Acta Medica Indonesiana

Mastery Learning in Intestinal Ultrasound Training: A Meaningful Step Forward, With Miles Still to Go

Ari Fahrial Syam — 2026-04-09

Intestinal ultrasound (IUS) is increasingly recognized as a vital, non-invasive tool for managing inflammatory bowel disease (IBD) due to its real-time assessment capabilities and patient comfort. However, the lack of standardized training pathways remains a significant barrier to its widespread adoption, particularly in low- and middle-income settings. This editorial evaluates the implementation of a mastery learning-based workshop in Indonesia designed to enhance IUS skills among physicians.

The mastery learning framework—incorporating flipped learning, deliberate practice, and real-time feedback led to significant improvements in technical performance with large effect sizes. Despite these gains, only about two-thirds of participants achieved competency in sigmoid colon scanning, and only half met the standard for terminal ileum assessment. This suggests that while short-term intensive workshops are effective for early skill acquisition, they may be insufficient for ensuring consistent proficiency in technically demanding tasks.

Mastery learning offers a structured and reproducible approach to gastroenterology procedural training. To translate these initial educational gains into durable clinical expertise, future programs should consider longitudinal curricula that include sustained practice, mentorship, and ongoing assessment.

Measles in Indonesia: Vaccination Coverage and Identified Challenges

Erni J Nelwan — 2026-04-09

Measles has re-emerged as a significant public health threat in Indonesia, signaling gaps in immunization coverage and systemic health inequities. Following the disruptions caused by the COVID-19 pandemic, the country has seen a troubling resurgence in cases. This editorial examines the current epidemiological situation, structural barriers to vaccination, and necessary strategies for elimination. In 2025, Indonesia recorded over 63,000 suspected cases, with the trend continuing into 2026. Current vaccination coverage for children aged 12–23 months stands at 73.46%, which is significantly below the 95% threshold required for herd immunity. Key barriers identified include maternal education levels, archipelagic geography, and sociocultural factors such as religious permissibility and safety concerns.

Addressing the measles resurgence requires a multi-faceted approach: strengthening routine and catch-up immunization services, addressing social determinants of health, and rebuilding public trust through community engagement. Achieving high coverage is essential to prevent severe clinical complications and protect vulnerable populations.

Effectiveness of Montelukast in Reducing the Risk of Severe Dengue in Dengue Fever Patients: An Evidence-Based Case Report

Nicholas Jason Wijaya — 2026-04-09

Background: Dengue fever continues to spread worldwide, particularly in tropical regions. Some patients with dengue fever may progress to severe dengue, which is associated with significantly higher morbidity and mortality. Despite this, no definitive treatment has been found to prevent its progression. Montelukast, a leukotriene receptor antagonist, has shown potential in reducing plasma leakage, a key factor in the pathophysiology of severe dengue. Therefore, this study aimed to evaluate the effectiveness of montelukast in reducing the risk of severe dengue. Methods: A systematic literature search was conducted on April 16, 2025, using keywords related to montelukast and dengue across four databases, which included PubMed, Taylor and Francis, Cochrane Library, and ScienceDirect. A critical appraisal was performed using the Oxford Centre for Evidence-Based Medicine framework, evaluating the validity, importance, and applicability of each study. The primary outcomes were the incidence of dengue shock syndrome and dengue with warning signs. The secondary outcomes included mortality rate and hospitalization duration. Results: This study included three studies involving a total of 1057 patients. Montelukast is associated with a reduced incidence of dengue shock syndrome and shorter duration of hospitalization. However, the effect of montelukast on dengue with warning signs and mortality rate was inconclusive. Conclusion: Montelukast shows potential as an adjuvant therapy in preventing the progression of dengue fever to severe dengue. However, further research is required before montelukast can be widely recommended for dengue fever patients in daily clinical practice and possibly integrated into dengue fever clinical guidelines.

