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Abstrak :
ABSTRAK Latar belakang: Mengetahui faktor-faktor yang berhubungan dengan mortalitas pada pasien ikterus obstruktif dengan etiologi maligna merupakan hal penting untuk membantu membuat perencanaan optimal dalam melakukan pendekatan terapi yang tepat untuk masing-masing etiologi dan faktor terkait guna membantu meningkatkan kesintasan dan kualitas hidup pasien. Tujuan: Mendapatkan kesintasan dan faktor-faktor yang berhubungan dengan mortalitas pada pasien ikterus obstruktif dengan etiologi maligna di RSCM. Metode: Penelitian kohort retrospektif dan prospektif dilakukan dengan data sekunder pasien ikterus obstruktif yang dirawat di ruang perawatan RSCM antara Januari 2010 ? Desember 2013. Faktor-faktor yang dinilai meliputi umur, jenis kelamin, sepsis, hipoalbumin, tingkat bilirubin serum, tingkat CA 19-9 serum, drainase bilier, keganasan non ca ampula Vater, dan komorbid dengan hasil keluaran berupa mortalitas pasien. Kesintasan kumulatif terjadinya mortalitas dalam 3 bulan setelah diagnosis dinyatakan dengan kurva Kaplan Meier. Analisis bivariat dan multivariat dilakukan dengan Cox Proportional Hazards Regression Model untuk mendapatkan Hazard Ratio (HR) dari setiap faktor prognosis. Skor prognosis dari setiap faktor bermakna ditentukan berdasarkan model akhir regresi. Hasil: Sebanyak 181 dari 402 pasien ikterus obstruktif dengan etiologi maligna memenuhi kriteria penelitian dengan proporsi laki-laki sebesar 58,6 % dengan pasien berumur ≥ 50 tahun sebesar 57,5 %. Sepsis (HR 2.462 ; IK 95% 1.552 ? 3.906), drainase bilier tidak berhasil/tidak ada (HR 1.604 ; IK 95% 0.988 ? 2.603), serta skor indeks komorbid Charlson ≥ 4 (HR 2.476 ; IK 95% 1.562 ? 3.923) merupakan faktor prognosis yang bermakna terhadap mortalitas pasien. Median kesintasan pasien dengan faktor prognosis bermakna 14 hari; IK 95% 9.66 ? 18.34 sedangkan median kesintasan keseluruhan 26 hari; IK 95% 20.82 ? 31.19 (p < 0.01). Ambang skor prognostik terbaik didapatkan pada skor ≥ 2 dengan sensitifitas 68% dan spesifisitas 75%. AUC pada kurva ROC 0.769. Kesimpulan: Kesintasan pasien dengan faktor prognosis sepsis, drainase bilier tidak berhasil/tidak ada, dan skor indeks komorbid Charlson ≥ 4 lebih pendek dibandingkan kesintasan keseluruhan pasien. Skor prognostik ≥ 2 termasuk dalam risiko tinggi kematian dan kemampuan prediksi mortalitas dari faktor prognosis bermakna sebesar 76.9%.

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ABSTRACT Background: Understanding any related factors affecting mortality in patients with malignant obstructive jaundice will better guide to an approriate and optimal planning in making theurapetic approach for each etiological and relating factors thus improving survival and patients? quality of life. Aim: To obtain survival rate and mortality-related factors of malignant obsructive jaundice patients in Cipto Mangunkusumo Hospital. Methods: Retrospective-prospective cohort study was conducted with medical records of obstructive jaundice inpatient from January 2010 to December 2013 were reviewed. Suggested mortality-related factors include age, gender, sepsis, hypoalbumin, serum bilirubin level, serum CA 19-9 level, billiary drainage, non-ampulla Vateri carcinoma, and comorbid were analyzed. Three-month cumulative overall survival was calculated by Kaplan-Meier curve. Bivariat and multivariat analysis was done with Cox Proportional Hazards Regression Model to obtain Hazard Ration (HR) of each prognostic factor. Prognosis score from each mortality-related factor was calculated based on the last regression model. Results: 181 from 402 patients were enrolled in this study with male proportion was 58.6% and patients aged 50 years or above was 57.5%. Sepsis (HR 2.462 ; CI 95% 1.552 ? 3.906), unsuccessful / no prior billiary drainage (HR 1.604 ; CI 95% 0.988 ? 2.603), and Charlson comorbid score ≥ 4 (HR 2.476 ; CI 95% 1.562 ? 3.923) were mortality-related factors with significant difference. Patients with significant prognostic factors had median survival 14 days; 95% CI: 9.66 ? 18.34 compared with overall median survival 26 days; 95% CI: 20.82 ? 31.19 (p < 0.01). Score ≥ 2 identified as the highest prognostic score threshold with sensitivity 68%, specificity 75%, and AUC on ROC curve 0.769. Conclusion: Patients with significant prognostic factors which were sepsis, unsuccessful / no prior billiary drainage, and Charlson comorbid score ≥ 4 had shorter survival than overall survival. Prognostic threshold ≥ 2 quite good to classify malignant obstructive jaundice inpatient into high risk mortality population. Mortality of patients with those significant prognostic factors can be predicted in 76,9%.

