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"ABSTRAK Latar belakang : Prevalens diabetes melitus (DM) terus meningkat di negaraberkembang yang merupakan negara endemis tuberkulosis (TB). Diabetes melitusmeningkatkan risiko infeksi, hambatan konversi sputum dan kegagalanpengobatan TB. Penelitian ini bertujuan menganalisis faktor-faktor yangmempengaruhi konversi sputum Basil Tahan Asam (BTA) mikroskopik padaakhir bulan kedua pengobatan TB pada pasien TB paru kasus baru dengan DM.Metode : Penelitian kohort retrospektif ini dilaksanakan di RSUP Perahabatanterhadap pasien-pasien TB paru BTA positif kasus baru dengan DM yang berobatpada periode Juli 2012 sampai Juni 2015. Hubungan faktor risiko dengan konversisputum BTA mikroskopik dianalisis dengan analisis bivariat dan multivariat.Hasil penelitian: Proporsi kegagalan konversi sputum BTA mikroskopik padapasien TB paru kasus baru dengan DM adalah 43,04%, sedangkan pada pasientanpa DM 22,75% (p<0,001, KI95% 0,11-0,30) dan risiko relatif (RR) kegagalankonversi 1,89 kali lebih tinggi pada kelompok DM. Faktor risiko yang meningkatbermakna pada pasien gagal konversi adalah kadar kepositifan sputum BTAsebelum terapi (p=0,021), HbA1c (p=0,014), GDP (p=0,047), GD 2jam PP(p=0,030) dan kavitas pada foto toraks (p=0,033) sedangkan albumin serum lebihrendah bermakna (p=0,013). Analisis multivariat mendapatkan faktor risikoterkuat untuk kegagalan konversi sputum adalah kadar albumin serum yangrendah (p=0,046, aOR 0,464, KI95% 0,218-0,986), tingkat kepositifan sputumBTA mikroskopik sebelum terapi yang tinggi (p=0,009, aOR 2,313, KI95%1,230-4,349) dan kadar HbA1c yang tinggi (p=0,018, aOR 1,298, KI 95% 1,047-1,610).Kesimpulan: Tingkat kepositifan sputum BTA sebelum terapi yang tinggi, statuskontrol DM yang tidak baik, kavitas pada foto toraks dan kadar albumin serumyang rendah meningkatkan risiko kegagalan konversi sputum BTA pada pasienTB dengan DM.ABSTRACT Background: The link of DM and TB is more prominent in developing countrieswhere TB is endemic and the burden of DM is increasing. Diabetes mellitusincreases the risk of TB infection, delayed sputum smear conversion and TBtreatment failure. This study would like to evaluate factors associated withdelayed sputum smear conversion in the end of two months of TB treatment innew cases TB with DM patients in Persahabatan Hospital.Methods: This retrospective cohort study was conducted in PersahabatanHospital, included all new cases TB with DM patients in the period from July2012 - June 2015. All the risk factors performed bivariate and multivariateanalysis in association with sputum smear conversion in the end of two months ofTB treatment.Results: The proportion of sputum smear conversion failure is higher in TB-DMthan non-DM patients (43,04 vs 22,75%) (p<0,001, CI95% 0,11-0,30) with therelative risk (RR) for sputum conversion failure 1,89 higher in TB-DM patients.Bivariate analysis resulted in significant higher of initial sputum smear level(p=0,021), HbA1c (p=0,014), FBG (p=0,047), post prandial Blood Glucose(p=0,030) and cavity at chest x-ray (p=0,033) and significant lower of serumalbumin (p=0,013) in non-conversion patients. Multivariate analysis resulted inrisk factors strongly associated with sputum conversion failure are low albuminlevel (p=0,046, CI95% 0,218-0,986), high initial sputum smear level (p=0,009,CI95% 1,230-4,349) and high HbA1c level (p=0,018, CI 95% 1,047-1,610).Conclusions: Higher initial sputum smear level, uncontrolled diabetic status,cavity at chest x-ray and lower albumin level associated with sputum smearconversion failure in TB-DM patients.;Background: The link of DM and TB is more prominent in developing countrieswhere TB is endemic and the burden of DM is increasing. Diabetes mellitusincreases the risk of TB infection, delayed sputum smear conversion and TBtreatment failure. This study would like to evaluate factors associated withdelayed sputum smear conversion in the end of two months of TB treatment innew cases TB with DM patients in Persahabatan Hospital.Methods: This retrospective cohort study was conducted in PersahabatanHospital, included all new cases TB with DM patients in the period from July2012 - June 2015. All the risk factors performed bivariate and multivariateanalysis in association with sputum smear conversion in the end of two months