Vitamin D in Office Workers: A Review of Musculoskeletal and Immune System Optimization for Enhanced Productivity

Theresia Santi — 2026-04-09

Vitamin D deficiency is a significant health issue, particularly among office workers. This literature review emphasizes the availability of evidence on vitamin D deficiency and its impacts on musculoskeletal health and immune functions, especially amongst office workers. A literature search of PubMed, Scopus, and Web of Science identified relevant studies on the relationship between vitamin D status and musculoskeletal health and infection risks, highlighting the prevalence of vitamin D deficiency in office workers due to limited sunlight exposure and sedentary lifestyles. The risks of osteoporosis, muscle weakness, and musculoskeletal pain, as well as impaired immune system function, are carefully examined. Potential intervention strategies include implementing work schedules allowing for outdoor breaks, providing access to vitamin D-fortified foods or supplements, and routine screening for vitamin D levels. Addressing the low level of vitamin D in office workers is essential for promoting musculoskeletal health, supporting immune functions, and enhancing workforce productivity. This review underscores the need for further research and the implementation of evidence-based interventions to mitigate the impact of vitamin D deficiency in this population.

Current Situation and Global Perspective of Nipah Virus

Erni Juwita Nelwan — 2026-04-09

The Nipah virus (NiV) is a highly pathogenic zoonotic virus associated with recurrent outbreaks in South and Southeast Asia. Since its first identification in 1998 among the pig farmers in Sungai Nipah Village in Malaysia, NiV has demonstrated high case fatality rates (40–75%) and significant epidemic potential. At that time, the virus spread to Singapore, and human cases were also identified in India, Bangladesh, and Philippine afterwards. No human cases have been reported in Indonesia; the country remains on high alert due to geographic concerns and the intensity of mobilization of people. To review the current global epidemiological situation of Nipah virus (as of 2026), evaluate public health preparedness, and analyze ongoing research efforts, including vaccine and therapeutic development.
Nipah virus outbreaks remain geographically concentrated in Bangladesh and India, with seasonal spillover events linked primarily to bat-to-human transmission through contaminated food products. Human-to-human transmission occurs but remains limited. Improved surveillance, rapid case isolation, and contact tracing have reduced outbreak sizes in recent years. Vaccine candidates are currently in Phase II clinical trials.
While the global pandemic risk remains low at present, the Nipah virus continues to represent a high-consequence emerging pathogen. Sustained surveillance, vaccine development, ecological research, and strengthened health systems are critical to mitigating future risks.

Efficacy and Safety of Pre-Endoscopy Regimens for Mucosal Visualization During Sedated Esophagogastro-duodenoscopy: A Randomized Controlled Trial

Fauzi Yusuf — 2026-04-09

Background: Optimal mucosal visibility during esophagogastroduodenoscopy (EGD) is critical for diagnostic accuracy but is often impaired by the presence of mucus and bubbles. This study aimed to compare the efficacy and safety of four premedication regimens for mucosal visualization during sedated EGD. Methods: A double-blind randomized controlled trial was conducted at the Endoscopy Unit of Dr. Zainoel Abidin General Hospital, Banda Aceh, Indonesia, from January to December 2024. Patients scheduled for elective diagnostic EGD were randomly assigned to: Group 1 (simethicone 40 mg at 30 minutes before the procedure), Group 2 (simethicone 40 mg + 100 mL 5% sodium bicarbonate at 2 hours), Group 3 (simethicone 40 mg + N-acetylcysteine 600 mg in 100 mL water at 2 hours), or Group 4 (all three agents at 2 hours). Primary outcomes were mucosal visibility (6-site, 3-point scoring system with lower scores indicating superior mucosal visibility); procedural metrics (irrigation volume and duration); and safety (the lowest recorded SpO₂%). Data were analyzed using ANOVA or Kruskal–Wallis for continuous variables, and Chi-square or Fisher’s exact test for categorical variables, with post hoc testing as applicable. Results: A total of 168 patients were randomized into four groups (n=42 each). Groups 3 and 4 showed superior mucosal visibility compared to Groups 1 and 2 (p=0.004), with no significant difference between Groups 3 and 4. Irrigation volume differed significantly (p=0.018), lowest in Group 4. Group 3 had the shortest procedure time (3.1 ± 1.2 minutes), significantly more efficient than Groups 1 and 2, but similar to Group 4. Oxygen saturation was slightly lower in Group 3 (p<0.005), though all groups remained within safe clinical limits. Conclusions: Simethicone and N-acetylcysteine given two hours before endoscopy effectively enhanced mucosal visibility and procedural efficiency without compromising safety, offering a practical alternative to more complex regimens.