Abstrak :
HIV coinfection in HCV-infected patients accelerates the course of disease and affects the outcome of Peg-IFN/RBV combination treatment. HCV-HIV coinfected patients are suspected to have HCV mutation in NS5A-ISDR/PKR-BD region that had a role to the successfulness of Peg-IFN/RBV therapy. SNP IL-28B polymorphism is predicted to have an effect on the HCV quasi-species evolution. However, until now the effect of HCV NS5A mutation and SNP IL-28B of the host to the response of treatment is still unclear. This study aimed to determine the presence and role of HCV NS5A-ISDR/PKR-BD region mutation and host SNP IL-28B on the succes of Peg-IFN/RBV combination treatment in HCV-HIV coinfected patients. Prospective cohort study design was conducted in this study. Plasma sample was collected from 22 monoinfected and 134 HCV-HIV coinfected patients prior to therapy. All of them were treated with Peg-IFN/RBV for 48 weeks. The examination of HCV RNA was performed 24 weeks after the end of therapy. PCR nucleotide sequencing was performed after the RNA virus extraction and cDNA synthesis had been performed. Analysis of secondary structure and prediction of mutation function were assessed by PredictProtein (PP) program. Sixteen from thirthy HCV-HIV co-infection patients and none from eight HCV patients achieved SVR. Nonneutral mutation ≥ 1 was found in 23/30 subjects with HCV-HIV co-infection. The presence of nonneutral mutation ≥ 1 was observed more frequent in SVR group than non-SVR group. Nonneutral mutation ≥ 1 was associated with SVR achievement, regardless the monoinfection or coinfection status (p = 0.04). Interaction of CC gene and nonneutral mutation was not associated with SVR. Secondary structure transformation of VHC NS5A was not associated with SVR in coinfected subjects. NS5A binding site structure was different from consensus in SVR group, while the structure was similar to consensus in non-SVR group. Nonneutral mutation ≥ 1 has the most important role on the SVR achievement in patients treated with Peg-IFN/RBV. The interaction of CC-gene and nonneutral mutation was not associated with SVR. The change of secondary structure was also not associated with SVR achievement, however, the changes of NS5A binding site structure were found in HCV-HIV coinfected patients who achieved SVR.

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Koinfeksi HIV pada pasien dengan infeksi VHC dapat memperberat perjalanan penyakit dan memengaruhi keberhasilan terapi kombinasi Peg-IFN/RBV. Pasien koinfeksi VHC-HIV diduga mengalami mutasi VHC pada regio NS5A-ISDR/PKR-BD yang mempunyai peran terhadap keberhasilan terapi Peg-IFN/RBV. Polimorfisme SNP IL-28B diprediksi berpengaruh terhadap evolusi quasi-spesies VHC, namun hingga saat ini keberadaan dan peran mutasi VHC NS5A serta SNP IL-28B pejamu pada koinfeksi VHC-HIV terhadap keberhasilan terapi masih belum diketahui secara jelas. Penelitian ini bertujuan untuk mengetahui keberadaan dan peran mutasi VHC NS5A-ISDR/PKR-BD serta SNP IL-28B pejamu terhadap keberhasilan terapi dengan kombinasi Peg-IFN/RBV pada pasien koinfeksi VHC-HIV. Penelitian ini menggunakan desain studi kohort prospektif. Sampel plasma dikumpulkan dari 22 subjek monoinfeksi dan 134 subjek koinfeksi sebelum menjalani terapi. Seluruh pasien mendapatkan terapi Peg-IFN/RBV selama 48 minggu. Pemeriksaan VHC RNA setelah 24 minggu dari akhir terapi dilakukan untuk menilai respons terapi (sustained virological response/SVR 24). Sekuensing nukleotida menggunakan PCR dilakukan setelah ekstraksi RNA virus dan sintesis cDNA dari sampel plasma. Analisis struktur sekunder dan prediksi fungsi mutasi menggunakan program PredictProtein (PP). Sebanyak 16 pasien dari 30 pasien koinfeksi VHC-HIV yang mengalami SVR serta tidak ada dari 8 pasien monoinfeksi VHC yang mengalami SVR. Mutasi nonnetral ≥ 1 ditemukan pada 23/30 pasien koinfeksi VHC-HIV. Keberadaan mutasi nonnetral ≥ 1 didapatkan lebih tinggi pada kelompok SVR (14 pasien) dibandingkan dengan non-SVR (9 pasien). Mutasi nonnetral ≥1 berhubungan dengan kejadian SVR, tanpa memandang status monoinfeksi dan koinfeksi (p = 0,04). Interaksi antara gen CC dan mutasi nonnetral tidak berhubungan dengan SVR. Perubahan struktur sekunder NS5A tidak berhubungan dengan SVR pada pasien koinfeksi. Struktur binding site NS5A pada kelompok SVR didapatkan berbeda dengan konsensus, sedangkan pada kelompok non-SVR mirip dengan konsensus. Mutasi nonnetral ≥ 1 berperan terhadap kejadian SVR pada pasien yang mendapat terapi Peg-IFN/RBV. Interaksi mutasi nonnetral dan gen CC tidak berhubungan dengan pencapaian SVR. Perubahan struktur sekunder juga tidak berhubungan dengan pencapaian SVR, akan tetapi perubahan struktur binding site NS5A-ISDR/PKR-BD ditemukan pada pasien koinfeksi VHC-HIV yang mencapai SVR dengan terapi Peg-IFN/RBV.

