MPox Skin Lesions.

Mpox is caused by the Monkeypox virus, which belongs to the Orthopoxvirus genus and Poxviridae family. The Monkeypox virus was first identified as a cause of disease in humans in the 1970s in the Democratic Republic of the Congo. Mpox was considered endemic in several African countries. A global outbreak of Mpox was first recognized in Europe in May 2022 and was declared a public health emergency of international concern on July 23, 2022. The first reported Mpox case in Indonesia was in October 2022 which was identified as an imported case, there were no new confirmed Mpox cases until 13 October 2023. Since then there were 72 cases of confirmed Mpox cases in Indonesia by the end of 2023, distributed across 6 provinces, mostly in the Java island.We present two different spectrums of Mpox skin lesions in patients living with HIV, with a positive polymerase chain reaction test for Mpox. The first patient is a 48-year-old male, who developed a maculopapular lesion, that was initially noticed on the face, the lesions were then spread to the back and hand. He identifies as men who have sex with men and living with HIV for the past 18 years. There were no lesions on the genitalia or mucosa. The second patient is a 28-year-old male, the initial symptom was fever, followed by skin lesions after around 1 week of fever. The lesion initially appears as pustules on the face and then spreads throughout the whole body, the lesions also grow larger and become pseudo-pustules and ulcers. There were also mucosal involvements in the mouth, making oral intake difficult. This patient also identified as men who have sex with men with multiple partners, HIV status was not known at the initial presentation. HIV screening was done with positive results.

Identifying Predictors of Mortality in Sepsis Patients with Malignancy: A Retrospective Cohort Study.

BACKGROUND: Sepsis is a major problem that contributes to a high mortality rate. Its mortality is especially high in patients with malignancy. One study reported that sepsis patients with malignancy have a 2.32 times higher risk of mortality compared to patients without malignancy. For this reason, factors that influence mortality in sepsis patients with malignancy become especially important to provide effective and efficient therapy. This study aims to identify factors that influence mortality in sepsis patients with malignancy. METHODS: This study is a retrospective cohort study using medical records of sepsis patients with malignancy who were treated at Cipto Mangunkusumo Hospital from 2020 to 2022. A bivariate analysis was carried out and followed by a logistic regression analysis on variables with p-value<0.25 on the bivariate analysis. RESULTS: Among the 350 eligible sepsis subjects with malignancy, there was an 82% mortality rate (287 subjects). Bivariate and multivariate analyses revealed significant associations between mortality and both SOFA score (adjusted Odds Ratio of 5.833, 95%CI 3.214-10.587) and ECOG performance status (adjusted Odds Ratio of 3.490, 95%CI 1.690-7.208). CONCLUSION: SOFA score and ECOG performance status are significantly associated with sepsis patient mortality in malignancy cases.

Immunogenicity and Safety of Half-Dose Heterologous mRNA-1273 Booster Vaccination for Adults Primed with the CoronaVac® and ChAdOx1-S Vaccines for SARS-CoV-2.

Coronavirus disease 2019 (COVID-19) has been extensively researched, particularly with regard to COVID-19 vaccines. However, issues with logistics and availability might cause delays in vaccination programs. Thus, the efficacy and safety of half-dose heterologous mRNA should be explored. This was an open-label observational study to evaluate the immunogenicity and safety of half-dose mRNA-1273 as a booster vaccine among adults aged >18 years who underwent a complete primary SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) vaccination regimen with CoronaVac® and ChAdOx1-S. Adverse events (AEs), seropositivity rate, seroconversion, geometric mean titer (GMT) of SARS-CoV-2 antibodies, neutralizing antibodies, and T cells (CD4+ and CD8+) specific for SARS-CoV-2 were analyzed. Two hundred subjects were included in the final analysis, with 100 subjects in each priming vaccine group. Most of the AEs were mild, with systemic manifestations occurring between 1 and 7 days following vaccination. A significant difference was observed in the GMT and seropositivity rate following booster dose administration between the two groups. CD8+/CD3+, IFN (interferon)-producing CD8+, and TNF (tumor necrosis factor)-producing CD8+ cells showed significant increases in both groups. The administration of the half-dose mRNA-1273 booster is safe and effective in increasing protection against SARS-CoV-2 infection.

Characteristics and clinical outcomes of patients with pre-delta, delta and omicron SARS-CoV-2 infection in Indonesia (2020-2023): a multicentre prospective cohort study.