Comparison of Longer and Shorter Hemodialysis Duration on Nutritional Status and Quality of Life of Hemodialysis Patients

Nur Samsu — 2026-04-09

Background: Important determinants of dialysis adequacy are blood flow rate (BFR) and dialysis time. This study aimed to evaluate the impact of BFR and duration of dialysis session on nutritional status and quality of life (QoL) in hemodialysis (HD) patients. Methods: Real-world evidence studies (RWE) of 3 HD units that differ in BFR and/or dialysis time. Group I, HD 5 hours and BFR 200-250 mL/minute; group II, HD 4 hours and BFR 270-320 mL/minute, and group III, HD 4 hours and BFR 200-250 mL/minute. All HD units use the same dialysate flow and dialysis frequency. The 3-point Subjective Global Assessment (SGA) scale is used to assess nutritional status, while QOL is assessed using the SF-36. Results: There were 291 chronic HD patients with an average age of 51 (12.3) years, 50.5% were male. The proportion of SGA classes between groups did not differ significantly. Group I was associated with significantly higher PF and RP domain scores of PC and VT domain scores of MC compared to Group III. On the other hand, Group II was associated with significantly lower VT and MH domain scores of MC compared to Group I, while the other domains were not significantly different. In general, Group III had the lowest SF-36 scores compared to the other 2 groups. Conclusion: Duration of HD was not associated with nutritional status. Compared with 4-hour HD but with a faster BFR, 5-hour HD was associated with higher Mental Component QOL scores, but not Physical Component scores.

Mastery Learning in an Intestinal Ultrasound Workshop for Inflammatory Bowel Disease: Evaluating Its Effectiveness in Enhancing Skill Acquisition

Rabbinu Rangga Pribadi — 2026-04-09

Background: Intestinal ultrasound (IUS) is a non-invasive tool for monitoring inflammatory bowel disease (IBD), offering high diagnostic accuracy and greater patient convenience than gastrointestinal endoscopy. The present study evaluated the feasibility of a mastery learning approach in Indonesia’s inaugural IUS workshop to enhance skill acquisition among physicians. Methods: A retrospective study was conducted on 37 physicians who participated in a two-day IUS workshop employing a mastery learning approach that included flipped learning, lectures, a pre-test, hands-on sessions with real-time feedback, and a post-test. Skill acquisition was assessed using standardized checklists for scanning the sigmoid colon and terminal ileum, with pre- and post-test performance evaluated against a minimum passing standard (MPS) established by expert faculties. Data was analyzed using SPSS with appropriate statistical tests to determine learning outcomes and effect sizes. Results: 34 out of 37 participants completed the workshop and skill assessment. Significant improvements were observed in both sigmoid colon and terminal ileum ultrasound scores after training (P < 0.001), with effect sizes of r = 0.89 and r = 0.86, respectively. The MPS was achieved by 67.65% of participants for the sigmoid colon and 50% for the terminal ileum. Conclusion: A mastery learning–based workshop significantly enhanced IUS skill acquisition among internists and gastroenterologists. Based on the MPS criteria, approximately one-third of participants would require additional training for sigmoid colon scanning, while about half would benefit from further training in terminal ileum scanning.

