif chief resident dan senior mengenai peningkatan kemampuan membimbing chief resident PPDS IPD FKUI setelah mengikuti pelatihan RaT. Sesuai dengan metode evaluasi Kirkpatrick, dilakukan evaluasi kepuasan peserta pelatihan, peningkatan pengetahuan pasca pelatihan, dan Focus Group Discussion untuk chief dan residen junior. Dilakukan pula triangulasi berupa observasi ronde chief dan observasi acara ilmiah siang serta analisis kasus negatif berupa in depth interview serta studi dokumen. Hasil: Berdasarkan hasil kuesioner kepuasan peserta pelatihan, materi pelatihan RaT bermanfaat untuk chief, praktis untuk diterapkan, sesi dalam pelatihan menarik dan instruktur dapat membawakan materi dengan baik. Hasil pre dan post test serta FGD menunjukkan peningkatan pengetahuan chief resident mengenai teknik microskills dan pemberian umpan balik efektif. Materi pelatihan RaT mampu laksana namun hambatan yang didtemui adalah kesulitan mencari waktu membimbing di antara beban pelayanan di Rumah Sakit Cipto Mangunkusumo (RSCM) dan kesulitan memberi umpan balik positif. Simpulan: Pelatihan RaT yang telah dilakukan sesuai dengan kebutuhan chief resident dan mampu meningkatkan pengetahuan serta keterampilan membimbing chief resident. Sebagian besar chief resident belum dapat memberi umpan balik positif. Selain itu, waktu membimbing terbatas karena tugas pelayanan yang banyak di RSCM.

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Background: Teaching junior resident and medical student is one of the responsibilities of chief resident. However, teaching skill is rarely trained formally to them. A format of Resident as Teacher (RaT) training program was developed and conducted for 20 chief residents in Internal Medicine Residency Program. The aim of this study is to evaluate the improvement of chief?s teaching skill after joining this training program, based on the first three steps of Kirkpatrick evaluation program.

Methods: Qualitative research based on phenomenology study was performed within two months after the training. Program questionnaire and pre-post test were conducted to evaluate the first (reaction) and second (learning) step of Kirkpatrick evaluation method respectively. The third step (behavior change) was evaluated by performing Focus Group Discussion for chief residents and junior residents. To increase the validity of the study, triangulation by doing indirect observation or rounds, classroom based activities and document study were done. Negative case analysis was also performed to explore further about the result of FGD.

Result: Based on the questionnaire, the participants were satisfied by the RaT program. Pre and post test evaluation and FGD show that there is improvement of knowledge about teaching and giving effective feedback. FGD results supported by observations and document study show that chiefs applied the microskills technique but had difficulty in giving positive feedback, as well as finding appropriate time for discussion within very busy schedule of junior resident in the main teaching hospital.

Conclusion: The training fulfills the need of chief resident, improves knowledge of teaching method and giving constructive feedback. However the chief residents was not used to give positive feedback to the junior residents and the busy clinical situation was identified as barrier to effective chief to junior resident learning process."

"ABSTRAKLatar Belakang: Kuesioner Identification of Senior at Risk ISAR merupakan instrumen penapis terbaik untuk stratifikasi risiko mortalitas pasien usia lanjut di IGD namun performanya belum cukup memuaskan sehingga perlu dilakukan modifikasi untuk meningkatkan kemampuan prediksinya. Delirium merupakan prediktor kuat kematian pasien usia lanjut di RSCM sehingga potensial ditambahkan untuk melakukan modifikasi ISAR. Tujuan: Menilai performa kuesioner ISAR dalam memprediksi mortalitas 30 hari pasien usia lanjut di IGD dan performa modifikasinya dengan penambahan variabel delirium Metode: Penelitian kohort prospektif berbasis penelitian prognostik pada pasien usia lanjut yang datang ke IGD RS Cipto Mangunkusumo selama September-Oktober 2016. Enam pertanyaan pada kuesioner ISAR dan 1 pertanyaan tentang delirium ditanyakan kepada pasien atau informan saat pasien tiba di triage IGD. Pasien kemudian diikuti 30 hari untuk dinilai luaran mortalitasnya. Performa ISAR dan modifikasinya dinilai melalui kemampuan kalibrasi uji Hosmer Lemeshow , diskriminasi area under ROC curve, ROC serta Nilai Duga Positif dan Nilai Duga Negatif. Hasil: Dari 306 subyek, didapatkan insidens mortalitas 30 hari sebesar 22,8 IK95 22,3-23,3 . Median usia subyek 68 tahun dengan 163 53,2 subyek laki-laki. Sebanyak 174 56,8 subyek memiliki skor ISAR lebih dari 2. Pasien yang datang dengan sindrom delirium sebanyak 26 subyek 8,4 . Kuesioner ISAR dengan titik potong 2 memiliki kalibrasi yang baik, AUC 0,59 IK95 0,56-0,62 , Nilai Duga Positif 0,26 IK95 0,21-0,35 , Nilai Duga Negatif 0,81 0,76-0,89 . Modifikasi kuesioner ISAR yang terdiri dari 3 pertanyaan saja ISAR-3 , berhasil meningkatkan AUC menjadi 0,67 IK95 0,62-0,72 dan Nilai Duga Negatif menjadi 0,87 IK95 0,84-0,89 . Simpulan: Kuesioner ISAR memiliki performa kalibrasi baik, diskriminasi kurang dan Nilai Duga Negatif baik. Modifikasi kuesioner ISAR dengan 3 pertanyaan ISAR-3 meningkatkan performa kalibrasi, diskriminasi dan Nilai Duga Negatif, sehingga dapat digunakan untuk mengidentifikasi pasien usia lanjut risiko rendah di IGD. Kata kunci: ISAR, modifikasi, delirium, usia lanjut, IGD

