Internal Medicine Commons^™

Multilevel Community Engagement To Inform A Randomized Clinical Trial, Kirby L. Wycoff, Jabina G. Coleman, Christine M. Santoro, Leah L. Zullig, Niesha Darden, Porsche M. Holland, Jane F. Cruice, Shukriyyah Mitchell, Michelle Smith, Saleemah J. Mcneil, Sharon J. Herring

Counseling and Behavioral Health Faculty Papers

OBJECTIVE: To explore how patients, community-based perinatal support professionals, and health system clinicians and staff perceived facilitators and barriers to implementation of a randomized clinical trial (RCT) designed to optimize Black maternal heart health.

METHODS: This article describes the formative work that we believed needed to occur before the start of the Change of H.E.A.R.T (Here for Equity, Advocacy, Reflection and Transformation) RCT. We used a qualitative, descriptive design and community-based, participatory approach, the latter of which allowed our team to intentionally focus on avoiding harm and equalizing power dynamics throughout the research process. Data were collected between November 2021 …

Assessment Of Portal System Hemodynamics For The Prediction Of Portal-Vein Thrombosis In Cirrhosis - A Systematic Review And Meta-Analysis, Marko Kozyk, Suprabhat Giri, Ankita Singh, Kailash Kolhe, Akash Roy, Kateryna Strubchevska

Conference Presentation Abstracts

Background: The pathogenesis of portal vein thrombosis (PVT) in cirrhosis is multifactorial, with altered hemodynamics being proposed as a possible contributor. The present systematic review was conducted to study the role of assessment of portal hemodynamics for the prediction of PVT in patients with cirrhosis. Methods: Three databases (Medline, Embase, and Scopus) were searched from inception to February 2023 for studies comparing portal venous system parameters in patients with cirrhosis developing PVT with those not. Results were presented as mean difference (MD) or odds ratio (OR) with their 95% confidence intervals (CI). Results: A total of 31 studies (patients with …

Efficacy And Safety Of Transjugular Intrahepatic Portosystemic Shunt In Patients With Hepatocelluar Carcinoma - A Systematic Review And Meta-Analysis, Marko Kozyk, Suprabhat Giri, Ankit Singh, Akash Roy, Kateryna Strubchevska, Taraprasad Tripathi, Ranjan Kumar Patel

Conference Presentation Abstracts

Background: Patients with hepatocellular carcinoma (HCC) and cirrhosis can present with features of severe portal hypertension, which can be worsened further with associated portal vein tumoral thrombosis (PVTT). Due to the technical difficulties and short survival of these patients, HCC was traditionally considered a relative contraindication for transjugular intrahepatic portosystemic shunt (TIPS). However, there is an increasing body of evidence supporting the use of TIPS in HCC. The present study aimed to analyze the efficacy and safety of TIPS in patients with HCC. Methods: A literature search of MEDLINE, Embase, and Scopus was conducted from 2000 to October 2022 for …

Deletion Of Interleukin-17a Augments Portal Fibrosis In A Mouse Model Of Cholestatic Liver Injury, Takashi Kitagataya, Kirsta Olson, Michelle Baez-Faria, Nazli Begum Ozturk, Kaiyel Cutshaw, Anuradha Krshnan, Maria Eugenia Guicciardi, Kevin D. Pavelko, Gregory J. Gores

Conference Presentation Abstracts

Background: The underlying mechanism contributing to cholestatic liver injury remains unclear. The proinflammatory cytokine interleukin-17A (IL-17A) has been implicated in human cholestatic liver injury. However, mechanistic insights on how IL-17A modulates cholestatic liver injury are lacking and require further exploration in preclinical models. Herein, we examined the effects of IL-17A genetic deletion in a mouse model of cholestasis. Methods: Ageand gender-matched littermate WT and Il-17a-/- were fed intermittently on 0.1% 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) diet or control diet (n=10, each) and standard diet for 21 days to induce cholestatic liver injury. We assessed liver inflammation, ductular reaction, and fibrosis using complementary approaches. …

