Vitrification alters growth differentiation factor 9 and follicle-stimulating hormone receptor expression in human cumulus-mural granulosa cells.

Objective: Ovarian tissue vitrification is widely utilized for fertility preservation in prepubertal and adolescent female patients with cancer. The current literature includes reports of successful pregnancy and live birth following autografting. However, the effects of the vitrification process on cumulus-mural granulosa cells (C-mGCs)-somatic cells in ovarian tissue crucial for oocyte maturation and early embryonic development-remain unclear. This study was conducted to explore the impact of vitrification on the cellular function of C-mGCs by quantifying the expression of growth differentiation factor 9 (GDF-9), bone morphogenetic protein 15 (BMP-15), follicle-stimulating hormone receptor (FSHR), luteinizing hormone receptor (LHR), connexin 37, survivin, and caspase 3. Methods: Mature and immature C-mGCs were obtained from 38 women with polycystic ovary syndrome who participated in an in vitro fertilization program. The C-mGCs were then divided into two groups: fresh and vitrified. The expression levels of target genes were assessed using real-time quantitative polymerase chain reaction. Results: After vitrification, GDF-9 expression was significantly decreased among both mature and immature C-mGCs, with 0.2- and 0.1-fold changes, respectively (p<0.01). Similarly, FSHR expression in the mature and immature groups was reduced by 0.1- and 0.02-fold, respectively, following vitrification (p<0.01). The expression levels of the other genes, including BMP-15, LHR, connexin 37, survivin, and caspase 3, remained similar across the examined groups (p>0.05). Conclusion: Vitrification may compromise oocyte maturation through reduced GDF-9 and FSHR expression in C-mGCs after warming.

Prospect of Mesenchymal Stem Cells in Enhancing Nerve Regeneration in Brachial Plexus Injury in Animals: A Systematic Review.

Objectives: Brachial plexus injuries (BPI), although rare, often results in significant morbidity. Stem cell was thought to be one of BPI treatment modalities because of their nerve-forming regeneration potential. Although there is a possibility for the use of mesenchymal stem cells as one of BPI treatment, it is still limited on animal studies. Therefore, this systematic review aimed to analyze the role of mesenchymal stem cells in nerve regeneration in animal models of brachial plexus injury. Method: This study is a systematic review with PROSPERO registration number CRD4202128321. Literature searching was conducted using keywords experimental, animal, brachial plexus injury, mesenchymal stem cell implantation, clinical outcomes, electrophysiological outcomes, and histologic outcomes. Searches were performed in the PubMed, Scopus, and ScienceDirect databases. The risk of bias was assessed using SYRCLE's risk of bias tool for animal studies. The data obtained were described and in-depth analysis was performed. Result: Four studies were included in this study involving 183 animals from different species those are rats and rabbits. There was an increase in muscle weight and shortened initial onset time of muscle contraction in the group treated with stem cells. Electrophysiological results showed that mesenchymal stem cells exhibited higher (Compound muscle action potential) CMAP amplitude and shorter CMAP latency than control but not better than autograft. Histological outcomes showed an increase in axon density, axon number, and the formation of connections between nerve cells and target muscles. Conclusion: Mesenchymal stem cell implantation to animals with brachial plexus injury showed its ability to regenerate nerve cells as evidenced by clinical, electrophysiological, and histopathological results. However, this systematic study involved experimental animals from various species so that the results cannot be uniformed, and conclusion should be drawn cautiously.

The Value of Warning Signs From the WHO 2009 Dengue Classification in Detecting Severe Dengue in Children.

BACKGROUND: World Health Organization proposed 7 warning signs to identify the risk of severe dengue in 2009. This study aimed to evaluate the value of these warning signs in detecting severe dengue in children. MATERIAL AND METHODS: A cross-sectional study was conducted utilizing data of children with clinical dengue infection obtained from medical records between January 2009 and December 2018 in Jakarta. Children with confirmed dengue were analyzed and stratified into 3 age groups: infants less than 1 year old, children 1-14 years and adolescents 15-18 years of age. Positive predictive value, negative predictive value (NPV), sensitivity and specificity of each warning sign present or absent on admission in detecting severe dengue were computed. RESULTS: Six hundred ninety-nine children with clinical dengue infection were enrolled, among whom 614 (87.8%) had confirmed dengue infection, either by antigen or antibody serological tests. Severe dengue occurred in 211/614 (34.4%) cases. In infants, important warning signs on admission to detect or exclude severe dengue were liver enlargement (NPV 80.8%) and clinical fluid accumulation (NPV 75%). In children and adolescents, warning sign with highest NPV (in children 76.6% and in adolescents 91.9%) was increase in hematocrit concurrent with a rapid decrease in platelet count. Other warning signs with high NPV values in children were abdominal pain (72%), vomiting (70%), clinical fluid accumulation (69.3%), and in adolescents' abdominal pain (80.7%), vomiting (75.7%), clinical fluid accumulation (82.7%). NPVs increase with more than 1 warning sign in all age groups. CONCLUSION: In infants, liver enlargement or clinical fluid accumulation are important warning signs for severe dengue, when both are absent, severe dengue is unlikely. In older children and adolescents, an increase in hematocrit with the concurrent rapid decrease in platelet count is most discriminative; followed by the absence of abdominal pain, vomiting or fluid accumulation are unlikely severe dengue.