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ABSTRACT Background Among others, Identification of Senior at Risk ISAR questionnaire is the best screening instrument for mortality risk stratification of elderly visiting Emergency Department ED . Yet, current systematic review suggests modification to improve its predictive performance. As delirium is a strong predictor of mortality in elderly in Cipto Mangunkusumo Hospital, it becomes potential modification variable to add into ISAR. Objective To measure predictive validity of ISAR and ISAR Modification by adding delirium as a new variable to predict 30 days mortality Methods Prospective cohort study in elderly visiting ED of Cipto Mangunkusumo between September to October 2016. Calibration Hosmer Lemeshow test , discrimination AUC and predictive value of 30 days mortality were measured. Model updating was performed by bivariate and multivariate analysis of ISAR questions as variables. Result Of 306 subjects, 163 53,2 were men. 30 days mortality incidence was 22,8 95 CI 22,3 23,3 . Median age was 68 year and 174 56,8 subjects had ISAR score more than 2. Patients with delirium were 26 8,4 . ISAR , with cut off score of 2, shows good calibration, AUC 0,59 95 CI 0,56 0,62 , Positive Predictive Value PPV 0,26 IK95 0,21 0,35 , and Negative Predictive Value NPV 0,81 0,76 0,89 . Delirium as seventh question gives added value to original version of ISAR by increasing AUC to 0,61 0,58 0,64 and NPV to 0,84 0,76 0,89 . ISAR Modification, consists of 3 ISAR questions only, improves AUC to 0,67 IK95 0,62 0,72 and NPV to 0,87 IK95 0,84 0,89 . Internal validation using bootstrapping shows good calibration. Conclusion ISAR shows good calibration, poor to fair discrimination, and good NPV. Updating ISAR, by modify its questions, improves its discrimination performance and NPV, thus ISAR modification can be used to identify low risk elderly patients in ED. Key words ISAR, modification, elderly, ED "

"ABSTRAKLatar Belakang: Alfacalcidol, sebuah vitamin D analog, potensial bermanfaat memperbaiki imunosenesens pada pasien usia lanjut dengan sindrom frailty karena bekerja sebagai anti inflamasi melalui Vitamin D Receptor VDR pada makrofag dan sel TTujuan: Mengkaji efek pemberian alfacalcidol in vitro dan in vivo terhadap perubahan sitokin inflamasi IL-6, IL-10 dan Interferon g serta subset limfosit T rasio CD4/CD8, persentase sel T CD 8 CD28- dari kultur Peripheral Blood Mononuclear Cell PBMC dan Immune Risk Profile IRP pada usila dengan sindrom frailtyMetode: Selama Januari sampai Juli 2017 di RS Cipto Mangunkusumo Jakarta, direkrut masing-masing 8 orang subyek usila fit, pre-frail dan frail dan 10 subyek dewasa sehat sebagai kontrol. Pada 34 subyek ini dinilai perubahan kadar IL-6, IL-10 dan IFN g yang diukur dengan kit ELISA dari supernatan kultur PBMC 24 jam yang distimulus Lipopolisakarida LPS 100 ng/ml dengan dan tanpa pretreatment alfacalcidol in vitro. Selain itu juga dilakukan uji klinis acak tersamar ganda dengan pemberian alfacalcidol 0,5 mcg 90 hari pada 110 subyek berusia lanjut lalu diamati perubahan kadar IL-6, IL-10 dan IFN , g perubahan rasio CD4/CD8 dan persentase sel T CD8 CD28- serta penilaian Immune Risk Profile. Dilakukan uji t tidak berpasangan untuk mengetahui perbedaan rerata kadar sitokin dan persentase populasi sel T dan uji chi square untuk menilai beda proporsi subyek dengan IRP positif.Hasil: Pada penelitian in vitro didapatkan rerata kadar 25 OH D serum yang semakin menurun seiring dengan perburukan status frailty. Alfacalcidol in vitro tidak menurunkan IL-6 dan IFN g, namun meningkatkan IL-10 pada seluruh kelompok. Dari uji klinis didaparkan alfacalcidol 0,5 mcg selama 90 hari tidak menurunkan IL-6 p=0,4 dan IFN gamma p=0,001 , namun mampu meningkatkan IL-10 p=0,005 dan menurunkan rasio IL6/IL10 p=0,008 . Alfacalcidol meningkatkan rasio CD4/CD8 dari 2,68 SB 2,45 menjadi 3,2 SB 2,9 ; p=0,001 dan menurunkan persentase CD8 CD28- dari 5,1 SB 3,96 menjadi 2,5 1,5 ; p