Pirh2-Dependent Dna Damage In Neurons Induced By The G-Quadruplex Ligand Pyridostatin, Rocio Diaz Escarcega, Abhijeet A Patil, Jose F Moruno-Manchon, Akihiko Urayama, Sean P Marrelli, Nayun Kim, David Monchaud, Louise D Mccullough, Andrey S Tsvetkov

Faculty, Staff and Student Publications

Noncanonical base pairing between four guanines (G) within single-stranded G-rich sequences leads to formation of а G-quartet. Self-stacking of G-quartets results in a columnar four-stranded DNA structure known as the G-quadruplex (G4 or G4-DNA). In cancer cells, G4-DNA regulates multiple DNA-dependent processes, including transcription, replication, and telomere function. How G4s function in neurons is poorly understood. Here, we performed a genome-wide gene expression analysis (RNA-Seq) to identify genes modulated by a G4-DNA ligand, pyridostatin (PDS), in primary cultured neurons. PDS promotes stabilization of G4 structures, thus allowing us to define genes directly or indirectly responsive to G4 regulation. We found …

Diabetes Risk During Pregnancy Among Second-Generation Immigrants: A National Cohort Study In Sweden, Per Wändell, Xinjun Li, Nouha Saleh Stattin, Axel C Carlsson, Jan Sundquist, Casey Crump, Kristina Sundquist

Faculty, Staff and Student Publications

BACKGROUND AND AIMS: Gestational diabetes is more common in many first-generation immigrant women in Europe and other Western countries. Less is known about second-generation immigrant women; such knowledge is needed to understand generational influences on diabetes risk. We aimed to study second-generation immigrant women regarding the presence of all types of diabetes during pregnancy.

METHODS AND RESULTS: A cohort study was conducted using the Swedish National Birth Register, the National Patient Register, and the total Population Register. We used Cox regression analysis to compute hazard ratios (HRs) and 99% confidence intervals (99% CI) for any diabetes during pregnancy and specific …