ofTB treatment.Results: The proportion of sputum smear conversion failure is higher in TB-DMthan non-DM patients (43,04 vs 22,75%) (p<0,001, CI95% 0,11-0,30) with therelative risk (RR) for sputum conversion failure 1,89 higher in TB-DM patients.Bivariate analysis resulted in significant higher of initial sputum smear level(p=0,021), HbA1c (p=0,014), FBG (p=0,047), post prandial Blood Glucose(p=0,030) and cavity at chest x-ray (p=0,033) and significant lower of serumalbumin (p=0,013) in non-conversion patients. Multivariate analysis resulted inrisk factors strongly associated with sputum conversion failure are low albuminlevel (p=0,046, CI95% 0,218-0,986), high initial sputum smear level (p=0,009,CI95% 1,230-4,349) and high HbA1c level (p=0,018, CI 95% 1,047-1,610).Conclusions: Higher initial sputum smear level, uncontrolled diabetic status,cavity at chest x-ray and lower albumin level associated with sputum smearconversion failure in TB-DM patients.;Background: The link of DM and TB is more prominent in developing countrieswhere TB is endemic and the burden of DM is increasing. Diabetes mellitusincreases the risk of TB infection, delayed sputum smear conversion and TBtreatment failure. This study would like to evaluate factors associated withdelayed sputum smear conversion in the end of two months of TB treatment innew cases TB with DM patients in Persahabatan Hospital.Methods: This retrospective cohort study was conducted in PersahabatanHospital, included all new cases TB with DM patients in the period from July2012 - June 2015. All the risk factors performed bivariate and multivariateanalysis in association with sputum smear conversion in the end of two months ofTB treatment.Results: The proportion of sputum smear conversion failure is higher in TB-DMthan non-DM patients (43,04 vs 22,75%) (p<0,001, CI95% 0,11-0,30) with therelative risk (RR) for sputum conversion failure 1,89 higher in TB-DM patients.Bivariate analysis resulted in significant higher of initial sputum smear level(p=0,021), HbA1c (p=0,014), FBG (p=0,047), post prandial Blood Glucose(p=0,030) and cavity at chest x-ray (p=0,033) and significant lower of serumalbumin (p=0,013) in non-conversion patients. Multivariate analysis resulted inrisk factors strongly associated with sputum conversion failure are low albuminlevel (p=0,046, CI95% 0,218-0,986), high initial sputum smear level (p=0,009,CI95% 1,230-4,349) and high HbA1c level (p=0,018, CI 95% 1,047-1,610).Conclusions: Higher initial sputum smear level, uncontrolled diabetic status,cavity at chest x-ray and lower albumin level associated with sputum smearconversion failure in TB-DM patients.;Background: The link of DM and TB is more prominent in developing countrieswhere TB is endemic and the burden of DM is increasing. Diabetes mellitusincreases the risk of TB infection, delayed sputum smear conversion and TBtreatment failure. This study would like to evaluate factors associated withdelayed sputum smear conversion in the end of two months of TB treatment innew cases TB with DM patients in Persahabatan Hospital.Methods: This retrospective cohort study was conducted in PersahabatanHospital, included all new cases TB with DM patients in the period from July2012 - June 2015. All the risk factors performed bivariate and multivariateanalysis in association with sputum smear conversion in the end of two months ofTB treatment.Results: The proportion of sputum smear conversion failure is higher in TB-DMthan non-DM patients (43,04 vs 22,75%) (p<0,001, CI95% 0,11-0,30) with therelative risk (RR) for sputum conversion failure 1,89 higher in TB-DM patients.Bivariate analysis resulted in significant higher of initial sputum smear level(p=0,021), HbA1c (p=0,014), FBG (p=0,047), post prandial Blood Glucose(p=0,030) and cavity at chest x-ray (p=0,033) and significant lower of serumalbumin (p=0,013) in non-conversion patients. Multivariate analysis resulted inrisk factors strongly associated with sputum conversion failure are low albuminlevel (p=0,046, CI95% 0,218-0,986), high initial sputum smear level (p=0,009,CI95% 1,230-4,349) and high HbA1c level (p=0,018, CI 95% 1,047-1,610).Conclusions: Higher initial sputum smear level, uncontrolled diabetic status,cavity at chest x-ray and lower albumin level associated with sputum smearconversion failure in TB-DM patients."

