Sriwijaya Journal of Internal Medicine

Efficacy and Safety of Recombinant Activated Factor VII versus Activated Prothrombin Complex Concentrate for Bleeding Control in Acquired Haemophilia A: A Systematic Review and Meta-Analysis

2026-07-23T03:24:27+00:00

Background: Acquired haemophilia A is a rare autoimmune coagulopathy with mortality of 3.3–22 per cent, in which uncontrolled haemorrhage is the principal cause of early death. Guidelines endorse both recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrate (aPCC) as first-line bypassing therapy without preference, yet their comparative efficacy has never been quantified by meta-analysis.

Objective: To estimate the pooled comparative effect of rFVIIa versus aPCC on bleeding control in adults with acquired haemophilia A, and to assess heterogeneity and thromboembolic safety.

Methods: Following PRISMA 2020, three databases were searched (1 May 2026) for cohort, registry, and comparative studies of adults treated with rFVIIa or aPCC. Bleeding-control proportions per arm were pooled as Hedges g under random-effects models, with risk ratio and risk difference as co-primary metrics. Risk of bias used a modified Newcastle–Ottawa Scale; certainty followed GRADE.

Results: Ten studies were reviewed and nine meta-analysed (rFVIIa n = 531; aPCC n = 385). Bleeding control occurred in 89.3 per cent (474/531) with rFVIIa and 89.1 per cent (343/385) with aPCC. Pooled Hedges g was 0.026 (95 per cent CI −0.232 to +0.285; p = 0.84), risk ratio 1.00 (0.95–1.06), and risk difference +0.18 percentage points. Heterogeneity was low (I² = 5.8 per cent); findings were robust in sensitivity and subgroup analyses, with low certainty.

Conclusion: rFVIIa and aPCC produced clinically equivalent bleeding-control rates in adults with acquired haemophilia A. Agent selection should be guided by availability, acquisition cost, and individual safety profile rather than presumed efficacy.

Omalizumab in Reducing Exacerbation Rate and Oral Corticosteroid Burden in Allergic Bronchopulmonary Aspergillosis: A Systematic Review and Meta-Analysis

2026-07-24T07:38:09+00:00

Background: Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder complicating severe asthma and cystic fibrosis. Systemic corticosteroids, the mainstay of treatment, carry substantial cumulative toxicity, and the steroid-sparing role of the anti-IgE antibody omalizumab remains incompletely defined, particularly in South-East Asia where ABPA is under-recognised.

Objective: To synthesise the most recent evidence on omalizumab for reducing exacerbations and oral corticosteroid (OCS) burden in adults with ABPA.

Methods: Following PRISMA 2020, six databases were searched for original studies enrolling at least ten ABPA patients treated with omalizumab. Standardised mean differences (Hedges' g) were pooled using a DerSimonian–Laird random-effects model with the Hartung–Knapp–Sidik–Jonkman correction. Risk of bias, subgroup, sensitivity and meta-regression analyses, and GRADE certainty of evidence were assessed.

Results: Ten studies (n = 286) were qualitatively synthesised; eight (n = 241) entered the quantitative pool. Omalizumab produced a moderate-to-large favourable composite effect (Hedges' g = −0.69; 95% CI −1.12 to −0.25; p = 0.007). Outcome-specific pooling confirmed reduced exacerbations (g = −0.74) and OCS dose (g = −0.81), and improved FEV1 (g = +0.48) and asthma control (g = +0.69) — about 1.9 fewer exacerbations per year and 9 mg/day prednisolone equivalent. Heterogeneity was substantial (I² = 78.4%) but robust across leave-one-out and sensitivity analyses.

Conclusion: Omalizumab confers a clinically meaningful steroid-sparing benefit in adults with ABPA, supporting its adoption as maintenance therapy, pending adequately powered randomised trials in South-East Asian populations.

Fatal Severe Community-Acquired Pneumonia with Sputum Retention in a 19-Year-Old Woman with Post-Poliomyelitis Syndrome: A Case Report

2026-07-28T04:12:58+00:00

Background: Post-poliomyelitis syndrome (PPS) is a late complication of paralytic poliomyelitis in which progressive failure of enlarged motor units extends to the respiratory muscles, eroding ventilatory reserve and the capacity to clear airway secretions. Fatal pneumonia in a young adult with PPS is rarely documented.

Objective: To describe a fatal case of severe community-acquired pneumonia in a young adult with PPS and to highlight the role of diminished respiratory reserve and sputum retention.