Gwas Meta-Analysis Of Suicide Attempt: Identification Of 12 Genome-Wide Significant Loci And Implication Of Genetic Risks For Specific Health Factors, Anna R Docherty, Niamh Mullins, Allison E Ashley-Koch, Xuejun Qin, Jonathan R I Coleman, Andrey Shabalin, Jooeun Kang, Balasz Murnyak, Frank Wendt, Mark Adams, Adrian I Campos, Emily Diblasi, Janice M Fullerton, Henry R Kranzler, Amanda V Bakian, Eric T Monson, Miguel E Rentería, Consuelo Walss-Bass, Ole A Andreassen, Chittaranjan Behera, Cynthia M Bulik, Howard J Edenberg, Ronald C Kessler, J John Mann, John I Nurnberger, Giorgio Pistis, Fabian Streit, Robert J Ursano, Renato Polimanti, Michelle Dennis, Melanie Garrett, Lauren Hair, Philip Harvey, Elizabeth R Hauser, Michael A Hauser, Jennifer Huffman, Daniel Jacobson, Ravi Madduri, Benjamin Mcmahon, David W Oslin, Jodie Trafton, Swapnil Awasthi, Wade H Berrettini, Martin Bohus, Xiao Chang, Hsi-Chung Chen, Wei J Chen, Erik D Christensen, Scott Crow, Philibert Duriez, Alexis C Edwards, Fernando Fernández-Aranda, Hanga Galfalvy, Michael Gandal, Philip Gorwood, Yiran Guo, Jonathan D Hafferty, Hakon Hakonarson, Katherine A Halmi, Akitoyo Hishimoto, Sonia Jain, Stéphane Jamain, Susana Jiménez-Murcia, Craig Johnson, Allan S Kaplan, Walter H Kaye, Pamela K Keel, James L Kennedy, Minsoo Kim, Kelly L Klump, Daniel F Levey, Dong Li, Shih-Cheng Liao, Klaus Lieb, Lisa Lilenfeld, Christian R Marshall, James E Mitchell, Satoshi Okazaki, Ikuo Otsuka, Dalila Pinto, Abigail Powers, Nicolas Ramoz, Stephan Ripke, Stefan Roepke, Vsevolod Rozanov, Stephen W Scherer, Christian Schmahl, Marcus Sokolowski, Anna Starnawska, Michael Strober, Mei-Hsin Su, Laura M Thornton, Janet Treasure, Erin B Ware, Hunna J Watson, Stephanie H Witt, D Blake Woodside, Zeynep Yilmaz, Lea Zillich, Rolf Adolfsson, Ingrid Agartz, Martin Alda, Lars Alfredsson, Vivek Appadurai, María Soler Artigas, Sandra Van Der Auwera, M Helena Azevedo, Nicholas Bass, Claiton H D Bau, Bernhard T Baune, Frank Bellivier, Klaus Berger, Joanna M Biernacka, Tim B Bigdeli, Elisabeth B Binder, Michael Boehnke, Marco P Boks, David L Braff, Richard Bryant, Monika Budde, Enda M Byrne, Wiepke Cahn, Enrique Castelao, Jorge A Cervilla, Boris Chaumette, Aiden Corvin, Nicholas Craddock, Srdjan Djurovic, Jerome C Foo, Andreas J Forstner, Mark Frye, Justine M Gatt, Ina Giegling, Hans J Grabe, Melissa J Green, Eugenio H Grevet, Maria Grigoroiu-Serbanescu, Blanca Gutierrez, Jose Guzman-Parra, Marian L Hamshere, Annette M Hartmann, Joanna Hauser, Stefanie Heilmann-Heimbach, Per Hoffmann, Marcus Ising, Ian Jones, Lisa A Jones, Lina Jonsson, René S Kahn, John R Kelsoe, Kenneth S Kendler, Stefan Kloiber, Karestan C Koenen, Manolis Kogevinas, Marie-Odile Krebs, Mikael Landén, Marion Leboyer, Phil H Lee, Douglas F Levinson, Calwing Liao, Jolanta Lissowska, Fermin Mayoral, Susan L Mcelroy, Patrick Mcgrath, Peter Mcguffin, Andrew Mcquillin, Divya Mehta, Ingrid Melle, Philip B Mitchell, Esther Molina, Gunnar Morken, Caroline Nievergelt, Markus M Nöthen, Michael C O'Donovan, Roel A Ophoff, Michael J Owen, Carlos Pato, Michele T Pato, Brenda W J H Penninx, James B Potash, Robert A Power, Martin Preisig, Digby Quested, Josep Antoni Ramos-Quiroga, Andreas Reif, Marta Ribasés, Vanesa Richarte, Marcella Rietschel, Margarita Rivera, Andrea Roberts, Gloria Roberts, Guy A Rouleau, Diego L Rovaris, Alan R Sanders, Peter R Schofield, Thomas G Schulze, Laura J Scott, Alessandro Serretti, Jianxin Shi, Lea Sirignano, Pamela Sklar, Olav B Smeland, Jordan W Smoller, Edmund J S Sonuga-Barke, Maciej Trzaskowski, Ming T Tsuang, Gustavo Turecki, Laura Vilar-Ribó, John B Vincent, Henry Völzke, James T R Walters, Cynthia Shannon Weickert, Thomas W Weickert, Myrna M Weissman, Leanne M Williams, Naomi R Wray, Clement C Zai, Esben Agerbo, Anders D Børglum, Gerome Breen, Ditte Demontis, Annette Erlangsen, Joel Gelernter, Stephen J Glatt, David M Hougaard, Hai-Gwo Hwu, Po-Hsiu Kuo, Cathryn M Lewis, Qingqin S Li, Chih-Min Liu, Nicholas G Martin, Andrew M Mcintosh, Sarah E Medland, Ole Mors, Merete Nordentoft, Catherine M Olsen, David Porteous, Daniel J Smith, Eli A Stahl, Murray B Stein, Danuta Wasserman, Thomas Werge, David C Whiteman, Virginia Willour, Hilary Coon, Jean C Beckham, Nathan A Kimbrel, Douglas M Ruderfer

Faculty, Staff and Student Publications

OBJECTIVE: Suicidal behavior is heritable and is a major cause of death worldwide. Two large-scale genome-wide association studies (GWASs) recently discovered and cross-validated genome-wide significant (GWS) loci for suicide attempt (SA). The present study leveraged the genetic cohorts from both studies to conduct the largest GWAS meta-analysis of SA to date. Multi-ancestry and admixture-specific meta-analyses were conducted within groups of significant African, East Asian, and European ancestry admixtures.