Background: Limited data exist from southeast Asia on the impact of SARS-CoV-2 variants and inactivated vaccines on disease severity and death among patients hospitalised with COVID-19. Methods: A multicentre hospital-based prospective cohort was enrolled from September 2020 through January 2023, spanning pre-delta, delta, and omicron periods. The participant hospitals were conveniently sampled based on existing collaborations, site willingness and available study resources, and included six urban and two rural general hospitals from East Nusa Tenggara, Jakarta, and North Sumatra provinces. Factors associated with severe disease and day-28 mortality were examined using logistic and Cox regression. Findings: Among 822 participants, the age-adjusted percentage of severe disease was 26.8% (95% CI 22.7-30.9) for pre-delta, 50.1% (44.0-56.2) for delta, and 15.2% (9.7-20.7) for omicron. The odds of severe disease were 64% (18-84%) lower for omicron than delta (p < 0.001). One or more vaccine doses reduced the odds of severe disease by 89% (65-97%) for delta and 98% (91-100%) for omicron. Age-adjusted mortality was 11.9% (8.8-15.0) for pre-delta, 24.4% (18.8-29.9) for delta and 9.6% (5.2-14.0) for omicron. The day-28 cumulative incidence of death was lower for omicron (9.2% [5.6-13.9%]) than delta (28.6% [22.0-35.5%]) (p < 0.001). Severe disease on admission was the predominant prognostic factor for death (aHR34.0 [16.6-69.9] vs mild-or-moderate; p < 0.001). After controlling for disease severity on admission as an intermediate, the risk of death was 48% (32-60%) lower for omicron than delta (p < 0.001); and 51% (38-61%; p < 0.001) lower for vaccinated participants than unvaccinated participants overall, and 56% (37-69%; p < 0.001) for omicron, 46% (-5 to 73%; p = 0.070) for pre-delta (not estimable for delta). Interpretation: Infections by omicron variant resulted in less severe and fatal outcomes than delta in hospitalised patients in Indonesia. However, older, and unvaccinated individuals remained at greater risk of adverse outcomes. Funding: University of Oxford and Wellcome Trust.

Diagnostic and antibiotic use practices among COVID-19 and non-COVID-19 patients in the Indonesian National Referral Hospital.

BACKGROUND: Little is known about diagnostic and antibiotic use practices in low and middle-income countries (LMICs) before and during COVID-19 pandemic. This information is crucial for monitoring and evaluation of diagnostic and antimicrobial stewardships in healthcare facilities. METHODS: We linked and analyzed routine databases of hospital admission, microbiology laboratory and drug dispensing of Indonesian National Referral Hospital from 2019 to 2020. Patients were classified as COVID-19 cases if their SARS-CoV-2 RT-PCR result were positive. Blood culture (BC) practices and time to discontinuation of parenteral antibiotics among inpatients who received a parenteral antibiotic for at least four consecutive days were used to assess diagnostic and antibiotic use practices, respectively. Fine and Grey subdistribution hazard model was used. RESULTS: Of 1,311 COVID-19 and 58,917 non-COVID-19 inpatients, 333 (25.4%) and 18,837 (32.0%) received a parenteral antibiotic for at least four consecutive days. Proportion of patients having BC taken within ±1 calendar day of parenteral antibiotics being started was higher in COVID-19 than in non-COVID-19 patients (21.0% [70/333] vs. 18.7% [3,529/18,837]; p<0.001). Cumulative incidence of having a BC taken within 28 days was higher in COVID-19 than in non-COVID-19 patients (44.7% [149/333] vs. 33.2% [6,254/18,837]; adjusted subdistribution-hazard ratio [aSHR] 1.71, 95% confidence interval [CI] 1.47-1.99, p<0.001). The median time to discontinuation of parenteral antibiotics was longer in COVID-19 than in non-COVID-19 patients (13 days vs. 8 days; aSHR 0.73, 95%Cl 0.65-0.83, p<0.001). CONCLUSIONS: Routine electronic data could be used to inform diagnostic and antibiotic use practices in LMICs. In Indonesia, the proportion of timely blood culture is low in both COVID-19 and non-COVID-19 patients, and duration of parenteral antibiotics is longer in COVID-19 patients. Improving diagnostic and antimicrobial stewardship is critically needed.

HIF2-α Expression in CML Patients Receiving Hydroxyurea Prior to Imatinib That Achieved Major Molecular Response (MMR) versus in Those Not Achieving MMR.