The Validity and Reliability of the Indonesian Version of Post-Intensive Care Syndrome Questionnaire (PICSQ) for Intensive Care Unit Survivors

Peggy Sunarjo — 2026-04-09

Background: Post-Intensive Care Syndrome (PICS) encompasses cognitive, motor, and mental impairments persisting for years in ICU survivors. Despite its significance, the prevalence of PICS in Indonesia remains uncertain due to limited research and a lack of validated measurement tools. This study aims to translate and validate the PICS Questionnaire for use among ICU survivors in Indonesia. Methods: The study followed a two-phase approach: translation and evaluation. The translation phase adhered to the 10-step process of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines. The analysis phase involved 184 subjects, using Confirmatory Factor Analysis (CFA) for validation and Cronbach's α and Intraclass Correlation Coefficient (ICC) for reliability testing. Results: The CFA reported factor loadings (λ >0.40) for each item in its relevant domain. Fit index values indicated a good-to-acceptable fit. Internal reliability was high for the mental, physical, and cognitive domains (0.812 vs. 0.779 vs. 0.855), with Cronbach's α of > 0.70. Test-retest reliability and ICC demonstrated dependable results (>0.70) for each domain. Conclusion: The translated and validated Indonesian PICS Questionnaire demonstrates good validity and reliability. This tool will enable healthcare professionals to assess PICS among ICU survivors in Indonesia and facilitate further research on its prevalence and impact on quality of life.

Effect of Programmed Exercise through Telerehabilitation at Home on Visual Analogue Scale, Body Mass Index, and WOMAC among Patients with Obesity and Knee Osteoarthritis: A Quasi-Experimental Study

Binar Sasono — 2026-04-09

Background: This study aims to determine the effectiveness of programmed exercise with telerehabilitation at home in patients with obesity and knee osteoarthritis on visual analogue scale scores, body mass index, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Methods: This research is a pre–post study in patients with obesity and knee osteoarthritis. Research subjects performed a series of exercise programs at home for 28 days. Before the program, there was an initial assessment from a psychologist and a nutritionist. During the program, there was tele-education, telemonitoring, and teleconsultation from doctors. Twenty-six female subjects participated. Results: Visual analogue scale scores decreased statistically significantly every week, until the end of the fourth week, compared with before the intervention (p<0.001). Body mass index and WOMAC scores decreased statistically significantly at the end of the fourth week compared with before the intervention (both p<0.001). Further analysis of all WOMAC components in the intervention group, including pain, stiffness, and physical function, also showed a statistically significant decrease (p<0.001). Conclusion: Programmed exercise as part of telerehabilitation at home has been statistically proven to reduce visual analogue scale scores, body mass index, and WOMAC in patients with obesity and knee osteoarthritis.

Effects of Garcinia mangostana Peel Extract on Glycemic Control in Type 2 Diabetes Mellitus: A Systematic Review of Human Studies

Yosef Purwoko — 2026-04-09

Introduction: Type 2 diabetes mellitus (T2DM) is a major global health concern characterized by insulin resistance, hyperglycemia, and chronic inflammation. Interest in natural adjunctive therapies has increased, particularly in mangosteen (Garcinia mangostana), which contains xanthone compounds in the peel with potential antidiabetic properties. Methods: This systematic review followed PRISMA 2020 guidelines. Literature searches were conducted using PubMed, Google Scholar, and ClinicalKey up to December 2022 for studies assessing mangosteen peel extract (MPE) or α-mangostin in diabetic human subjects. Eligible studies included randomized controlled and quasi-experimental trials reporting glycemic or metabolic outcomes. Risk of bias was evaluated using the Cochrane RoB tool. The primary result of this study is to evaluate the effects of mangosteen peel extract supplementation on key glycemic outcomes in patients with T2DM, specifically fasting blood glucose (FBG), HOMA-IR, and HbA1c. Results: A total of two studies (n=2) met the inclusion criteria. A randomized controlled pilot trial reported significant improvement in insulin sensitivity (HOMA-IR −53.2% vs −15.2%; p = 0.004) after 26 weeks of standardized mangosteen extract. A small quasi-experimental study reported a significant reduction in FBG following 7 days of mangosteen peel decoction. Discussion: Limited clinical evidence indicates that mangosteen peel extract may improve insulin sensitivity and lower fasting glucose in T2DM. However, the conclusions are limited by the small number of available studies, the short follow-up duration in one trial, and variability in extract preparation. Conclusion: Mangosteen peel extract demonstrates promising glycemic benefits, including improved insulin sensitivity and reduced fasting glucose. However, the available evidence remains limited by small sample sizes, short follow-up periods, and heterogeneity in extract formulations. Larger randomized controlled trials using standardized preparations are required before clinical recommendations can be made.