METHODS: This study comprised 22 cohorts, including 43,871 SA cases and 915,025 ancestry-matched controls. Analytical methods across multi-ancestry and individual ancestry admixtures included inverse variance-weighted fixed-effects meta-analyses, followed by gene, gene-set, tissue-set, …

Risk Of Covid-19 After Natural Infection Or Vaccination, Anne-Marie Rick, Matthew B Laurens, Ying Huang, Chenchen Yu, Thomas C S Martin, Carina A Rodriguez, Christina A Rostad, Rebone M Maboa, Lindsey R Baden, Hana M El Sahly, Beatriz Grinsztejn, Glenda E Gray, Cynthia L Gay, Peter B Gilbert, Holly E Janes, James G Kublin, Yunda Huang, Brett Leav, Ian Hirsch, Frank Struyf, Lisa M Dunkle, Kathleen M Neuzil, Lawrence Corey, Paul A Goepfert, Stephen R Walsh, Dean Follmann, Karen L Kotloff

Faculty, Staff and Student Publications

BACKGROUND: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection.

METHODS: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection …

Medication Reconciliation During Transitions Of Care Across Institutions: A Quantitative Analysis Of Challenges And Opportunities, Alejandro Araya, Logan R Thornton, Deukwoo Kwon, Gayla M Ferguson, Linda D Highfield, Kevin O Hwang, Holly M Holmes, Elmer V Bernstam

Faculty, Staff and Student Publications

OBJECTIVE: Medication discrepancies between clinical systems may pose a patient safety hazard. In this paper, we identify challenges and quantify medication discrepancies across transitions of care.

METHODS: We used structured clinical data and free-text hospital discharge summaries to compare active medications' lists at four time points: preadmission (outpatient), at-admission (inpatient), at-discharge (inpatient), and postdischarge (outpatient). Medication lists were normalized to RxNorm. RxNorm identifiers were further processed using the RxNav API to identify the ingredient. The specific drugs and ingredients from inpatient and outpatient medication lists were compared.

RESULTS: Using RxNorm drugs, the median percentage intersection when comparing active medication lists …

Hiccups: Nerve Irritation Or Masquerading As Acute Coronary Syndrome, Dessiree Cordero, Patrik Schmidt, Franklin Sosa, Maulin Patel, Eduard Sklyar

Faculty, Staff and Student Publications

The typical clinical presentation of acute coronary syndrome (ACS) includes chest pain that may radiate to the left arm, shoulder, jaw, and neck, accompanied by diaphoresis, dyspnea, nausea, vomiting, and hiccups, which have been observed as the sole symptom of presentation. The mechanism of hiccups involves the activation of the vagus and phrenic nerves, leading to the activation of the diaphragm and intercostal muscles. Several hypotheses link hiccups to ACS, associating irritation of the left anterior descending artery with activation of sympathetic phrenic and vagal nerves. This case report highlights the occurrence of hiccups in patients with inferior and right …

Partnering With Patients And Families To Improve Diagnostic Safety Through The Ourdx Tool: Effects Of Race, Ethnicity, And Language Preference, Fabienne C Bourgeois, Nicholas J Hart, Zhiyong Dong, Long H Ngo, Catherine M Desroches, Eric J Thomas, Sigall K Bell

Faculty, Staff and Student Publications

BACKGROUND: Patients and families at risk for health disparities may also be at higher risk for diagnostic errors but less likely to report them.

OBJECTIVES: This study aimed to explore differences in race, ethnicity, and language preference associated with patient and family contributions and concerns using an electronic previsit tool designed to engage patients and families in the diagnostic process (DxP).