Introduction: Currently, Imatinib (IM) which is a Tyrosine Kinase Inhibitor (TKI), is the main treatment for patients with chronic myeloid leukemia (CML). Major molecular response (MMR) is used as therapeutic response. Resistance to IM may be caused by hypoxia which is regulated by hypoxia inducible factor (HIF) 2-α. The role of HIF2-α is currently not researched extensively. This study aimed to analyse the differences in HIF-2α expression between chronic phase CML patients that achieved MMR and those that did not achieve MMR. Methods: This study used a cross-sectional method which analysed secondary data from whole blood samples in chronic phase CML patients aged 18-60 years that received hydroxyurea (HU) before IM, aged 18-60 years, received IM therapy for more than 12 months, and were willing to participate in the study. The exclusion criteria for this study were patients who were receiving IM at a dose of more than 400 mg/day. HIF-2α protein expression was examined using the enzyme-linked immunosorbent assay (ELISA) method. Differences between HIF-2α protein expression in groups that achieved MMR versus not achieving MMR was analysed using the Mann-Whitney test. Results: A total of 79 subjects were obtained. The median HIF-2α was 90.56 pg/mg protein (3.01-4628.74). There was no statistically significant difference in expression of HIF-2α in the group that reached MMR and did not reach MMR, namely 123.45 pg/mg protein and 89.25 pg/mg protein respectively (p 0.718). Conclusion: This study found no statistically significant difference between HIF-2α expression level and MMR achievement of chronic phase CML patients who received HU before IM therapy.

The correlation of anxiety and depression with C3 and C4 Levels and systemic lupus erythematosus activity.

BACKGROUND: Anxiety and depression are psychosomatic disorders that are frequently observed in chronic conditions such as systemic lupus erythematosus (SLE). Anxiety and depression can be induced by immunological and neurotransmitter dysregulation, which is characterized by hypothalamic-pituitary-adrenal (HPA) axis dysfunction, production of proinflammatory cytokines, and activation of complement in the blood, such as C3 and C4. The causes of anxiety and depression in SLE are complex, ranging from neuropsychiatric involvement to drug adverse effects. Detecting anxiety and depression symptoms in SLE patients is critical to preventing disability from impacting quality of life. OBJECTIVE: To assess the relationship between anxiety and depression symptomatology, SLE disease activity with levels of C3 and C4 in Cipto Mangunkusumo National Hospital. METHODS: This study used a cross-sectional design. The study included 120 SLE patients from Cipto Mangunkusumo National Hospital, aged 18 to 60 years. All patients were requested to complete a Hospital Anxiety and Depression Scale (HADS) questionnaire to assess their anxiety and depression symptoms. Subjects with anxiety and depression were assessed for disease activity using the Mexican Systemic Lupus Erythematosus Systemic Disease Activity (Mex-SLEDAI), and blood samples were collected to test complement C3 and C4 levels. Spearman's correlation test was used to examine the relationship between HADS scores, Mex-SLEDAI, and C3 and C4 levels. RESULTS: The results of the study showed a very weak statistically significant negative correlation between anxiety symptoms based on HADS and C3 levels (r = -0.189; p = 0.038) and a weak correlation between anxiety symptoms and C4 levels (r = -204; p = 0.026). Depressive symptoms based on HADS revealed a very poor connection and no statistical significance with levels of C3 (r = -0.056; p = 0.546) and C4 (r = -0.068; p = 0.461). Anxiety (r = 0.06; p = 0.173) and depression (r = 0.031; p = 0.753) symptoms have a weak and insignificant positive connection with SLE activity. CONCLUSION: C3 and C4 serum levels appeared to decrease when the presence of anxious symptoms increased. There was no significant correlation in SLE disease activity between anxious and depressed patients.

Validation of the Nelwan Score as a screening tool for the diagnosis of typhoid fever in adults in Indonesia.

INTRODUCTION: Typhoid fever diagnosis is challenging for clinicians in areas with limited laboratory facilities. Scoring methods based on signs and symptoms are useful for screening for probable cases of typhoid fever. The Nelwan Score variables are derived from the clinical signs and symptoms of patients with suspected typhoid. We validated the Nelwan Score compared to laboratory tests as the gold standard. METHODS: This cross-sectional study was conducted between July 2017 and January 2018 in five hospitals and two primary health care centers in Jakarta and Tangerang, Indonesia. Patients with fever for 3-14 days and gastrointestinal symptoms were evaluated using the Nelwan Score. Blood cultures, samples for polymerase chain reaction testing, and additional rectal swab cultures were collected simultaneously to confirm the diagnosis of typhoid. Data were analyzed using a contingency table to measure sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), and the optimal cut-off of the Nelwan Score for typhoid diagnosis was determined using a receiver-operating characteristic curve. RESULT: Typhoid was confirmed in 11 of the 233 patients (4.7%) with suspected typhoid. Among laboratory-confirmed typhoid cases, the median Nelwan Score was 11 (range: 9-13) and the optimal cut-off value was 10, with an area under the curve of 71.3%, sensitivity of 81.8%, specificity of 60.8%, PPV of 9.3%, and NPV of 98.5%. CONCLUSION: A Nelwan Score of 10 is the best cut-off value for screening for typhoid fever. It is useful as screening tool for typhoid fever, where laboratory resources are limited, and could help to decrease irrational antibiotic use.