"Latar belakang: Hubungan antara TB dan DM sudah lama diketahui. Sistem imun rendah pada DM sehingga risiko berkembangnya TB laten menjadi TB aktif lebih tinggi. Penderita DM memiliki 2-3 kali risiko untuk menderita TB dibanding tanpa DM. Sekitar 10% kasus TB secara global berhubungan dengan DM. Prevalensi TB DM berdasarkan penelitian potong lintang oleh Wijayanto di Poli Endokrin RSUP Persahabatan pada pasien DM tipe 2 dari Oktober sampai Nopember 2013 adalah 28,2%. Pablos-Mendez dkk. menemukan bahwa hanya DM yang kurang terkontrol atau tidak terkontrol dikaitkan dengan peningkatan risiko TB. Tujuan: Tujuan utama dari penelitian ini adalah untuk menentukan sensitivitas dan spesifisitas mikroskop sputum BTA dan Xpert MTB / RIF untuk diagnosis TB pada pasien dengan DM. Metode: Penelitian ini adalah studi analitik deskriptif potong lintang pada pasien kelompok DM yang masih menjalani pengobatan di RS Persahabatan dari bulan Mei 2014 sampai jumlah sampel tercapai. Penelitian akan dilakukan di poli Paru dan Penyakit Dalam divisi Endokrin dan Metabolik RS Persahabatan. Pasien dengan keluhan tuberklosis baik yang belum pernah minum OAT atau dengan riwayat pengobatan sbelumnya dan didukung dari foto toraks yang menunjukan gambaran kecurigaan TB akan dilakukan pemeriksaan diagnostik mikrobiologis sputum BTA dan Xpert MTB/RIF. Hasil: Tujuh puluh subjek diskrining dan hanya 55 subjek memenuhi kriteria inklusi. Terdapat 32 laki-laki (58,2%) dan 23 perempuan (41,8%). Umur antara 25-72 tahun. Indeks massa tubuh kurang 11 (20%), normal 31(56,4%) dan lebih 13(23,6%). Gula darah antara 110-481 mg/dl. Lama menderita DM <5 tahun adalah 40 (72,7%), 5-10 tahun adalah 7(12,7 %), 10-15 tahun adalah 6(10,9%) dan >15 tahun adalah 2(3,6%). HbA1c terkontrol 11(20%) dan tidak terkontrol 44(80 %). Riwayat tidak pernah TB 41 (74,5%), TB sembuh 9(16,4%) dan gagal atau putus obat 5 (9,1%). Sputum BTA(+) 29 (52,7%) dan Xpert MTB/RIF(+) 36(65,5%). Tingkat HbA1c tidak terkontrol BTA(+)/Xpert MTB/RIF(+) 30 (54,5%). Uji diagnostik kedua alat memiliki sensitivitas 77,8 % dan spesifisitas 94,7%. Kesimpulan: Xpert MTB/RIF memiliki nilai kepositifan yang lebih tinggi daripada sputum BTA dalam mendeteksi M.Tb. Tidak ada perbedaan sensitivitas dan spesifisitas pemeriksaan mikroskopik sputum BTA dan Xpert MTB/RIF dalam upaya penegakan diagnosis TB pada pasien DM.

