Learning from the COVID-19 pandemic: health care disturbances and telemedicine as an alternative rheumatology practice in Indonesia.

BACKGROUND: Coronavirus disease 2019 (COVID-19) affects health care services. Our aim was to assess health care disruptions, treatment interruptions, and telemedicine reception regarding autoimmune rheumatic diseases (ARDs) in Indonesia. METHOD: A cross-sectional population online-based questionnaire was conducted in Indonesia from September to December 2021. RESULTS: A total of 311 ARD patients were included, of whom 81 (26.0%) underwent consultations via telemedicine during the COVID-19 pandemic. The respondents showed increased concern about their susceptibility to COVID-19 (score of 3.9/5). Approximately 81 (26.0%) avoided hospital visits, and 76 (24.4%) stopped taking the medication without medical advice. Respondents' concerns correlated with their social distancing behaviors (p value 0.000, r 0.458). Respondent concerns, behaviors, and blocked access to the hospital during the pandemic were associated with avoiding hospital visits (p value 0.014; 0.001; 0.045; 0.008). Sex was associated with stopping medication (p value 0.005). In multivariate analysis, blocked access and sex remained significant. Approximately 81 (26%) respondents who used telemedicine services during the COVID-19 pandemic as an alternative medical consultation method showed high satisfaction (3.8/5). CONCLUSION: Health care disruptions and treatment interruptions were affected by patients' internal and external factors during the COVID-19 pandemic. Telemedicine may be the best option to address barriers to health care access in Indonesia's rheumatology practice during and after the pandemic situation.

Type 2 Diabetes Mellitus and Cognitive Impairment.

Type 2 diabetes mellitus (T2DM) is strongly associated with lower performance on multiple domains of cognitive function and with structural abnormalities of the brain. With the growing epidemic of diabetes and aging population, neural complications of diabetes are expected to rise and becoming a challenge for future health implications. Understanding pathophysiology, factors associated with this complication, manifestation of cognitive impairment and various metabolic and neuroradiologic markers suggestive of this pathologic condition is crucial for proper management of this potentially debilitating complication of T2DM. This review will discuss briefly important aspects of cognitive impairment in T2DM.

Comparison of Effects of ACEIs and ARBs on Albuminuria and Hyperkalemia in Indonesian Hypertensive Type 2 Diabetes Mellitus Patients.

PURPOSE: Due to economic consideration, Indonesia's formulary restrictions are at odds with the treatment guidelines of the American Diabetes Association (ADA) and the Eighth Joint National Committee (JNC 8). ADA and JNC 8 equally recommend the prescription of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) for hypertensive patients with type 2 diabetes mellitus (T2DM) with overt proteinuria (urine albumin to creatinine ratio (UACR) ≥ 300 mg/g creatinine). However, since 1 April 2018, Indonesian formulary restricted telmisartan and valsartan only for T2DM patients with declined renal function as shown by eGFR value. There is no compelling evidence in favor of ACEI over ARB or vice versa except for data supporting the early use of both drugs in patients with overt proteinuria. However, ARB is a choice if ACEI's side effects, that is, coughing, occurs. Therefore, it necessitates a detailed evaluation of the effects of ACEIs and ARBs on albuminuria and their side effect, hyperkalemia, specific to Indonesian T2DM patients. METHODS: This cross-sectional study involved 134 T2DM patients whose treatment was restricted to either ACEIs (n = 57) or ARBs (n = 77) for at least two months before the study during May-October 2018. Patients with known end-stage renal disease and those receiving dialysis were excluded. UACR and blood potassium levels were compared between the two study groups. Also, the risk factors of albuminuria and hyperkalemia were estimated using multivariate analysis. RESULTS: T2DM patients in the ACEI and ARB groups had similar characteristics except for a higher body mass index (p=0.008), lower glomerular filtration rate (p=0.04), and a longer duration of prior treatment (p < 0.001) in the ARB group. This study showed no differences between the ACEI and ARB groups in the proportion of cases with albuminuria (p=0.97) and hyperkalemia (p=0.86), even after adjustment for confounders. In addition, uncontrolled diastolic blood pressure was a significant factor associated with albuminuria (OR: 4.897, 95% CI: 1.026-23.366; p=0.046), whereas a female was 70.1% less likely to develop hyperkalemia than a male (OR: 0.299, 95% CI: 0.102-0.877; p=0.028). CONCLUSION: This cross-sectional study demonstrated that ACEIs and ARBs have a similar effect on albuminuria and hyperkalemia in Indonesian hypertensive T2DM patients, even after correction for potentially confounding variables.

Association between serum homocysteine level and cognitive function in middle-aged type 2 diabetes mellitus patients.

Type-2 diabetes mellitus (T2DM) is strongly associated with various complications, including cognitive impairment. Diabetic complication is related with structural and functional changes of brain. Studies investigated that homocysteine as an independent risk factor of several organ complications. This marker might have a role in pathogenesis of cognitive impairment in T2DM patients. We aimed to know the association between serum homocysteine level and cognitive impairment in middle-aged T2DM populations. The study was a cross-sectional study involving 97 T2DM patients aged <60 years old. Cognitive assessment was based on validated Indonesian version of Montreal Cognitive Assessment (MoCA-INA) test. Besides, serum homocysteine level (Hcy) was measured based on standard laboratory assay. Filling out the questionnaire of MoCA-INA was conducted when patients came to take the blood sample. This study used independent t-test, chi-square and multivariate logistic regression model to analyze the data. There were 47 subjects (48.5%) with mild cognitive impairment (MCI). Delayed recall was the most impaired domain (94.8%). There was no significant mean difference of serum Hcy level in MCI and non-MCI group (11.99±3.27 µmol/L vs 12.36±4.07 µmol/L respectively, p = 0.62). Final model of logistic regression showed no association between serum Hcy and cognitive function after adjusting confounding variables (OR: 1.778; 95%CI: 0.69-4.54). Further investigation involving slight elderly T2DM patients with larger sample size should be conducted to confirm this finding.