COVID-19 Screening Score for Patients without Acute Respiratory Symptoms Undergoing Emergency Medical Procedures in Indonesia.

To rule out coronavirus disease-2019 (COVID-19) in patients scheduled to undergo emergency medical procedures, SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) must be performed. In developing countries, the use of SARS-CoV-2 RT-PCR has been limited by its unavailability and long processing time. Hence, a quick screening score to predict COVID-19 may help healthcare practitioners determine which patients without acute respiratory symptoms can safely undergo an emergency medical procedure. We conducted a cross-sectional study of adult patients without acute respiratory symptoms who were admitted to the emergency department and underwent an emergency medical procedure within 24 hours after admittance. We collected baseline demographic data, COVID-19 screening variables, and SARS-CoV-2 RT-PCR as the gold standard for COVID-19 diagnosis. Bivariate and multivariate analyses were performed, and a scoring system was developed using statistically significant variables from the multivariate analysis. With data from 357 patients, multivariate backward stepwise logistic regression analysis resulted in two significant COVID-19 predictors: the presence of SARS-CoV-2-IgM antibody (adjusted odds ratio [aOR]: 7.02 [95% CI: 1.49-32.96]) and typical chest x-ray (aOR: 23.21 [95% CI: 10.01-53.78]). A scoring system was developed using these predictors with an area under the receiver operating characteristic curve of 0.71 (95% CI: 0.64-0.78). For a cutoff point of ≥ 2, the scoring system showed 42.5% sensitivity and 97.1% specificity but had poor calibration (Hosmer-Lemeshow test P value < 0.001). We believe that the development of this COVID-19 quick screening score may be helpful in a resource-limited clinical setting, but its moderate discrimination and poor calibration hinder its use as a replacement for the SARS-CoV-2 RT-PCR test for COVID-19 screening.

Antibody Responses and Reactogenicity of a Heterologous, Full-Dose Messenger RNA-1273 Booster in Heavily SARS-CoV-2-Exposed CoronaVac-Vaccinated Health-Care Workers in Indonesia: A Real-World Observational Study.

Real-world data on heterologous boosting with messenger RNA (mRNA)-1273 (Moderna) after inactivated COVID-19 vaccination are limited. We report mRNA-1273 boosting in heavily SARS-CoV-2-exposed Indonesian health-care workers who received a two-dose CoronaVac 6 months prior. Between August and November 2021, we measured SARS-CoV-2 spike-specific IgG binding antibody (Bab) titers in all 304 participants, and neutralizing antibody titers in a random subset of 71 participants, on stored paired serum samples taken before and 28 days after a full-dose (100-µg) mRNA-1273 booster. At the time of the mRNA-1273 boost, 107 participants (35.2%) were not previously infected (naive vaccinated), 42 (13.8%) were infected before CoronaVac (infected vaccinated), and 155 (51.0%) were infected after CoronaVac (mostly during the Delta wave; vaccinated infected). At time of the mRNA-1273 boost, neutralizing antibodies could still be detected in 83% of participants (59 of 71) overall, 60% of naive-vaccinated participants (15 of 25), 95.7% of vaccinated-infected participants (22 of 23), and 95.7% of infected vaccinated participants (22 of 23). After the mRNA-1273 boost, 100% of participants (71 of 71) had neutralizing antibody activity, with increases in median Bab and neutralizing antibody serum titers of 9.3- and 27.0-fold overall, 89.1- and 2,803.4-fold in naive-vaccinated participants, 15.9- and 19.9-fold in infected-vaccinated participants, and 2.2- and 18.4-fold in vaccinated-infected participants. In the multivariable analysis, Bab titers after the mRNA-1273 boost were greatest in individuals who had a previous virus breakthrough post-CoronaVac, and when a longer time period (> 4 months) had elapsed since the most recent prior "spike antigen exposure" (either second CoronaVac or virus breakthrough). Overall, adverse reactions were mild and short-lived. In conclusion, a full-dose mRNA-1273 booster after CoronaVac was well tolerated and immunogenic after 28 days, including in those with very low antibody levels.