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Background: The relationship between Tuberculosis (TB) and Diabetes Mellitus (DM) has long been known. People with DM have 2-3 times the risk of developing TB. The prevalence of TB-DM based on cross sectional study by Wijayanto in Endocrine clinic at Persahabatan Hospital in DM type 2 patients in 2013 was 28.2%. Pablos-Mendez et al. found that only DM poorly controlled or uncontrolled associated with the increased risk of TB.

Purpose: The main purpose of this study is to determine the sensitivity and specificity of Acid Fast Bacilli (AFB) smear and Xpert MTB/RIF for diagnosis of TB in DM.

Methods: This study is a cross-sectional descriptive analytic study in patients with DM group who are still undergoing treatment at Persahabatan Hospital from May 2014. The study is conducted in Pulmonary clinic and Internal Medicine clinic. Patients with DM who have TB complaints that have not been taken either TB drug or with a history of treatment and supported from chest X-ray shows the suspicion of TB will require the microbiological diagnosis of AFB smear and Xpert MTB/RIF.

Result: Seventy subjects are screening and only 55 subjects meet the inclusion criteria. There are 32 males (58.2%) and 23 females (41.8%). There are ages between 25-72 years old. Their body mass index are less than 11(20%), normal 31(56.4%) and over 13(23.6%). The blood sugar is between 110-481 g/dl. The length of suffer DM <5 years are 40(72.7%), 5-10 years were 7(12.7%), 10-15 years were 6(10.9%) and >15 years are 2(3.6%). The controlled HbA1c is 11(20%) and uncontrolled is 44(80%). By history of TB which has never been suffered are 41(74.5%), treatment cured are 9(16.4%) and failure or withdrawal are 5(9.1%). Smear of AFB(+)ve are 29(52,7%) and Xpert MTB/RIF(+) are 36(65,5%). Uncontrolled HbA1c levels pulmonary TB with AFB smear/Xpert (+)ve are 30(54.5%). Sensitivity and specificity by using both are 77.8% and 94.7%.

Conclusion: The Xpert MTB/RIF has a higher value of positivity that detect M.Tb than AFB smear.There is no difference in the sensitivity and specificity of AFB smear and Xpert MTB/RIF for TB diagnosis in patients with DM."

"ABSTRAKLatar belakang: Penyakit paru obstruktif kronik merupakan penyebab utama morbiditas dan mortalitas di dunia. Penyakit komorbid pada PPOK berkontribusi terhadap rendahnya status kesehatan, mempengaruhi lama perawatan bahkan kematian. Osteoporosis merupakan komorbid yang cukup sering ditemukan pada PPOK. Di Indonesia khususnya di RSUP Persahabatan belum ada data prevalens osteoporosis pasien PPOK stabil.Objektif: Tujuan penelitian ini adalah mendapatkan angka prevalens osteoporosis pada pasien PPOK stabil di RSUP Persahabatan Jakarta.Metode: Disain penelitian ini adalah potong lintang. Pasien PPOK stabil yang berkunjung di poliklinik Asma/PPOK RSUP Persahabatan yang memenuhi kriteria inklusi dan eksklusi. Subjek diperiksa densitas mineral tulang menggunakan dual energy x-ray absorptiometry (DXA) dan diperiksa kadar vitamin D darah. Saat pasien berkunjung, dilakukan anamnesis gejala, eksaserbasi, riwayat merokok, penggunaan kortikosteroid (oral atau inhalasi), komorbid, penilaian status gizi. Selanjutnya dilakukan analisis dengan uji statistik.Hasil: Subjek terbanyak adalah laki-laki (90,6%) dengan kelompok usia 65-75 tahun (53,1%), riwayat merokok terbanyak (84,4%). Berdasarkan derajat PPOK terbanyak adalah GOLD II (46,9%) dan grup B (50%) dengan menggunakan kortikosteroid sebanyak (65,7%). Pada penelitian ini didapatkan prevalens osteoporosis sebesar 37,5%, artinya lebih dari sepertiga pasien mengalami osteoporosis. Dalam Penelitian ini tidak terdapat hubungan bermakna secara statistik antara grup PPOK, derajat PPOK, jenis kelamin, riwayat merokok, riwayat kortikosteroid, usia, kadar 25-OHD, faal paru dengan terjadinya osteoporosis pada pasien PPOK stabil (p>0,05). Pada penelitian ini didapatkan hubungan bermakna pada IMT yang rendah sebagai faktor risiko osteoporosis pada PPOK stabil (p<0,001).Kesimpulan: Prevalens osteoporosis pada pasien PPOK stabil di RSUP Persahabatan Jakarta adalah 37,5%. Terdapat hubungan yang bermakna secara statistik antara IMT dengan osteoporosis pada pasien PPOK stabil (p<0,001).

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ABSTRACT

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the world. Comorbid diseases in COPD contributing to low health status, affecting the duration of treatment and even death. Osteoporosis is a quite often comorbid that found in COPD. In Indonesia, particularly in Persahabatan Hospital there are no data of prevalence on osteoporosis in patient with stable COPD.

