Remote Medical Education in Indonesia: Analysis of 10 Years of Activities

Introduction: With ongoing development of technology, and especially amid the current COVID-19 pandemic, there is rapidly increasing need for remote communications, including in the field of medical education. This study aimed to evaluate our telemedicine activities between Japan and Indonesia. Methods: We retrospectively analysed the data acquired for the period 2010–2019 inclusive, looking at number of programmes, content, participating sites, and videoconferencing systems. We also digitally sent questionnaires to attendees to request their evaluation of image quality and programmes. Results: There were a total 135 programmes, with 29 participating institutions in Indonesia. The number of programmes increased rapidly in 2017, following a rapid increase of participating sites in 2016. Programmes included endoscopy (50 programmes, 37%), neurology (25, 19%), and dentistry (12, 9%). Between 5 and 10 sites connected with 81 programmes (60% of all), and more than 10 sites with 33 (24%). The most commonly used videoconferencing system was Vidyo (108, 80%), followed by Zoom (15, 11%). Participating institutions were located among 19 cities on the five major islands. Image quality received a favourable evaluation from 98% (504/516) of questionnaire respondents, with 100% (400/400) holding a favourable view of the programmes. Conclusion: Remote medical education expanded in Indonesia in the 10 years under review. This expansion is expected to continue to foster more specialists and it is anticipated to improve medical care nationwide

Neuromyelitis optic with positive Anti-AQP4 and Anti-SSA/Ro antibody

Neuromyelitis Optic (NMO) is an inflammatory disorder involving central nervous system which often co-exists with other autoimmune diseases such as Sjögren’s syndrome (SS). NMO manifestation could precede or follow SS, but the role of anti-SSA in the pathogenesis of NMO remains unclear. We present a case of NMO with anti-AQP4 anti-SSA antibody positive. A-44-year-old female presented with right side weakness. The symptoms began with numbness that improved spontaneously. She also complained pain and dry sensations on her eyes. Schirmer test on her left eye, antinuclear antibody (ANA) and anti- SSA antibody were positive. Cervical MRI revealed intramedullary lesion on T2- weighted-image at C2-C5 level. She was diagnosed as NMO with positive anti- AQP4 and probable SS. She received 1g methylprednisolone for 5 days proceeded with mycophenolic acid. One-year observation showed clinical improvement. Systemic autoantibodies must substantially be evaluated in NMO. Comprehensive diagnosis and providing appropriate immunosuppressant might prevent further disability and relapse

Barriers to diagnosis and management of CNS infections in Indonesia

Little is known about the management and outcome of CNS infections in Indonesia (population: approximately 261 million), and the burden of CNS infections is increasing as result of a rapidly growing HIV epidemic. Indeed, in a recent study in Jakarta,1 54% of patients with a CNS infection were HIV-infected, vs 25% in a similar study conducted in Bandung, the second largest city on Java.2 Establishing the etiology of CNS infections is important for clinical management and outcome, but anecdotal evidence suggests that there are major gaps in clinical management, including a failure to recognize CNS infections, perform appropriate diagnostics, or initiate necessary drug treatment. In this study, we address some of these barriers by interviewing a group of Indonesian neurologists

Tryptophan metabolism determines outcome in tuberculous meningitis: a targeted metabolomic analysis