The Adjunctive Effects of Acupuncture for Hospitalized COVID-19 Patients: a Single-Blinded Randomized Clinical Study.

Background: Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a coronavirus (SARS-CoV-2) that can induce cytokine storm. To this point, no specific drug has been effective for curing COVID-19. Objectives: The aim of this study was to determine the effects of a combination of acupuncture intervention and pharmacologic treatment in hospitalized COVID-19 patients with mild-moderate symptoms. Methods: A single-blinded randomized controlled clinical trial of hospitalized COVID-19 patients confirmed by RT-PCR examination with mild-moderate symptoms was conducted from August to September 2020. Participants were assigned to the treatment group (receiving pharmacologic treatment and manual acupuncture intervention) or the control group (receiving only pharmacologic treatment). Laboratory outcomes, including complete blood count, C-reactive protein (CRP) and ferritin levels, and erythrocyte sedimentation rate (ESR), were measured before and after the intervention. For clinical outcomes, we evaluated the duration of the cough symptom. Results: We found that participants in the treatment group had a shorter duration of the cough symptom compared to the control group, and the difference was statistically significant. In the treatment group, we found an increase in the percentage of lymphocyte count and ESR, while in the control group, both parameters were decreased; however, the differences were not statistically significant. There was a decrease in the mean of CRP and ferritin levels in both groups, and the differences were not statistically significant. Conclusion: Our study has shown promising results for the effects of combined treatment of acupuncture and pharmacologic treatment on the duration of the cough symptom in hospitalized COVID-19 patients with mild-moderate symptoms. Further large-scale studies with rigorous design are needed to examine these preliminary results.

Observational Study on Secondary Bacterial Infection and the Use of Antibiotics in COVID-19 Patients Treated in a Tertiary Referral Hospital.

BACKGROUND: Data on secondary bacterial infection in patients with COVID-19 in Indonesia are still limited, while the use of empirical antibiotics continues to increase. This study aims to determine the secondary bacterial infection rate in hospitalized COVID-19 patients and factors related to secondary bacterial infection. METHODS: This is a retrospective cohort study on hospitalized COVID-19 patients undergoing treatment at Cipto Mangunkusumo Hospital from March 2020 to September 2020. Secondary bacterial infection is defined as the identification of a bacterial pathogen from a microbiological examination. RESULTS: From a total of 255 subjects, secondary infection was identified in 14.5%. Predictors of secondary infection were early symptoms of shortness of breath (OR 5.31, 95% CI 1.3 - 21.5), decreased consciousness (OR 4.81, 95% CI 1.77 - 13.0), length of stay > 12 days (OR 8.2, 95% CI 2.9 - 23.3), and central venous catheter placement (OR 3.0, 95% CI 1.1 - 8.0) The most common pathogen of secondary bacterial infection is Acinetobacter sp. (n=9; 28%). Empirical antibiotics were administered to 82.4% of subjects with predominant use of macrolides (n=141; 32.4%). CONCLUSION: The secondary bacterial infection rate in COVID-19 was 14.5% and is associated with dyspnea, decreased consciousness, length of stay >12 days, and central venous catheter placement. The use of antibiotics in COVID-19 reaches 82.4% and requires special attention to prevent the occurrence of antibiotic resistance.

COVID-19 Pandemic-to-Endemic Transition in Indonesia: What Does the Future Hold?