Abstrak :
ABSTRACT Riedels lobe is a normal variant form of right liver lobe rarely found. Here we report a case of 38 years old female with an incidental finding not revealed in physical examination, but then known to have hepatomegaly by gynecological ultrasonography. Diagnosis of Riedels lobe was strengthened by similar results on hepatobiliary ultrasonography, abdominal MRI, and diagnostic laparoscopy. Our patient was discharged and had follow up examination three months later. Knowledge regarding this anomaly is essential to be understood because the finding of accessory liver lobe does not always remain asymptomatic as in our patient, but rather can be related to significant clinical complication.

Abstrak :
Tujuan: mendapatkan kesintasan dan faktor-faktor yang berhubungan dengan mortalitas pada pasien ikterus obstruktif dengan etiologi maligna. Metode: penelitian kohort retrospektif dan prospektif dilakukan dengan data sekunder pasien ikterus obstruktif yang dirawat di RS. Cipto Mangunkusumo, Jakarta antara Januari 2010-Desember 2013. Faktor-faktor yang dinilai meliputi umur, jenis kelamin, sepsis, hipoalbumin, tingkat bilirubin serum, tingkat CA 19-9 serum, drainase bilier, keganasan non ca ampula Vater, dan komorbid dengan hasil keluaran berupa mortalitas pasien. Hasil: sebanyak 181 dari 402 pasien ikterus obstruktif dengan etiologi maligna memenuhi kriteria penelitian dengan proporsi laki-laki sebesar 58,6 % dengan pasien berumur ≥50 tahun sebesar 57,5%. Analisis multivariat menunjukkan bahwa sepsis, riwayat drainase bilier sebelumnya dan skor komorbid Charlson ≥4 merupakan prediktor independen terhadap mortalitas. Median kesintasan pasien dengan faktor prognosis bermakna adalah 14 hari sedangkan median kesintasan keseluruhan 26 hari. Ambang skor prognostik terbaik didapatkan pada skor ≥2 dengan sensitivitas 68% dan spesifisitas 75%. AUC pada kurva ROC 0.769. Kesimpulan: kesintasan pasien dengan faktor prognosis sepsis, drainase bilier tidak berhasil/tidak ada, dan skor indeks komorbid Charlson ≥4 lebih pendek dibandingkan kesintasan keseluruhan pasien. Skor prognostik ≥2 termasuk dalam risiko tinggi kematian dan kemampuan prediksi mortalitas dari faktor prognosis bermakna adalah 76.9%.

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Aim: to obtain survival rate and mortality-related factors of malignant obstructive jaundice patients. Methods: all medical records of obstructive jaundice inpatient at Cipto Mangunkusumo Hospital, Jakarta from January 2010 to December 2013 were reviewed retrospectively. The following factors were analyzed in terms of mortality: age, gender, sepsis, hypoalbumin, serum bilirubin level, serum CA 19-9 level, billiary drainage, non-ampulla Vateri carcinoma, and comorbid factors. Results: total 181 out of 402 patients were enrolled in this study with male proportion was 58.6%, and patients aged 50 years or above was 57.5%. Multivariate analysis showed that only sepsis, unsuccessful or no prior biliary drainage and Charlson comorbid score ≥4 were independent predictors of mortality. Patients with significant prognostic factors had median survival 14 days compared with overall median survival 26 days. Score ≥2 identified as the highest prognostic score threshold with sensitivity 68%, specificity 75%, and AUC on ROC curve 0.769. Conclusion: sepsis, unsuccessful or no prior bilirary drainage, and Charlson comorbid score ≥4 are factors significantly associated with shortened survival in malignant obstructive jaundice patients. Prognostic score ≥2 was determined to classify patients into high risk mortality group. Mortality of patients with those significant prognostic factors can be predicted in 76.9%.

Abstrak :
ABSTRACT
Hepatocellular adenoma is an extremely rare benign tumor of the liver which predominantly in young women. Its rare incidence with estimated 3-4 cases per 1.000.000 annually makes it a diagnostic challenge. Here we present a 30-year-old female patient with hepatocellular adenoma without classic risk factors. A series of work up tools have been performed in order to diagnose the condition. None but excision biopsy from segmental resection had been showed to increase diagnostic confidence. This case illustrates the role of immunohistochemical staining from excision biopsy as the best diagnostic modality of hepatocellular adenoma as well as therapeutic modality to prevent malignant transformation.