Case presentation: A 19-year-old Indonesian woman with childhood paralytic poliomyelitis, generalized atrophy, thoracolumbar scoliosis, and pectus carinatum presented with one hour of acute dyspnoea preceded by three days of productive cough and fever. She was febrile (38.8°C), tachypnoeic and hypoxaemic (PaO₂ 58 mmHg; SpO₂ 93% on room air), with bilateral crackles, severe leukocytosis (30,100/µL), mild anaemia (9.0 g/dL) and Gram-positive cocci on sputum microscopy. Despite empirical antibiotics, bronchodilators, mucolytics, fluids and oxygen, she deteriorated within 24 hours, requiring intubation and mechanical ventilation; repeat blood gas showed profound metabolic acidosis (pH 6.914, base excess −26.5 mmol/L). She developed vasopressor-dependent septic shock with multi-organ failure and died on the sixth hospital day.

Conclusion: The diminished respiratory reserve, ineffective cough and impaired airway clearance intrinsic to PPS can convert an otherwise moderate community-acquired pneumonia into rapidly fatal respiratory failure and septic shock; such patients warrant early severity stratification, aggressive airway clearance and a low threshold for ventilatory support.

Severe Thalassemia Bone Disease in a Young Woman with Transfusion-Dependent β-Thalassemia Major: Erlenmeyer Flask Deformity, Muscular Hemosiderin Deposition, and Profound Osteoporosis — A Case Report

2026-07-28T04:13:53+00:00

Background: Beta-thalassemia major (β-TM) is a chronic transfusion-dependent hemolytic disorder in which thalassemia bone disease (TBD) is among the most frequent and least resolved long-term complications, driven by ineffective erythropoiesis with marrow expansion, iron-overload toxicity, and endocrine and nutritional deficiencies.

Objective: To report a case of severe thalassemia bone disease in a young woman with transfusion-dependent β-TM and to highlight its diagnostic and therapeutic complexity.

Case presentation: A 27-year-old woman with β-TM diagnosed at age two and a long history of iron overload presented with severe, movement-limiting right lower-limb pain, intermittent since 2019 and acutely worsened over the preceding month. She had documented hypersensitivity to deferasirox and was maintained on deferiprone. Examination showed clinical anemia, hepatosplenomegaly, and a painful, immobile right lower limb. Investigations confirmed hypochromic microcytic anemia (hemoglobin 5 g/dL), elevated ferritin, and low calcium and vitamin D. Pelvic radiography showed diffuse osteopenia; femoral radiography showed medullary widening with an Erlenmeyer flask deformity; and MRI revealed extensive hemosiderin deposition throughout the visualized bone and within the right rectus femoris muscle. DXA showed a lowest Z-score of −3.5, confirming profound low bone mineral density for age.

Conclusion: This case highlights the diagnostic and therapeutic complexity of advanced TBD — structural deformity, soft-tissue iron deposition, and profound osteoporosis compounded by chelation-limited iron control — and underscores the need for an urgent, individualized, multidisciplinary approach.

Corticosteroid Therapy and the Risk of Kidney Failure in IgA Nephropathy: A Dose- and Ethnicity-Stratified Meta-Analysis of Randomised Controlled Trials

2026-07-28T04:15:34+00:00

Background: Corticosteroids are widely used in IgA nephropathy, but their net benefit is contested because the largest trials show both protection against kidney-function decline and excess serious infection; the optimal dose and consistency across ethnic groups are uncertain.

Objective: To quantify the effect of systemic corticosteroids on the risk of kidney failure in IgA nephropathy and to explore modification by dose and ethnicity.

Methods: Four databases were searched from inception for randomised controlled trials. Risk ratios (RR) were pooled with a DerSimonian–Laird random-effects model and proteinuria as Hedges' g; heterogeneity was assessed with I² and a prediction interval, bias with RoB 2 and the Egger test, and certainty with GRADE.

Results: Ten non-overlapping trials (1,153 participants; 104 vs 165 events) were included. Corticosteroids reduced the risk of kidney failure (RR 0.61, 95% CI 0.42–0.90; I² = 21%; p = 0.012), remaining significant under the Hartung–Knapp correction (0.39–0.97); a dose subgroup difference was significant (p = 0.010, larger effect with high-dose regimens). Proteinuria fell moderately (Hedges' g −0.68, −1.00 to −0.35). Serious infection was more frequent with corticosteroids.

Conclusion: Corticosteroids reduce kidney failure and proteinuria but increase serious infection; a reduced-dose strategy preserves benefit while improving safety, supporting individualised, risk-stratified use.

Calcineurin Inhibitor–Based versus Cyclophosphamide-Based Immunosuppression for Primary Membranous Nephropathy: A Meta-Analysis of Remission and Relapse

2026-07-28T04:18:06+00:00

Background: Primary membranous nephropathy (MN) is a leading cause of the nephrotic syndrome in adults. Calcineurin inhibitor (CNI)-based and cyclophosphamide-based regimens are both endorsed as first-line therapy, but their comparative efficacy and the durability of the remission they induce remain uncertain.