Objective: The purpose of this research is to get the prevalence?s data of osteoporosis in patients with stable COPD at Persahabatan Hospital-Jakarta.

Method: The studie?s design was cross-sectional. Patients with stable COPD who came to the Asthma/COPD policlinic at Persahabatan Hospital-Jakarta who meet the criteria of inclusion and exclusion. Subjects had an examined of bone mineral density using dual energy x-ray absorptiometry (DXA) and had an examined of vitamin D blood level. At the time of visit, conducted anamnesis of symptoms, exacerbations, history of smoking, used of corticosteroid (oral or inhaled), comorbid, assessment of nutritional status. Then we did statistical test for analysis.

Results: Subjects were dominated with male (90.6%) in the age group 65-75 years old (53.1%), and smoking history (84.4%). The most degree of COPD of the subject were GOLD II (46.9%) and group B (50%) that using corticosteroid (65.7%). In this study we found prevalence of osteoporosis was 37.5%, meaning that approximately more than one third of the patients have had osteoporosis. There were no statistically significant relationship between COPD group, the degree of COPD, sex, smoking history, history of corticosteroid, age, levels of 25-OHD, pulmonary function with the occurrence of osteoporosis in patients with stable COPD (p>0.05). We found a significant relationship on low BMI as a risk factor for osteoporosis in stable COPD (p<0.001).

Conclusion: The prevalence of osteoporosis in patients with stable COPD in Persahabatan Hospital-Jakarta is 37.5%. There are a statistically significant relationship between BMI with osteoporosis in patients with stable COPD (p <0.001)."

"Latar belakang: Diabetes melitus tipe 2 merupakan penyakit komorbid yang sering ditemui pada pasien PPOK. Penyakit paru obstruktif kronik dipertimbangkan sebagai faktor risiko berkembangnya diabetes tipe 2 melalui beberapa mekanisme antara lain inflamasi sitemik, merokok, stres oksidatif, obesitas dan penggunaan kortikosteroid inhalasi. Prevalens DM pada pasien PPOK di Indonesia belum diketahui secara pasti. Diabetes melitus sebagai penyakit komorbid pada pasien PPOK akan mempengaruhi morbiditas dan mortalitas pasien PPOK. Metode: Penelitian ini merupakan penelitian potong lintang dengan analisis deskriptif yang dilakukan di poliklinik asma ndash;PPOK Rumah sakit umum pusat Persahabatan pada bulan Februari ndash; Maret 2017 untuk melihat kejadian diabetes pada pasien PPOK. Enam puluh empat pasien PPOk di ambil untuk ikut dalam penelitian ini secara consecutive sampling. Pada semua pasien dilakukan wawancara, pemeriksaan fisis dan pemeriksaan laboratorium. Hasil: Pada penelitian ini diambil 64 pasien PPOK lakilaki: 60, perempuan : 4 dengan usia rata rata 65 8.7 tahun. Sebanyak 12 subjek 18.8 sudah memiliki riwayat DM sebelumnya dan pasien ini dimasukan kedalam kelompok DM tanpa memandang hasil laboratorium. Dari 52 81.3 subjek yang belum diketahui status DM ditemukan 2 subjek 3,1 dengan diagnosis DM. Prevalens DM pada pasien PPOK pada penelitian ini sebesar 21.9. Ditemukan 16 subjek 25 dengan kadar HbA1c sesuai dengan prediabetes. Tidak ditemukan hubungan bermakna antara usia, jenis kelamin, riwayat merokok, sataus gizi, hambatan aliran udara dan penggunaan kortikosteroid inhalasi dengan kejadian DM pada pasien PPOK. Kesimpulan: Prevalens DM pada pasien PPOK dalam penelitian ini adalah sebesar 21..9 . Penapisan komorbid DM penting dilakukan secara berkala.

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Background: Type 2 diabetes mellitus DM is a common comorbidity of COPD. COPD may be considered as a risk factor for new onset type 2 DM via multiple pathophysiological alterations such as systemic inflammation, smoking, oxidative stress, obesity and inhaled corticosteroid use. Exact prevalence of DM in COPD patients in Indonesia are still unclear. Co morbid conditions like DM have great impacts on the outcome of COPD in the form of severity, morbidity and mortality

Method: A cross sectional study with descriptive analysis was done in Asthma COPD clinic Persahabatan Hospital from February to March 2017 to screen COPD patients for DM. Sixty four subjects were recruited consecutively. Interview, physical examination and laboratory testing were performed in all subjects.