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ABSTRACTIntroduction Chronic low grade inflammation and dysregulation of cellular immunity are the cardinal signs of immunosenescence in elderly with frailty syndrome. Alphacalcidol, a vitamin D analog shows immunoregulatory potency as it works on the macrophage and T cell, to control inflammation and T cell dysregulation in the elderly.Objective to determine the effect of alphacalcidol on inflammatory cytokines IL 6, IL 10, IFN gamma and T cell subsets CD4 CD8 ratio and CD8 CD28 and Immune Risk Profile of the elderly with frailty syndromeMethods During January to August 2017, in vitro study was conducted involving 10 healthy adults volunteer and 8 elderly each in fit, pre frail and frail category from Outpatient Clinics of Cipto Mangunkusumo Hospital Jakarta Indonesia using 24h Peripheral Blood Mononuclear Cells PBMC culture supernatants to determine the change of IL 6, IL 10 and g IFN level measured by ELISA, following stimulation with Lipopolisaccharide LPS 100 nm, with and without pretreatment with alphacalcidol. A double blind randomized controlled trial RCT with allocation concealment, involving 110 elderly subjects was also conducted to measure the effect of 0,5 mcg alphacalcidol administration for 90 days on inflammatory cytokines IL 6, IL 10, g IFN from 24 h PBMC culture supernatant, as well as CD4 CD8 and CD8 CD28 count and change of Immune Risk Profile. Statistical analysis was performed using t test to measure mean difference of cytokines and T cell count and chi square to measure proportion difference of IRP.Result In vitro study using PBMC showed alphacalcidol administration did not decrease IL 6 level IL p 0,24 and g IFN p 0,36 , but it increased IL 10 p 0,02 . Of 110 subjects involved in the RCT consisting of 27 fit elderly, 27 pre frail elderly and 56 frail elderly, it can be observed that Alphacalcidol 0,5 mcg for 90 did not decrease IL 6 p 0,4 and g IFN p 0,001 , but increased IL 10 p 0,005 and decrease IL6 IL10 ratio p 0,008 . Alphacalcidol increased CD4 CD8 ratio from 2,68 SD 2,45 to 3,2 SD 2,9 p 0,001 and decrease CD8 CD28 percentage from 5,1 SD 3,96 to 2,5 1,5 p"