Background: Cellular metabolism is critical for the host immune function against pathogens, and metabolomic analysis may help understand the characteristic immunopathology of tuberculosis. We performed targeted metabolomic analyses in a large cohort of patients with tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, focusing on tryptophan metabolism. Methods: We studied 1069 Indonesian and Vietnamese adults with TBM (26.6% HIV-positive), 54 non-infectious controls, 50 with bacterial meningitis, and 60 with cryptococcal meningitis. Tryptophan and downstream metabolites were measured in cerebrospinal fluid (CSF) and plasma using targeted liquid chromatography–mass spectrometry. Individual metabolite levels were associated with survival, clinical parameters, CSF bacterial load and 92 CSF inflammatory proteins. Results: CSF tryptophan was associated with 60-day mortality from TBM (hazard ratio [HR] = 1.16, 95% confidence interval [CI] = 1.10–1.24, for each doubling in CSF tryptophan) both in HIV-negative and -positive patients. CSF tryptophan concentrations did not correlate with CSF bacterial load nor CSF inflammation but were negatively correlated with CSF interferon-gamma concentrations. Unlike tryptophan, CSF concentrations of an intercorrelating cluster of downstream kynurenine metabolites did not predict mortality. These CSF kynurenine metabolites did however correlate with CSF inflammation and markers of blood–CSF leakage, and plasma kynurenine predicted death (HR 1.54, 95% CI = 1.22–1.93). These findings were mostly specific for TBM, although high CSF tryptophan was also associated with mortality from cryptococcal meningitis. Conclusions: TBM patients with a high baseline CSF tryptophan or high systemic (plasma) kynurenine are at increased risk of death. These findings may reveal new targets for host-directed therapy

High dose oral rifampicin to improve survival from adult tuberculous meningitis: A randomised placebo-controlled double-blinded phase III trial (the HARVEST study)

Background: Tuberculous meningitis (TBM), the most severe form of tuberculosis (TB), results in death or neurological disability in >50%, despite World Health Organisation recommended therapy. Current TBM regimen dosages are based on data from pulmonary TB alone. Evidence from recent phase II pharmacokinetic studies suggests that high dose rifampicin (R) administered intravenously or orally enhances central nervous system penetration and may reduce TBM associated mortality. We hypothesize that, among persons with TBM, high dose oral rifampicin (35 mg/kg) for 8 weeks will improve survival compared to standard of care (10 mg/kg), without excess adverse events. Protocol: We will perform a parallel group, randomised, placebo-controlled, double blind, phase III multicentre clinical trial comparing high dose oral rifampicin to standard of care. The trial will be conducted across five clinical sites in Uganda, South Africa and Indonesia. Participants are HIV-positive or negative adults with clinically suspected TBM, who will be randomised (1:1) to one of two arms: 35 mg/kg oral rifampicin daily for 8 weeks (in combination with standard dose isoniazid [H], pyrazinamide [Z] and ethambutol [E]) or standard of care (oral HRZE, containing 10 mg/kg/day rifampicin). The primary end-point is 6-month survival. Secondary end points are: i) 12-month survival ii) functional and neurocognitive outcomes and iii) safety and tolerability. Tertiary outcomes are: i) pharmacokinetic outcomes and ii) cost-effectiveness of the intervention. We will enrol 500 participants over 2.5 years, with follow-up continuing until 12 months post-enrolment. Discussion: Our best TBM treatment still results in unacceptably high mortality and morbidity. Strong evidence supports the increased cerebrospinal fluid penetration of high dose rifampicin, however conclusive evidence regarding survival benefit is lacking. This study will answer the important question of whether high dose oral rifampicin conveys a survival benefit in TBM in HIV-positive and -negative individuals from Africa and Asia. Trial registration: ISRCTN15668391 (17/06/2019

Sklerosis Multipel

Sklerosis Multipel (MS) adalah penyakit autoimun yang terutama menyerang perempuan usia muda, tergolong penyakit langka di Indonesia. Meskipun demikian, penyakit ini dapat mengakibatkan kecacatan dan menurunkan kualitas hidup. Penegakan diagnosis yang akurat sangat diperlukan agar pasien MS bisa mendapatkan pengobatan yang adekuat sedini mungkin. Tata laksana pasien MS perlu memperhatikan tipe MS dan gejala yang menyertai.Multiple sclerosis (MS) is an autoimmune disease that mostly affected young women; this disease is rare in Indonesia. Nevertheless, MS can result in severe disability and decreased quality of life. Accurate diagnosis is needed as early as possible to initiate proper treatment. In MS management it is important to classify the disease and also treat the accompanying symptoms