MMP9 and ADNP Gene Expressions in Secondary Bone Metastasis of Locally Advanced Nasopharyngeal Cancer

Rahmat Cahyanur — 2026-04-09

Background: Nasopharyngeal cancer (NPC) is a malignancy of the nasopharyngeal mucosal epithelium. Primary and secondary metastases in nasopharyngeal cancer are generally prevalent in the bones. Gene expression plays a critical role in regulating fundamental cellular processes in cancer cells, including metastasis. Methods: A total of 29 patients with non-metastatic NPC were included in the study. Results: The mean age of the participants was 48.45±9.98 years old. Most participants were male (75.9%). More than half of the participants had T4 and N2, 52.7% and 51.0% respectively). Secondary metastasis was observed in 9 of the 29 participants within two years. Patients with secondary metastases had a higher proportion of T4 (7/9) and N2 (4/9) disease. Bone was the first site of secondary metastasis (6/9 patients). The median time to secondary bone metastasis was 14.0 (6.8-21.2) months. Based on the differential expression gene (DEG) analysis, the MMP9 gene was upregulated 12.50 (4.18–37.40), adjusted p <0.01, and the ADNP gene was downregulated 0.141 (0.04–0.43), adjusted p 0.04, among patients with secondary bone metastasis. Conclusion: Bones are the first site of metastasis, with a time to metastasis of 14.0 (6.8-21,2) months. MMP9 was upregulated, and ANDP was downregulated in patients with bone metastasis compared to those without metastasis.

Components of Sarcopenia and Frailty in Relation to Cognitive Impairment in Older Adults: An Ambispective Cohort Study from a Tertiary Hospital

Jessica Marsigit — 2026-04-09

Background: Sarcopenia and frailty are common geriatric syndromes that may contribute to mild cognitive impairment (MCI). Evidence regarding the independent roles of individual sarcopenia components and frailty in MCI remains limited in low- and middle-income countries. This study evaluated the association between sarcopenia components, frailty, and MCI among older adults in Indonesia. Methods: An ambispective cohort study was conducted among adults aged ≥60 years attending the Geriatric Outpatient Clinic of Dr. Cipto Mangunkusumo National General Hospital, Jakarta. Sarcopenia components were assessed using SARC-Calf (low muscle mass indicator), handgrip strength, and the five-times sit-to-stand test. Frailty was evaluated using the FRAIL scale. Cognitive function was assessed using the Rapid Cognitive Screening. Multivariate log-binomial or Poisson regression with robust variance was used to estimate adjusted risk ratios (RRs) for MCI. Results: A total of 121 participants (median age 74 years; 68.6% female) were included, with an MCI prevalence of 21.5%. After adjustment for confounders, low muscle mass indicator (RR 2.206; 95% CI 1.045–4.652) and low muscle strength (RR 3.006; 95% CI 1.202–7.517) were independently associated with MCI. Low physical performance (RR 1.773; 95% CI 0.796–3.773) and frailty (RR 1.086; 95% CI 0.377–3.134) were not significantly associated with MCI. Conclusion: Low muscle mass indicators and reduced muscle strength were independently associated with MCI, supporting the integration of simple sarcopenia screening tools into routine geriatric cognitive assessment.

Cytomegalovirus Encephalitis and Cerebral Toxoplasmosis in an Immunocompetent Patient: A Rare Case Report