Since first reported in December 2019, SARS-2 Coronavirus (SARS-CoV-2) infection has become a world-class pandemic, overwhelming every aspect of the global system. Globally, 526 billion confirmed cases with 6,3 billion death cases were reported by World Health Organization (WHO) by 31 May 2022. In that period, Indonesia has reported 6 billion confirmed cases with a case fatality rate reaching 2.58%. The number of new weekly cases and new weekly death have continued the declining trend observed since its peak in January 2022, i.e. 3% decrease of new weekly cases and 11% decrease of new weekly death as compared to the previous week. In response to the current epidemiology improvement, countries including Indonesia have relaxed some regulations on COVID-19 as the preparation for pandemic-to-endemic transition.Endemic is not equal to harmless. Commonly, endemic is falsely interpreted as the end of COVID-19, bringing to a false complacency. Endemic "label" on an infectious disease, such as malaria, HIV infection, tuberculosis in certain regions of the world, means the overall rates of infection are static - neither rising nor falling. Endemic "label" defines nothing about time duration to reach disease end or how many populations will still be susceptible to the disease. Therefore, transition for pandemic-to-endemic of COVID-19 could not simply translated into the end of either public and health service awareness, or research on COVID-19. It then should add new emerging perspective on COVID-19 research as was mandated by WHO. One example of which is evidence-based strategies for infection prevention control and personal protective equipment for infection control de-escalation in relation to COVID-19 pandemic scaling back.In the spirit of nurturing research and publication in this transition for pandemic-to-endemic era, the Indonesian Journal of Internal Medicine published various COVID-19 associated-original articles, systematic review, and case series across various COVID-19 condition. Atici, et. al. and Tunjungputri, et. al. report articles on factors and treatment that is associated with higher COVID-19 survival. Corticosteroids, Interleukin-6 inhibitors and anticoagulant administered to the proper subset of COVID-19 population are several beneficial treatments among limited evidence-based proven treatment available today. These supportive treatments, whenever indicated at the proper time, should be considered in managing every COVID-19 patient. In addition, high antibiotic use in COVID-19 patients despite low secondary bacterial infection has been widely reported. Chen, et. al. report a similar situation in Indonesia and should raise the awareness of antimicrobial resistance thread now and in the future. Together with proper diagnostic stewardship, the simple predictors of secondary bacterial infection that have been concluded could potentially be used to reduce liberal antibiotic use while optimizing the use in indicated patients. Prabowo, et al. enriched our understanding on usage of telemedicine to monitor post COVID-19 condition in Indonesian populations.High quality research has, and will again, save the livelihoods of people across the world. While future pandemics could not be completely prevented, the research infrastructures that have built during last 2 years could be used as a strong modality to be better prepared and coordinated in future outbreak/ pandemic response by detecting and preventing the emerging diseases at their very early stage. Waste in COVID-19 research and multiple COVID-19 associated research article retractions should caution researchers -as evidence-producer- and clinicians -as evidence-user- in prioritizing the scientific inquiry and questioning individual conflict of interest. Insightful articles addressing the multitude aspects of the COVID-19 pandemic-to-endemic transition related topics are still needed in the future.

Diagnostic accuracy of palpation versus ultrasound-guided fine needle aspiration biopsy for diagnosis of malignancy in thyroid nodules: a systematic review and meta-analysis.

Thyroid nodule is a common health problem in endocrinology. Thyroid fine-needle aspiration biopsy (FNAB) cytology performed by palpation guided FNAB (PGFNAB) and ultrasound-guided FNAB (USGFNAB) are the preferred examinations for the diagnosis of thyroid cancer and part of the integration of the current thyroid nodule assessment. Although studies have shown USGFNAB to be more accurate than PGFNAB, inconsistencies from several studies and clinical guidelines still exist.The purpose of this study is to compare the diagnostic accuracy of Palpation versus Ultrasound-Guided Fine Needle Aspiration Biopsy in diagnosing malignancy of thyroid nodules.The systematic review and meta-analysis were prepared based on the PRISMA standards. Literature searches were carried out on three online databases (Pubmed/MEDLINE, Embase, and Proquest) and grey literatures. Data extraction was carried out manually from various studies that met the eligibility, followed by analysis to obtain pooled data on sensitivity, specificity, Diagnostic Odds Ratio (DOR) and Area Under Curve (AUC), and the comparison of the two methods.Total of 2517 articles were obtained, with 11 studies were included in this systematic review. The total sample was 2382, including 1128 subjects using PGFNAB and 1254 subjects using USGFNAB. The risk of bias was assessed using QUADAS-2 with mild-moderate results. The results of sensitivity, specificity, AUC and DOR in diagnosing thyroid nodules using PGFNAB were 76% (95% CI, 49-89%), 77% (95% CI, 56-95%), 0.827 and 11.6 (95% CI, 6-21) respectively. The results of sensitivity, specificity, AUC and DOR in diagnosing thyroid nodules using USGFNAB were 90% (95% CI, 81-95%), 80% (95% CI, 66-89%), 0.92 and 40 (95% CI, 23-69), respectively the results of the comparison test between PGFNAB and USGFNAB; Tsens USGFNAB of 0.99 (p = 0.023), AUC difference test of 0.093 (p = 0.000023).The diagnostic accuracy of USGFNAB is higher than PGFNAB in diagnosing malignancy of thyroid nodules. If it is accessible, the author recommends using USGFNAB as a diagnostic tool for thyroid nodules.

Blood culture utilization and epidemiology of antimicrobial-resistant bloodstream infections before and during the COVID-19 pandemic in the Indonesian national referral hospital.