METHODS: Cross-sectional study of 5,731 patients and families presenting to three subspecialty clinics at an urban pediatric hospital May to December 2021 who completed a previsit tool, codeveloped and tested with patients and families. Prior to each visit, patients/families …

An Efficient Strategy For Evaluating New Non-Invasive Screening Tests For Colorectal Cancer: The Guiding Principles, Robert S Bresalier, Carlo Senore, Graeme P Young, James Allison, Robert Benamouzig, Sally Benton, Patrick M M Bossuyt, Luis Caro, Beatriz Carvalho, Han-Mo Chiu, Veerle M H Coupé, Willemijn De Klaver, Clasine Maria De Klerk, Evelien Dekker, Sunil Dolwani, Callum G Fraser, William Grady, Lydia Guittet, Samir Gupta, Stephen P Halloran, Ulrike Haug, Geir Hoff, Steven Itzkowitz, Tim Kortlever, Anastasios Koulaouzidis, Uri Ladabaum, Beatrice Lauby-Secretan, Mārcis Leja, Bernard Levin, Theodore Robert Levin, Finlay Macrae, Gerrit A Meijer, Joshua Melson, Colm O'Morain, Susan Parry, Linda Rabeneck, David F Ransohoff, Roque Sáenz, Hiroshi Saito, Silvia Sanduleanu-Dascalescu, Robert E Schoen, Kevin Selby, Harminder Singh, Robert J C Steele, Joseph J Y Sung, Erin Leigh Symonds, Sidney J Winawer, Members Of The World Endoscopy Colorectal Cancer Screening New Test Evaluation Expert Working Group

Faculty, Staff and Student Publications

OBJECTIVE: New screening tests for colorectal cancer (CRC) are rapidly emerging. Conducting trials with mortality reduction as the end point supporting their adoption is challenging. We re-examined the principles underlying evaluation of new non-invasive tests in view of technological developments and identification of new biomarkers.

DESIGN: A formal consensus approach involving a multidisciplinary expert panel revised eight previously established principles.

RESULTS: Twelve newly stated principles emerged. Effectiveness of a new test can be evaluated by comparison with a proven comparator non-invasive test. The faecal immunochemical test is now considered the appropriate comparator, while colonoscopy remains the diagnostic standard. For a …

Zyxin Inhibits The Epithelial-Mesenchymal Transition Process In Gastric Cancer By Upregulating Sirt1, Jing Lou, Sha Geng, Wei He, Song-Bai Liu, Xinghong Shi, Ying Chang, Shiyuan Han, Panting Qian, Hesham M Amin, Yao-Hua Song, Yangxin Li, Jin Zhou

Faculty, Staff and Student Publications

Tumor development relies on the stemness of cancer stem cells, which is regulated by environmental cues. Previous studies have shown that zyxin can inhibit the expression of genes for embryonic stem cell status. In the present study, the expression levels of zyxin protein in cancer tissues and adjacent noncancerous tissues from 73 gastric cancer patients with different clinical stages were analyzed by Western blot. We showed that the relative expression levels of zyxin in gastric cancer tissues (cancer tissues/adjacent tissues) were significantly downregulated in advanced clinical stages. Overexpression of zyxin inhibited the stemness and epithelial-mesenchymal transition (EMT) processes in gastric …

A Single Center Analysis Of Patients Undergoing Liver Resection For Intrahepatic Cholangiocarcinoma, Nazli Begum Ozturk, Laith H. Jamil

Conference Presentation Abstracts

Background: Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver cancer with increasing rates of incidence and mortality. Surgical resection with negative margins and regional lymphadenectomy is the mainstay of the treatment for patients with resectable-iCCA. Because of its rarity and low resectability rate of iCCA, prognostic markers and outcomes of patients who undergo liver resection are not well defined. We aimed to evaluate the characteristics of patients undergoing liver resection for iCCA at our institution over ten years. Methods: All patients with iCCA who had liver resection between 3/2013-3/2023 at our institution were included in the study. An …

Recent Insights Into The Pathogenesis And Therapeutic Targets Of Chronic Liver Diseases, Yankai Wen, Lichun Ma, Cynthia Ju

Faculty, Staff and Student Publications

Viral hepatitis, alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) are the three major causes of chronic liver diseases, which account for approximately 2 million deaths per year worldwide. The current direct-acting antiviral drugs and vaccinations have effectively reduced and ameliorated viral hepatitis infection, but there are still no effective drug treatments for ALD, NAFLD and liver cancer due to the poor understanding of their pathogenesis. To better understand the pathogenesis, the fifth Chinese American Liver Society/Society of Chinese Bioscientists in America Hepatology Division Annual Symposium, which was held virtually on 21-22 October 2022, focused on the topics …