Ni Putu Merlynda Pusvita Dewi — 2026-04-09

Cytomegalovirus (CMV) and Toxoplasma gondii infections are typically associated with immunocompromised individuals, in whom they can cause severe central nervous system (CNS) complications. However, their concurrent manifestation in immunocompetent hosts (IMCh) is exceptionally rare and underreported. We present the case of a 51-year-old immunocompetent male with a three-month history of progressive headache, nausea, and intermittent joint pain, without neurological deficits. Imaging revealed chronic infarcts in the basal ganglia and frontal lobe, as well as multifocal lesions in the periventricular area. Serological testing indicated high-avidity IgG for both CMV and T. gondii, consistent with chronic latent infections. Despite being HIV-negative and without prior immunosuppressive therapy, the patient exhibited hematologic abnormalities, including thrombocytopenia, lymphopenia, and eosinophilia. Treatment with valganciclovir, cotrimoxazole, and clindamycin led to symptomatic improvement. This case underscores the diagnostic challenges of CMV encephalitis and cerebral toxoplasmosis in IMCh, where nonspecific symptoms and overlapping radiological findings may mimic other etiologies such as stroke. Given the neurotropic nature of T. gondii and the hematologic impact of CMV, coinfection—though rare—should be considered in patients with atypical CNS symptoms and hematological abnormalities, even in the absence of immunodeficiency. This report showed the need for heightened clinical suspicion and thorough evaluation to avoid misdiagnosis and ensure timely intervention. Clinicians should recognize that serious manifestations of CMV and toxoplasmosis are possible in IMCh and may present subtly, necessitating comprehensive serologic and imaging workups for accurate diagnosis and management.

Embryonal Rhabdomyosarcoma of the Prostate in a Young Adult

Xhyrel June Tagaylo — 2026-04-09

Embryonal rhabdomyosarcoma (ERMS) is a primitive and aggressive soft tissue tumor that arises from premature mesenchymal cells and accounts for less than 1% of prostate malignancies. We present the case of a 26-year-old Filipino male who initially sought consultation and work-up for acute urinary retention. Although his prostate-specific antigen (PSA) level was normal, a kidney-ureter-bladder (KUB) ultrasound revealed an incidental finding of an enlarged prostate gland. Subsequent imaging tests (MRI and CT) identified a large, partially exophytic mass on the prostate with intravesical extension. The patient underwent a biopsy via transurethral resection at another institution, which yielded findings of a poorly differentiated carcinoma, primarily suggesting prostatic adenocarcinoma with a Gleason score of 10 (5+5). A request for slide review was submitted to our institution, and subsequent immunohistochemistry (IHC) studies—highlighting the tumor's immunoreactivity to myogenin and desmin—confirmed the diagnosis of ERMS. In this report, we discuss the clinical features, pathogenesis, treatment, diagnosis, and prognosis of this rare prostate tumor.

Ectopic Hepatocellular Carcinoma in the Mediastinum with Brain Metastasis: A Rare Case Report

Vidi Prasetyo Utomo — 2026-04-09

Ectopic hepatocellular carcinoma (EHCC) is an extremely rare neoplasm, especially in the mediastinum, which shares morphologic characteristics with intrahepatic hepatocellular carcinoma (HCC). Its clinical features remain unclear, posing significant diagnostic and therapeutic challenges. The prognosis is also unclear due to its rarity and potential variability. This study reports the first case of EHCC in the mediastinum with subsequent brain metastasis. A 50-year-old man presented with shoulder and chest discomfort persisting for 5 months, accompanied by progressive weight loss and fatigue over the preceding 2 years. Imaging showed a mediastinal mass initially suspected to be lymphoma due to its malignant characteristics. However, histopathological examination identified the lesion as HCC, supported by characteristic immunohistochemical markers, despite normal abdominal imaging. Two months later, the tumor progressed despite intensive radiotherapy, and the patient experienced recurrent seizures. Subsequent brain imaging confirmed multiple intracranial metastases. Unfortunately, the patient died 6 months after diagnosis. The ectopic liver is more susceptible to hepatocarcinogenesis than the main liver; this is attributed to its incomplete functional structure. EHCC can be considered as differential diagnosis of mediastinal masses, even when no intrahepatic HCC is found. The rarity of EHCC in the mediastinum poses difficulties in developing treatment protocols. This case emphasizes the diagnostic challenges and aggressive nature of ectopic HCC and the need for comprehensive management strategies. There are currently no definite guidelines regarding the diagnosis, treatment, and prognosis of EHCC.