BACKGROUND: There is a paucity of data regarding blood culture utilization and antimicrobial-resistant (AMR) infections in low and middle-income countries (LMICs). In addition, there has been a concern for increasing AMR infections among COVID-19 cases in LMICs. Here, we investigated epidemiology of AMR bloodstream infections (BSI) before and during the COVID-19 pandemic in the Indonesian national referral hospital. METHODS: We evaluated blood culture utilization rate, and proportion and incidence rate of AMR-BSI caused by WHO-defined priority bacteria using routine hospital databases from 2019 to 2020. A patient was classified as a COVID-19 case if their SARS-CoV-2 RT-PCR result was positive. The proportion of resistance was defined as the ratio of the number of patients having a positive blood culture for a WHO global priority resistant pathogen per the total number of patients having a positive blood culture for the given pathogen. Poisson regression models were used to assess changes in rate over time. RESULTS: Of 60,228 in-hospital patients, 8,175 had at least one blood culture taken (total 17,819 blood cultures), giving a blood culture utilization rate of 30.6 per 1,000 patient-days. A total of 1,311 patients were COVID-19 cases. Blood culture utilization rate had been increasing before and during the COVID-19 pandemic (both p < 0.001), and was higher among COVID-19 cases than non-COVID-19 cases (43.5 vs. 30.2 per 1,000 patient-days, p < 0.001). The most common pathogens identified were K. pneumoniae (23.3%), Acinetobacter spp. (13.9%) and E. coli (13.1%). The proportion of resistance for each bacterial pathogen was similar between COVID-19 and non-COVID-19 cases (all p > 0.10). Incidence rate of hospital-origin AMR-BSI increased from 130.1 cases per 100,000 patient-days in 2019 to 165.5 in 2020 (incidence rate ratio 1.016 per month, 95%CI:1.016-1.017, p < 0.001), and was not associated with COVID-19 (p = 0.96). CONCLUSIONS: In our setting, AMR-BSI incidence and etiology were similar between COVID-19 and non-COVID-19 cases. Incidence rates of hospital-origin AMR-BSI increased in 2020, which was likely due to increased blood culture utilization. We recommend increasing blood culture utilization and generating AMR surveillance reports in LMICs to inform local health care providers and policy makers.

Effect of calorie restriction diet on levels of C reactive protein (CRP) in obesity: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Chronic inflammation in obese patients can be managed through a calorie-restricted diet, characterized by reduced C - reactive protein (CRP). This study aims to assess the role of such diet on CRP. METHODS: Literature searches were performed using search engines. Randomized controlled trials were included. Calorie-restricted diets in combination with non-diet interventions were excluded. RESULTS: Calorie restriction decreased CRP in obese patients with a mean difference of -0.22 (95% CI -0.40 to -0.04, p 0.006). CONCLUSIONS: Calorie-restricted diet reduces CRP. Diet administration >12 weeks had a beneficial effect.

Optimizing antibiotic use in Indonesia: A systematic review and evidence synthesis to inform opportunities for intervention.

Background: A major driver of antimicrobial resistance (AMR) and poor clinical outcomes is suboptimal antibiotic use, although data are lacking in low-resource settings. We reviewed studies on systemic antibiotic use (WHO ATC/DDD category J01) for human health in Indonesia, and synthesized available evidence to identify opportunities for intervention. Methods: We systematically searched five international and national databases for eligible peer-reviewed articles, in English and Indonesian, published between 1 January 2000 and 1 June 2021 including: (1) antibiotic consumption; (2) prescribing appropriateness; (3) antimicrobial stewardship (AMS); (4) consumers' and providers' perceptions. Two independent reviewers included studies and extracted data. Study-level data were summarized using random-effects model meta-analysis for consumption and prescribing appropriateness, effect direction analysis for antimicrobial stewardship (AMS) interventions, and qualitative synthesis for perception surveys. (PROSPERO: CRD42019134641). Findings: Of 9323 search hits, we included 100 reports on antibiotic consumption (20), prescribing appropriateness (49), AMS interventions (13), and/or perception (25) (8 categorized in >1 domain). The pooled estimate of overall antibiotic consumption was 134.8 DDD per 100 bed-days (95%CI 82.5-187.0) for inpatients and 121.1 DDD per 1000 inhabitants per day (10.4-231.8) for outpatients. Ceftriaxone, levofloxacin, and ampicillin were the most consumed antibiotics in inpatients, and amoxicillin, ciprofloxacin, and cefadroxil in outpatients. Pooled estimates for overall appropriate prescribing (according to Gyssens method) were 33.5% (18.1-53.4) in hospitals and 49.4% (23.7-75.4) in primary care. Pooled estimates for appropriate prescribing (according to reference guidelines) were, in hospitals, 99.7% (97.4-100) for indication, 84.9% (38.5-98.0) for drug choice, and 6.1% (0.2-63.2) for overall appropriateness, and, in primary care, 98.9% (60.9-100) for indication, 82.6% (50.5-95.7) for drug choice and 10.5% (0.8-62.6) for overall appropriateness. Studies to date evaluating bundled AMS interventions, although sparse and heterogeneous, suggested favourable effects on antibiotic consumption, prescribing appropriateness, guideline compliance, and patient outcomes. Key themes identified in perception surveys were lack of community antibiotic knowledge, and common non-prescription antibiotic self-medication. Interpretation: Context-specific intervention strategies are urgently needed to improve appropriate antibiotic use in Indonesian hospitals and communities, with critical evidence gaps concerning the private and informal healthcare sectors. Funding: Wellcome Africa Asia Programme Vietnam.