Profilaksis Vs. Terapi Preemtif Penyakit Cytomegalovirus (Cmv) Pada Pasien Transplantasi Ginjal Risiko Tinggi: Suatu Laporan Kasus Berbasis Bukti, Ariani Intan Wardhani, Rahajeng N. Tunjungputri, Erpryta Nurdia Tetrasiwi, Maruhum Bonar Marbun

Jurnal Penyakit Dalam Indonesia

Kidney transplant recipients require the use of immunosuppressive agents to prevent multiple organ rejection. Administration of immunosuppressive agents triggers an increased risk of impaired immunity and microbial infections, one of which is cytomegalovirus (CMV). Prevention of cytomegalovirus infection can be given as a prophylaxis or preemptive therapy. However, the efficacy of choosing prophylaxis or preemptive therapy is still under debate, thus we conducted this study to identify current approach in preventing CMV disease in clinical practice. A literature search was carried out using the PubMed, Cochrane Library, Embase and Scopus databases with the keywords “high risk …

Faktor-Faktor Yang Memengaruhi Kesintasan Pasien Yang Dilakukan Intervensi Koroner Perkutan Primer, Birry Karim

Jurnal Penyakit Dalam Indonesia

No abstract provided.

Sarkopenia Pada Lanjut Usia: Patogenesis, Diagnosis Dan Tata Laksana, Edwin Nugroho Njoto, I Gusti Putu Suka Aryana

Jurnal Penyakit Dalam Indonesia

‘Sarcopenia’ involves a progressive age-related loss of muscle mass and associated muscle weakness that renders frail elders susceptible to serious injury from sudden falls and fractures and losing their functional independence. This disease has a complex multifactorial pathogenesis, which involves not only age-related changes in neuromuscular function, muscle protein turnover, and hormone levels and sensitivity, but also a chronic pro-inflammatory state, oxidative stress, and behavioral factors – in particular, nutritional status and degree of physical activity. In the previous definition by the European Working Group on Sarcopenia in Older People (EWGSOP) in 2010, the diagnosis of sarcopenia requires the presence …

Manajemen Koinfeksi Malaria Berat Dengan Hiv Belum Mendapat Terapi Antiretrovirus Di Era Pandemi Covid-19: Sebuah Laporan Kasus, Paul Harijanto, Rosye Mawuntu, Novia Rusli, Randy Adiwinata, Agung Nugroho

Jurnal Penyakit Dalam Indonesia

Severe malaria is a serious infectious disease that required immediate diagnosis and prompt treatment. Severe malaria may result several organ failures which is similar with other infectious diseases like SARS-CoV-2, sepsis, dengue, and HIV infection. Most of those infection have similar symptoms such as fever, myalgia, and headache, therefore physician should have high suspicion regarding co-infection with other infectious agents. The overlapping symptoms of co-infections may become a challenge for physician in diagnosing and delivering prompt therapy. Failure to deliver prompt treatment may lead to fatal outcome such as in severe malaria case. Stigmatization of all patients with fever and …

Kesintasan Satu Tahun Pasien Yang Menjalani Intervensi Koroner Perkutan Primer Di Rumah Sakit Dr. Cipto Mangukusumo, Muhammad Afriadi Hamdan, Ika Prasetya Wijaya, Alvina Widhani, Muhammad Yamin

Jurnal Penyakit Dalam Indonesia

Introduction. Primary percutaneous coronary intervention (PPCI) is an angioplasty (with or without a stent) performed immediately on the infarct-related artery without prior administration of fibrinolytics. Although PPCI is the reperfusion therapy of choice in ST-segment Elevation Myocardial Infarction (STEMI) patients, survival in post-PPCI patients still varied and research on its determinant factors still showed inconsistent results. This study aimed to determine the predictors of oneyear survival in patients undergoing PPCI at Dr Cipto Mangunkusumo General Hospital.

Methods. This retrospective cohort study evaluated the medical records of patients who underwent PPCI at Dr. Cipto Mangunkusumo General Hospital from January …