Graves' disease (GD) is an autoimmune disease characterized by excessive autoantibody formation by the lymphocyte B cells (B cells). The autoantibodies will bind to Thyroid Stimulating Hormone receptors (TSHR) and enhance the production of thyroid hormone. Previous studies indicate that the impairment of immune response in GD happens in several points in the adaptive immune response, particularly the profile of the intrathyroidal dendritic cells (tDC), the imbalance of T helper-1 (Th1) and T helper-2 (Th2), the Th17 cells that act as pro-inflammatory cells and the dysfunction of immune modulating T regulator (Treg) cells.6-11 Vitamin D is a steroid hormone which has pleiotropic effects. The role of vitamin D in bone and calcium metabolism is already established. The discovery of vitamin D receptor (VDR) in immune cells such as monocytes/macrophages, T cells and B cells, demonstrates that vitamin D may influence innate and adaptive immune process. Recent studies try to explore the relationship between vitamin D and autoimmune disease, furthermore they consider vitamin D as a modifiable environmental factor in autoimmune diseases.13,40 Most people with autoimmune diseases have lower vitamin D level than that of healthy subjects. Vitamin D level also has been associated with disease activity of Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA). Vitamin D influences adaptive immune response through its ability to modulate dendritic Cells (DC), T cells, B cells and Treg cells. Although previous studies reported the immune response disturbance in GD include the tDC, Thelper and Treg cells,6-11 little is known whether the immunoregulatory effect of vitamin D can interfere with the natural history of GD. The effect of vitamin D in GD remains to be explored.
Graves Disease ; Adaptive Immunity ; Vitamin D

BACKGROUND/OBJECTIVES: Malnutrition during hospitalization is linked to increased morbidity and mortality, but there are insufficient studies observing clinical factors contributing to weight loss during hospitalization in Indonesia. This study was therefore undertaken to determine the rate of weight loss during hospitalization and the contributing factors. SUBJECTS/METHODS: This was a prospective study involving hospitalized adult patients aged 18–59 yrs, conducted between July and September 2019. Body weight measurement was taken at the time of admission and on the last day of hospitalization. The factors studied were malnutrition at admission (body mass index < 18.5 kg/m2 ), immobilization, depression (Beck Depression Inventory-II Indonesia), polypharmacy, inflammatory status (neutrophil-lymphocytes ratio;NLR), comorbidity status (Charlson Comorbidity Index; CCI), and length of stay. RESULTS: Totally, 55 patients were included in the final analysis, with a median age of 39 (18-59 yrs) yrs. Of these, 27% had malnutrition at admission, 31% had a CCI score > 2, and 26% had an NLR value of ≥ 9. In all, 62% presented with gastrointestinal symptoms, and depression was documented in one-third of the subjects at admission. Overall, we recorded a mean weight loss of 0.41 kg (P = 0.038) during hospitalization, with significant weight loss observed among patients hospitalized for 7 days or more (P = 0.009). The bivariate analysis revealed that inflammatory status (P = 0.016) was associated with in-hospital weight loss, while the multivariate analysis determined that the contributing factors were length of stay (P < 0.001) and depression (P = 0.019). CONCLUSIONS We found that inflammatory status of the patient might influence the incidence of weight loss during hospitalization, while depression and length of stay were independent predictors of weight loss during hospitalization.

Individuals with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) are at increased risk for fragility fractures. Bone mineral density (BMD) is decreased in T1DM but often normal or even elevated in T2DM when compared with age-matched non-DM populations. However, bone turnover is decreased in both T1DM and T2DM. The pathophysiologic mechanisms leading to bone fragility is multifactorial, and potentially leads to reduced bone formation, altered bone microstructure and decreased bone strength. Interestingly, different antidiabetic treatments may influence fracture risk due to effects on glycemic control, triggering of hypoglycemic events or osteoblastogenesis.
Diabetes Mellitus ; Bone Remodeling ; Biomarkers

Background: Insulin resistance is the core of Metabolic Syndrome which carries a high risk for cardiovascular events. Insulin resistance had been reported to be higher in GERD patients than subjects without GERD, specifically in erosive esophagitis. Objective: To compare the degree of insulin resistance, using HOMA-IR index, between erosive and non-erosive reflux disease. Methodology: A cross-sectional study of 84 adult patients with GERD symptoms was conducted. The subjects were recruited consecutively between January 2017 and April 2017 at Cipto Mangunkusumo National Hospital in Jakarta. Gastroesophageal Reflux Disease Questionnaire (GERDQ) was used for subject recruitment. Homeostatic model assessment-insulin resistance (HOMA-IR) index was used to evaluate insulin sensitivity. Esophageal erosions were diagnosed using upper gastrointestinal endoscopy. Bivariate analysis was used to determine HOMA-IR difference between esophagitis and non-esophagitis group. Results: The median of HOMA-IR in all subjects was 1.46 (0.32-13.85). Mann-Whitney test revealed that HOMA-IR index was higher in patients with erosive esophagitis [median 1.74 (0.35-13.85)] than those without erosive esophagitis [median 1.21 (0.32-10.78)] (p=0.05). Conclusion Insulin resistance is significantly higher in gastroesophageal reflux disease patients with esophageal erosions than in those without esophageal erosion.
Insulin Resistance

Untreated thyroid dysfunction during pregnancy increases morbidity in the mother and fetus. Anti-thyroid medication is the first-line therapy for hyperthyroidism during pregnancy. The diagnosis of thyroid dysfunction in pregnancy is complicated because of seemingly insignificant and non-specific symptoms which overlap with normal changes during pregnancy. Early detection and management should be done to prevent maternal and fetal complications.
Thyroid Gland ; Pregnancy ; Practice Guideline ; Indonesia

Diabetes Mellitus (DM) in pregnancy has serious impact on both mother and baby if not optimally managed. The Indonesian Task Force on Reproductive Diseases determined that diabetes in pregnancy represents a priority area in need of updated evidence-based practice guidelines. The aim of the guidelines is to provide the best evidence-based recommendations for diagnostic evaluation and management of diabetes in pregnancy. The following article summarizes the guidelines.
Pregnancy ; Practice Guideline ; Indonesia

One of the neglected complications of patients with HIV/AIDS is primary adrenal insufficiency also known as Addison’s disease. This condition can be caused by several mechanisms, such as tuberculosis, CMV, cryptococcal, or HIV-related adrenalitis, and also drugs commonly used for HIV/AIDS especially antifungal therapy. This is a case report of a man infected with HIV/AIDS and multiple opportunistic infections. He reported darkening of the skin and reduction of body hair 4 months after diagnosis of HIV/AIDS. From the clinical features and laboratory examinations, he was diagnosed as having primary adrenal insufficiency and was then treated with longterm corticosteroids.
Addison Disease ; Opportunistic Infections ; HIV ; Acquired Immunodeficiency Syndrome