Comprehensive Case Analysis: Diagnosing and Managing Myositis in Newly Diagnosed Systemic Lupus Erythematosus Patients in Indonesia

Nabila Abiyasa Putri — 2026-04-09

An 18-year-old female with Systemic Lupus Erythematosus (SLE) presented with bilateral thigh pain, fever, and diarrhea three days before admission. Diagnosed with SLE one month earlier, she reported prior symptoms, including joint pain, malar rash, hair loss, and hyperpigmented lesions. Initial investigations revealed elevated transaminase levels (AST 355, ALT 132), positive ANA, decreased complement levels (C3 68, C4 16.8), and raised creatine kinase (619). A muscle biopsy confirmed myositis. The patient was treated with immunosuppressant (a combination of steroids and hydroxychloroquine) and supportive therapy. By the eighth day of hospitalization, her symptoms, especially thigh pain, resolved. Electromyocardiography was done, and the results were normal, indicating therapeutic success. This case highlights the importance of prompt diagnosis and management of myositis as a rare SLE manifestation to achieve favorable outcomes.

Acromegaly in an Elderly Woman

Laurentius Aswin Pramono — 2026-04-09

Pituitary adenomas are common intracranial tumors that can be classified based on their hormonal activity and size. While microadenomas are more frequent, macroadenomas often present with significant clinical manifestations due to hormone excess or mass effects. In older populations, diagnosis is often delayed as physical changes may be subtly attributed to normal aging. A 61-year-old woman presented with progressively coarsening facial features and enlargement of the hands and feet. Physical examination confirmed acral enlargement, and the patient reported persistent headaches and a history of hypertension. Laboratory investigations revealed significantly elevated levels of growth hormone (GH) at 18.9 ng/mL and insulin-like growth factor-1 (IGF-1) at 865.6 ng/mL. Other pituitary functions, including prolactin and morning cortisol, were within normal limits. Magnetic resonance imaging (MRI) identified a 1.3 × 2.5 × 1.0 cm pituitary macroadenoma. The patient subsequently underwent successful endonasal endoscopic transsphenoidal surgery for tumor resection.

This case underscores the necessity of maintaining a high index of suspicion for acromegaly in elderly patients presenting with unexplained acral and facial changes. Comprehensive endocrine evaluation and advanced imaging are critical for achieving an accurate diagnosis and ensuring timely surgical intervention to prevent disease progression.

Expert Opinion on the Management of Hyperkalemia in Patients with Cardiorenal Diseases Treated with Renin Angiotensin Aldosterone System Inhibitors: An Indonesian Perspective

Pringgodigdo Nugroho — 2026-04-09

Hyperkalemia (serum potassium >5.0 mEq/l) is a significant complication in patients with heart failure, chronic kidney disease, and diabetes mellitus, particularly when treated with renin-angiotensin-aldosterone system inhibitors (RAASi). Both hyperkalemia and RAASi interruption are associated with increased cardiovascular events, hospitalizations, and mortality. This expert opinion document, developed between January and December 2024 through a systematic process, aims to establish guidance for hyperkalemia treatment in Indonesian patients with cardiorenal diseases receiving RAASi therapy, addressing the unique challenges within the Indonesian healthcare context. A comprehensive literature review of international guidelines and regional studies was conducted by a panel of 11 expert specialists (3 cardiologists, 6 internist-nephrologists, and 2 internist-cardiologists), who evaluated 29 statements covering diagnosis, monitoring, prevention, and treatment of hyperkalemia. Of the 29 statements, 26 reached consensus: 17 statements achieved very high agreement (≥90%) and 9 attained high agreement (≥67% – <90%). The agreed statements covered key areas, including potassium monitoring frequency, RAASi dose optimization strategies, dietary modifications, and treatment thresholds. Three statements regarding alternative therapeutic approaches did not receive agreement (<67%) due to limited local availability and cost considerations. Key recommendations include structured monitoring protocols for high-risk patients, strategies for RAASi dose optimization while managing hyperkalemia risk, and specific interventions adapted to local resources. This document provides a practical approach for managing hyperkalemia in Indonesian patients with cardiorenal diseases while maintaining optimal RAASi therapy, considering local Indonesian healthcare resources and constraints.