Impact of diabetes mellitus on COVID-19 clinical symptoms and mortality: Jakarta's COVID-19 epidemiological registry.

BACKGROUND AND AIMS: While the higher prevalence of diabetes mellitus (DM) at younger age in Indonesia might contribute to the relatively higher COVID-19 mortality rate in Indonesia, there were currently no available evidence nor specific policy in terms of COVID-19 prevention and management among DM patients. We aimed to find out the association between diagnosed diabetes mellitus (DM) with COVID-19 mortality in Indonesia. METHODS: We performed a retrospective cohort study using Jakarta Province's COVID-19 epidemiological registry within the first 6 months of the pandemic. All COVID-19 confirmed patients, aged >15 years with known DM status were included. Patients were assessed for their clinical symptoms and mortality outcome based on their DM status. A multivariate Cox-regression test was performed to obtain the relative risk (RR) of COVID-19 mortality in the diagnosed DM group. RESULTS: Of 20,481 patients with COVID-19, 705 (3.4%) had DM. COVID-19 mortality rate in DM group was 21.28%, significantly higher compared to 2.77% mortality in the non-DM group [adjusted RR 1.98 (CI 95% 1.57-2.51), p < 0.001]. In addition, COVID-19 patients with DM generally developed more symptoms. CONCLUSIONS: DM is associated not only with development of more COVID-19 clinical symptoms, but also with a higher risk of COVID-19 mortality. This finding may provide a basis for future policy regarding COVID-19 prevention and management among diabetes patients in Indonesia.

Molnupiravir and Nirmatrelvir/Ritonavir: The New Available Antiviral Options for COVID-19.

Coronavirus disease 2019 (COVID-19) is a respiratory tract disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With the complexity of multimorbidity in Indonesia, it is crucial to find another line of antiviral for COVID-19. This article aims to review two antivirals, molnupiravir and nirmatrelvir/ritonavir, that have been studied extensively in treating COVID-19 with promising results, and their availability in Indonesia. Molnupiravir and nirmatrelvir/ritonavir are two of many repurposed drugs in clinical trials, which have been reported to have a mechanism in quick clearance of SARS-CoV-2, reduction in viral load, and fast symptoms recovery time in phase 1 and 2 clinical trials. Phase 2/3 clinical study in COVID-19 patients without any indication for hospitalization showed that molnupiravir and nirmatrelvir/ritonavir significantly reduced the risk of hospitalization and death.

Revisiting the Overlooked Infection: Rickettsioses.

The prevalence of human Rickettsioses cases in Indonesia is unknown and could probably be underestimated. The high prevalence of seropositive Rickettsia sp. was reported in small mammals (as vectors) and humans. In Indonesia, a recent study in patients with acute fever revealed that the prevalence of Rickettsioses is 10%. Many cases of Rickettsioses were often misdiagnosed with dengue fever, enteric fever, or leptospirosis due to their overlapping clinical manifestation. The limitation of point of care testing in Indonesia hindered the adequacy of diagnosis confirmation. Appropriate empirical or definitive treatment with macrolide, mainly doxycycline, is preferable compared to other broad-spectrum antibiotics, such as cephalosporin or quinolones. Moreover, when left untreated, Rickettsioses may deteriorate progressively to fatal outcomes, such as meningitis, sepsis, and even death. The awareness of health care practitioners, the availability of confirmatory rapid diagnostic tests and adequate treatment choices are important in eradicating this disease.