Objective: To compare CNI-based versus cyclophosphamide-based regimens for total remission, complete remission and relapse in adults with primary MN.

Methods: PubMed/MEDLINE, with Scopus and Web of Science indexing checks and manual reference screening, was searched for randomised controlled trials comparing a CNI-based regimen (tacrolimus or cyclosporine) with a cyclophosphamide-based regimen. Risk ratios (RRs) were pooled with a DerSimonian–Laird random-effects model; heterogeneity was quantified with I²; risk of bias used the Cochrane RoB 2 tool.

Results: Nine RCTs (eleven articles; 599 participants) were included. Total remission did not differ between strategies (RR 1.02, 95% CI 0.86–1.20; I²=67%; 95% prediction interval 0.61–1.72). Complete remission did not differ (RR 0.84, 95% CI 0.34–2.04). Relapse tended to be more frequent after CNI-based therapy (RR 1.76, 95% CI 0.95–3.24; I²=0%) without reaching significance. Estimates were stable across all sensitivity analyses, and no small-study effect was detected (Egger p=0.87).

Conclusion: CNI-based and cyclophosphamide-based regimens produced comparable remission in primary MN; a non-significant signal towards more frequent relapse after CNI therapy supports individualised, durability- and toxicity-aware treatment selection.

Preoperative CR-POSSUM Predicts Mortality but Not Length of Stay in Colorectal Cancer: A Retrospective Cohort Study at Prof. Dr. I.G.N.G. Ngoerah General Hospital, Bali, Indonesia

2026-07-28T04:21:50+00:00

Background: Preoperative risk stratification is central to perioperative internal-medicine practice, yet whether mortality-oriented surgical scores can be repurposed to predict hospital resource use is unclear. Colorectal cancer (CRC) is a leading cause of cancer death in Southeast Asia, and prolonged postoperative length of stay (PLOS) carries clinical and economic cost.

Objective: To examine whether the Colorectal-POSSUM (CR-POSSUM) score predicts prolonged PLOS, 30-day mortality and morbidity after CRC surgery.

Methods: This retrospective analytical cohort study, reported per STROBE, enrolled 53 consecutive patients undergoing colorectal resection at Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, between January and March 2025. Proportions used Wilson 95% confidence intervals (CI); associations were tested by chi-square/Fisher test with relative risk (RR), odds ratio (OR) and Cramér's V, and upgraded with multivariable logistic regression, ROC analysis and number-needed-to-treat (NNT).

Results: Prolonged PLOS (≥6 days) occurred in 22 patients (41.5%; 95% CI 29.3–54.9). CR-POSSUM did not predict prolonged PLOS (RR 1.12, 95% CI 0.59–2.12; p=0.728; AUC 0.42) but strongly predicted 30-day mortality (13.2%; RR 6.72, 95% CI 0.87–52.05; p=0.035; AUC 0.93, 95% CI 0.79–1.00; Cohen's d 2.49). Preoperative anaemia (adjusted OR 5.20, 95% CI 1.45–18.69; p=0.012) and in-hospital morbidity (RR 2.11, 95% CI 1.20–3.70; p=0.045) independently predicted prolonged PLOS (Nagelkerke R²=0.276).

Conclusion: CR-POSSUM is a valid mortality predictor but should not be used to guide discharge planning; correcting anaemia and preventing complications are the actionable levers to shorten stay for internists managing colorectal-cancer surgery in Indonesian tertiary practice.

The Many Faces of Expanded Dengue Syndrome: A Two-Case Series of Renal and Hepatic–Neurological Organ Involvement in Adult Patients

2026-07-28T06:42:50+00:00

Background: The rising global incidence of dengue has been accompanied by increasing recognition of atypical, organ-dominant presentations collectively termed expanded dengue syndrome (EDS), in which severe involvement of the liver, kidney, heart, lung or central nervous system dominates the clinical picture and drives mortality.

Objective: To describe two adult men who illustrate contrasting EDS phenotypes — renal and hepatic–neurological organ involvement.

Case presentation: Case I, a 30-year-old man with serologically confirmed secondary dengue (IgM-negative, IgG-positive), presented with gross haematuria, dysuria and warning signs and developed acute kidney injury (oliguria, rising creatinine, proteinuria, marked erythrocyturia) on a background of leucopenia, severe thrombocytopenia and haemoconcentration; he recovered fully with carefully titrated crystalloid and renoprotective measures. Case II, a 23-year-old man with primary infection, deteriorated on day six with agitated delirium and acute liver failure (transaminases >100× the upper limit, hyperbilirubinaemia, coagulopathy, hypoalbuminaemia) complicated by hepatic encephalopathy; he improved with supportive care, electrolyte correction and multidisciplinary management.