Diagnosis dan Tatalaksana Meningitis Bakterialis

Meningitis bakterialis (MB) adalah kegawatdaruratan neurologik yang mengancam jiwa dan memerlukan diagnosis serta terapi yang cepat. Penanganan MB memerlukan pendekatan interdisipliner. Penegakan diagnosis MB kadang sulit jika hanya mengandalkan anamnesis dan pemeriksaan fisik. Hasil pemeriksaan cairan serebrospinal (CSS) harus diinterpretasikan secara hati-hati. Pemahaman karakter pasien sangat dibutuhkan untuk memberikan antibiotik empirik yang tepat.Bacterial meningitis is a life-threatening neurologic emergency that needs rapid diagnosis and treatment. Management of bacterial meningitis needs interdisciplinary approach. The diagnosis of bacterial meningitis can sometimes be difficult when relying only on history and physical examination. Cerebrospinal fluid (CSF) examination results must be interpreted carefully. To provide appropriate empiric antibiotics therapy, understanding of patient's characteristic is essential

Neurocognitive outcomes in indonesians living with HIV are influenced by polymorphisms in the gene encoding purinergic P2X receptor 7

The advent of effective antiretroviral therapy (ART) has decreased the prevalence and severity of HIV-associated neurocognitive disorders (HAND), but milder forms of HAND remain despite optimal treatment. Neuronal injury and loss due to inflammation may mediate HAND. P2X7R encodes purinergic P2X receptor 7 which influences neuroinflammatory pathways and carries polymorphisms associated with sensory neuropathy in HIV patients. We assessed associations between P2X7R polymorphisms and neurocognitive outcomes in Indonesian patients (n ​= ​59) as they commenced ART and after 3, 6 and 12 months. Z-scores were calculated over 5 domains using local controls and evaluated as continuous variables. Optimal linear regression models identified polymorphisms influencing attention, memory, executive function, motor speed and total cognitive function at each time point. rs504677 was associated with lower executive and motor speed Z-scores at 0, 3, 6, and 12 months, and with memory at 0 and 12 months. Memory was positively influenced by carriage of the rs208296 minor allele at 0, 3 and 6 months and by carriage of the rs208307 minor allele at 0 and 12 months. Higher attention Z-scores associated with carriage of minor alleles of rs1653598 after 0 and 12 months. These also positively influenced executive function and motor speed after 0–6 months. This study identifies polymorphisms in P2X7R which influence domain-specific neurocognitive outcomes in HIV+ ​Indonesians prior to and shortly after commencing ART. This implicates purinergic P2X receptor 7 in the pathogenesis of HAND

Factors Related to Knowledge, Perception, and Practices Towards COVID-19 Among Patients with Autoimmune Diseases: A Multicenter Online Survey

Background: autoimmune patients can be more susceptible to infection. Proper knowledge, perception, and practices towards COVID-19 are essential for these patients during pandemic. This study aimed to know their knowledge, perception, and practices regarding COVID-19. Methods: cross sectional study using online survey was conducted from April to May 2020. Patients with autoimmune disease were asked about demographic characteristics, diagnosis, history of treatment, knowledge, perception, and practice regarding COVID-19. Results: there were 685 respondents. Most of them were female and had systemic lupus erythematosus with median age of 37 years old. Almost all respondents had good knowledge regarding transmission of COVID-19 and did proper prevention practices. Adequacy of information and steroid or mycophenolate mofetil/mycophenolic acid (MMF/MPA) use were related to perception of the effect of pandemic to their own health. Visiting private clinic and receiving hydroxychloroquine/chloroquine sulfate or sulfasalazine were related to perception that autoimmune conditions would make them more prone to COVID-19. Work from home was related to perception that when contracting COVID-19, the symptoms would be more severe. Living in Sumatra region and getting hydroxychloroquine/chloroquine sulfate or MMF/MPA were related to perception that autoimmune medications could reduce risk of getting COVID-19. Adequate information, university education, private clinic visit, and hydroxychloroquine/chloroquine sulfate use were related to perception that COVID-19 pandemic would cause difficulties in getting medications. Conclusion: almost all respondents had good knowledge and practices regarding COVID-19. Adequacy of information, autoimmune treatment, work from home, educational background, area of living, and health care facilities contributed to perception regarding COVID-19 pandemic