"ABSTRACTBACKGROUND: Alphacalcidol, a vitamin D analog, shows immune regulatory potency as it works on the macrophage and T cell to control inflammation and T cell dysregulation in elderly. None has been known about its effect on elderly with various states of frailty syndrome, which have different level of chronic low grade inflammation. This study aimed to determine the effect of alphacalcidol on inflammatory cytokines (IL-6, IL-10, g-IFN ) and T cell subsets (CD4/CD8 ratio and CD8+ CD28-) of elderly with various stages of frailty syndrome. METHODS: from January to July 2017, a double blind randomized controlled trial (RCT) with allocation concealment, involving 110 elderly subjects from Geriatric Outpatient Clinic Cipto Mangunkusumo Hospital Jakarta, was conducted to measure the effect of 0.5 mcg alphacalcidol administration for 90 days to inflammatory cytokines (IL-6, IL-10, g-IFN) from PBMC culture supernatant, as well as CD4/CD8 and CD8+CD28- percentage using flow cytometry. Statistical analysis using SPSS version 20 was performed with t-test to measure mean difference. RESULTS: of 110 subjects involved in the RCT consisting of 27 fit, 27 pre-frail and 56 frail elderly, 25(OH)D serum level was found to be as low as 25.59 (12.2) ng/ml in alphacalcidol group and 28.27 (10.4) ng/ml in placebo group. Alphacalcidol did not decrease IL-6 (p=0.4) and g- IFN (p=0.001), but it increased IL-10 (p=0,005) and decreased IL6/IL10 ratio (p=0.008). Alphacalcidol increased CD4/CD8 ratio from 2.68 (SD 2.45) to 3.2 (SD 2.9); p=0.001 and decreased CD8+ CD28- percentage from 5.1 (SD 3.96) to 2.5 (1.5); p<0.001. Sub group analysis showed similar patterns in all frailty states. CONCLUSION: Alphacalcidol improves immune senescence by acting as anti-inflammatory agent through increased IL-10 and decreased IL6/IL-10 ratio and also improves cellular immunity through increased CD4/CD8 ratio and decreased CD8+ CD28- subset in elderly. This effect is not influenced by frailty state."

"Latar Belakang. Kemoterapi merupakan salah satu modalitas terapi kanker pada pasien usia lanjut yang dapat menyebabkan risiko berat, terutama pada pasien usia lanjut dengan sindrom frailty. Hingga saat ini belum ada model prediksi kemotoksisitas dengan variabel frailty. Penelitian ini bertujuan mengembangkan model prediksi kemotoksisitas berat pada usia lanjut yang melibatkan penilaian status frailty.Metode. Penelitian kohort retrospektif menggunakan data sekunder terhadap pasien usia lanjut yang menjalani kemoterapi di RSCM tahun 2019-2021. Dilakukan pemeriksaan determinan (jenis kelamin, usia, jenis kanker, jumlah regimen kemoterapi, status nutrisi, status frailty, polifarmasi, fungsi kognitif, status fungsional dan depresi) sebelum kemoterapi. Pasien diikuti hingga 21 hari pasca kemoterapi siklus pertama untuk dinilai apakah mengalami luaran kemotoksisitas berat berdasarkan kriteria CTCAE grade 3-5. Dilakukan analisis untuk pengembangan model prediksi dengan regresi Cox dan perhitungan performa prognostiknya menggunakan perangkat SPSS.Hasil. Dari 193 subyek yang menjalani kemoterapi, sebagian besar laki-laki dengan median usia 65,6 (RIK 60-82). Toksisitas berat terjadi pada 36% subyek. Model prediksi yang dikembangkan terdiri dari 4 determinan yaitu polifarmasi, penggunaan regimen kemoterapi lebih dari satu obat, status frailty dan jenis kanker saluran cerna. Model ini memiliki AUC 0,79 (IK95% 0,70-0,88) dengan p=0,01.Kesimpulan. Model prediksi dengan variabel polifarmasi, regimen kemoterapi lebih dari satu, status frailty dan jenis kanker saluran cerna dapat memprediksi kejadian toksisitas berat kemoterapi pada usia lanjut dengan performa baik

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Background. Chemotherapy is a therapeutic modality for elderly with cancer which can pose elderly, especially frail patients, to fatal side effect. To date, there is no prediction model incorporating frailty in clincal practice. This study aims to develop prediction model which includes frailty state evaluation in predicting severe chemotoxicity in elderly.

Methods. A retrospective cohort study using secondary data of elderly underwent chemotherapy during 2019-2021 was conducted in Cipto Mangunkusumo Hospital. Data of determinants ( sex, age, polypharmacy, frailty status, nutritional status, depression, cognitive status, cancer type, polychemotherapy, and functional status) and the incidence severe chemotherapy side effect according to grade 3-5 CTCAE were collected. Data was analyzed to develop prediction model with Cox regression using SPSS

Results. Of 193 subjects, most of them are male, with median age of 65.6 (IQR 60-82) years old. Severe chemotoxicity was found in 36% of the subjects. Prediction model consists of polypharmacy, number of chemotherapy drugs, cancer type and frailty status was developed. The model has AUC of 0.79 (95% CI 0.70-0.88), p value 0,01

Conclusion. A prognostic Model consists of polypharmacy, number of chemotherapy drugs, cancer type and frailty status can predict incidence of severe chemotoxicity in elderly with AUC 0.79 (95%CI 0.70-0.88)"