Results: A total of 64 patients with COPD Males 60, Female 4 with mean age 65 8.7 were screened for DM. Patients with known history of DM were 12 18.8 and were enrolled as Known DM cases. Remaining 52 81.3 patients whose DM status were unclear and screened by random or fasting blood sugar and HbA1c. Two subjects 3.1 were considered as newly diagnosed DM cases. Prevalence of DM in present study was 21.9. Number of patients with prediabetes were 16 subjects 25. There were no significant relationship among gender, age, smoking, nutritional status, airflow limitation and inhaled corticosteroid use in occurrence of DM among COPD patients.

Conclusion: Prevalence of DM in COPD patients in the present study is 21.9. It is important to screen all COPD patients for DM routinely. "

"Latar Belakang. Mikroangiopati diabetik DM seperti nefropati, retinopati, dan neuropati merupakan komplikasi umum diabetes melitus tipe 2 T2DM . Paru merupakan salah satu organ target dari komplikasi mikrovaskular dan penurunan kapasitas difusi paru pada mikroangiopati DM masih sedikit diketahui.Metode. Penelitian ini bersifat potong lintang pada subjek T2DM yang menjalani pemeriksaan kapasitas difusi paru terhadap karbon monoksida DLCO, albumin urin, funduskopi dan elektromiografi EMG di poliklinik rawat jalan DM terpadu. Kriteria eksklusi yaitu penyakit paru akut atau kronis.Hasil. Sebanyak 52 subjek L/P:20/32 usia 58 10,4 tahun sebagian besar menunjukkan HbA1c>6,5 41/52 78 , tidak pernah merokok 41/52 78,8 . rerata terdiagnosis DM 10,5 6,9 tahun, sebanyak 33 63,5 le;10 tahun dan 19 36,5 subjek >10 tahun. Subjek dengan neuropati lebih banyak ditemukan yaitu sebesar 41/52 26,3 diikuti nefropati 29/52 18,6 dan retinopati 9/52 5,8 dengan rerata DLCO sebesar 16,01 4,12 ml/menit/mmHg . Penurunan kapasitas difusi pada Mikroangiopati DM ditemukan sebanyak 14/52 25 subjek, didapatkan nilai p pada nefropati sebesar p=0,27, retinopati p=0,36 dan neuropati p=0,49.Kesimpulan. Gangguan kapasitas difusi paru pada mikroangiopati DM mengalami penurunan namun tidak mempunyai hubungan yang yang bermkana, hal ini menunjukkan gangguan faal difusi paru pada mikroangiopati DM.

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Background. Diabetic microangiopathy such as nephropathy, retinopathy and neuropathy is a common complications of type 2 diabetes mellitus T2DM . The lung is one of the target organs in the development of vascular complications in diabetic patients and little is known about the impairment of pulmonary diffusing capacity due to the diabetic microangiopathy.Method. The subjects were T2DM patients underwent carbon monoxide lung diffusion capacity DLCO test, urine test, funduscopy and electromyography EMG examination with consecutively from diabetic outpatient clinic. The exclusion criterias were acute or chronic pulmonary diseases. Results. A total of 52 subjects m/f: 20/32 ages 58 10.4 years mostly showed HbA1c> 6.5 41/52 78 , never smoked 41/52 78.8 . diagnosed DM rates of 10.5 6.9 years, 33 63.5 le;10 years and 19 36.5 subjects> 10 years. Subjects with more neuropathy were 41/52 26.3 followed by nephropathy 29/52 18.6 and retinopathy 9/52 5.8 with DLCO average of 16.01 4.12 ml / min / mmHg . The decrease in diffusion capacity in Microangiopathy DM was found in 14/52 25 subjects, obtained p value on nephropathy of p=0.27, retinopathy p=0.36 and neuropathy p=0.49 respectively.Conclusion. This study demonstrated that diffusion capacity is impairment in diabetic microangiopathy patients. Pulmonary diffusion capacity has no association with diabetic microangiopathy but there is a decreased pulmonary diffusion physiology."