Conclusion: EDS may arise from either secondary or primary infection, and organ dysfunction tends to resolve in step with the natural history of dengue. Meticulous, clinical-group–stratified fluid stewardship and systematic evaluation for intensive-care needs are the cornerstone of management; early recognition of organ-specific complications is essential to reduce preventable morbidity and mortality.

Vancomycin Plus Piperacillin–Tazobactam Versus Vancomycin Plus Cefepime and the Risk of Acute Kidney Injury in Hospitalised Adults: A Meta-Analysis

2026-07-28T06:47:42+00:00

Introduction: Vancomycin with piperacillin–tazobactam is a common empirical regimen but may increase acute kidney injury (AKI) risk. Because vancomycin is common to most comparisons, the cleanest test of the piperacillin–tazobactam effect is a head-to-head comparison against vancomycin plus cefepime. This meta-analysis quantified the association between the two regimens and AKI in hospitalised adults.

Methods: PubMed/MEDLINE, Scopus and Web of Science were searched for comparative cohort studies and randomised trials in adults reporting AKI with vancomycin plus piperacillin–tazobactam versus vancomycin plus cefepime. Risk of bias was appraised with ROBINS-I and certainty with GRADE. Odds ratios (OR) were pooled using a DerSimonian–Laird random-effects model; heterogeneity (I²), a prediction interval, leave-one-out analysis and the Egger test were computed.

Results: Ten cohort studies were eligible and nine (>11,000 adults) were pooled. Piperacillin–tazobactam was associated with significantly higher odds of AKI (pooled OR 1.90, 95% CI 1.43–2.52; p<0.001; I²=81%). The prediction interval (0.77–4.69) was wide, and the result was robust to leave-one-out analysis (OR 1.71–2.06). The number needed to harm ranged from about 15 to about 8 across baseline incidences of 9% to 21%. The Egger test suggested small-study effects (p=0.04); certainty was graded low.

Conclusion: In hospitalised adults, vancomycin plus piperacillin–tazobactam was associated with roughly twofold higher odds of AKI than vancomycin plus cefepime; where both regimens are appropriate, cefepime may be the safer renal companion.

Platelet-to-Lymphocyte Ratio as a Predictor of Exacerbation Severity and Hospital Length of Stay in Acute Exacerbation of COPD: A Dual-Center Study in West Sumatra, Indonesia

2026-07-28T06:48:19+00:00

Introduction: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a leading driver of morbidity, mortality and health-care expenditure, and simple admission biomarkers that grade severity are needed in resource-limited settings. The platelet-lymphocyte ratio (PLR) integrates thrombo-inflammation and relative lymphopenia, yet Indonesian evidence linking it to exacerbation severity and length of stay (LOS) remains limited.

Methods: In this dual-center analytical cross-sectional study, 141 hospitalized AECOPD patients at Dr. M. Djamil General Hospital, Padang and RS Madina Bukittinggi (January-December 2024) were analyzed. Admission PLR was related to Anthonisen exacerbation severity and LOS (>7 days) using Kruskal-Wallis and Mann-Whitney tests, Spearman correlation, receiver-operating-characteristic (ROC) analysis and multivariable logistic regression (adjusted odds ratios, aOR).

Results: Most patients were male (86.5%), aged 40-70 years (56.0%) and heavy smokers (87.5%). Mean PLR increased across severity strata (mild 126.8±40.8, moderate 192.3±69.1, severe 444.9±241.7; p<0.001) and correlated moderately with severity (ρ=0.534, p<0.001) but weakly with LOS (ρ=0.295). PLR discriminated severe exacerbation with excellent accuracy (AUC 0.929, 95% CI 0.874-0.985; cut-off ≥216.3, sensitivity 100.0%, specificity 73.2%, accuracy 89.6%) but predicted LOS poorly (AUC 0.566, p=0.273). After adjustment, PLR independently predicted severe exacerbation (aOR 3.73 per 50 units, 95% CI 1.87-7.42, p<0.001; Nagelkerke R2=0.642), whereas prolonged stay was driven by pneumonia (aOR 6.40, 95% CI 2.50-16.37, p<0.001) rather than PLR (aOR 1.15, p=0.139).

Conclusion: Admission PLR is an inexpensive, widely available biomarker that accurately identifies severe AECOPD and may support early risk stratification, although it should not be used alone to predict length of stay, which is governed chiefly by comorbidity.