Association between spinopelvic alignment and the development of degenerative spondylolisthesis: a systematic review and meta-analysis.

INTRODUCTION: Spinopelvic parameter may result in the development of degenerative spondylolisthesis. However, previous studies show conflicting results; some found a significant relationship of some of these parameters with degenerative spondylolisthesis, while others did not. Previously, there was no meta-analysis regarding the association between spinopelvic alignment and degenerative spondylolisthesis. This meta-analysis aims to determine the association between spinopelvic alignment and degenerative spondylolisthesis. METHODS: Systematic reviews and meta-analyses are based on the selected item reporting method for systematic review and meta-analysis (PRISMA). A literature search was performed using PubMed, EMBASE, ScienceDirect, Cochrane, and Google Scholar. Methodological quality is based on the cross-sectional checklist of the Agency for Healthcare Research and Quality (AHRQ) quality check methodology and the Newcastle-Ottawa scale (NOS) for cohort studies. Statistical analysis was performed using Rev-Man 5.3. Subgroup analyses were performed based on ethnicity and study design to ascertain racial relations and heterogeneity. RESULTS: A total of 3236 articles were obtained. Of these, we found that pelvic incidence (mean difference [MD] = 11.94 [1.81-22.08], P = 0.02), pelvic tilt (MD = 4.47 [0.81-8.14]), P = 0.02), and age (MD = 11.94 [1.81-22.08], P = 0.02) were associated with the development of degenerative spondylolisthesis. CONCLUSION: This meta-analysis proves that pelvic incidence, pelvic tilt, and age are associated with degenerative spondylolisthesis.

The role of the glucocorticoid receptor and its impact on steroid response in moderate-severe COVID-19 patients.

The effect of corticosteroid therapy in COVID-19 patients is mediated by its suppressive effect on the regulations of inflammatory response. However, its clinical outcome is often unpredictable. This study aimed to explore the role of glucocorticoid receptors in corticosteroid response in Moderate-Severe COVID-19 patients. In this cross-sectional study, we attempted to find the relationship between the expression of the glucocorticoid receptor (encoded by NR3C1), the variation of glucocorticoid receptors isoform, and the mutations of glucocorticoid receptors exon with clinical response to corticosteroids. In addition, the relationship between glucocorticoid receptors expression and the expression of IκBα (encoded by NFKBIA) and glucocorticoid-induced leucine zipper protein (GILZ; encoded by TSC22D3) as steroid pathways was also evaluated. Thirty-four COVID-19 patients were studied. Blood was drawn before and on day 5 of corticosteroid treatment. Glucocorticoid receptors expression, isoform, and mutation were determined by RNA sequencing from white blood cells. Based on the improvement of clinical and oxygen status, patients were classified into responder and non-responder groups. Of thirty-four patients, 23 (67.6%) showed excellent responses to corticosteroids, and 11 (32.4%) were non-responders. The NR3C1 gene expression was significantly higher in the responsive group at baseline and after five days of glucocorticoid treatment. Isoform variant and mutation of glucocorticoid receptors did not correlate with clinical response. The expression of IκBα and GILZ correlated positively with glucocorticoid receptors expression. This study elucidates the relationship between glucocorticoid receptor expression with therapeutic responses to corticosteroids in moderate-severe COVID-19.

General versus spinal anesthesia in percutaneous nephrolithotomy: A systematic review and meta-analysis.

Background: Percutaneous nephrolithotomy (PCNL) is the preferred treatment for the removal of large kidney stones, sized >20 mm. However, there is still an ongoing debate concerning the best anesthesia for PCNL. This study aimed to compare the efficacy and safety between general and spinal anesthesia for PCNL. Methods: A systematic review and meta-analysis study. A systematic, electronic literature search was performed in several databases, including PubMed, Scopus, and Google Scholar until July 1 st, 2022. The quality of the articles was examined using Crombie's Items (for non-randomized controlled trials (RCTs)) and Jadad Scale (for RCTs). The outcomes assessed were operation time, fluoroscopy time, length of stay, stone-free rate, overall complication rate, specific postoperative complications, cost, pain score, and postoperative analgesic requirement. The article selection was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We assessed four RCTs and eight retrospective studies. Meta-analysis of selected studies was performed using the Review Manager 5.3. Results: General anesthesia resulted in fewer Clavien-Dindo grade II (OR: 0.68; 95% CI: 0.49 - 0.94; p=0.02), major complications (OR: 0.65; 95% CI: 0.45 - 0.94; p=0.02, and lower transfusion rates (OR: 0.70; 95% CI: 0.53 - 0.94; p=0.02). Whereas spinal anesthesia resulted in faster operation time (Mean Difference: -12.98; 95% CI: -20.56 - -5.41; p<0.001, fluoroscopy time (MD: -26.15; 95% CI: -42.79 - -9.50; p=0.002), reduced length of stay (MD: -0.47; 95% CI: -0.75 - 0.20; p<0.001), and lower postoperative analgesic requirement and cost. No significant difference in stone-free rate (OR: 1.08; 95% CI: 0.92 - 1.26; p=0.37). PCNL performed using either general anesthesia or spinal anesthesia is equally safe and effective. Conclusions: Each method of anesthesia has its own advantages and disadvantages. The final choice between general and spinal anesthesia should be based on the patient's condition and surgical team preference.

Mental Health Awareness and Promotion during the First 1000 Days of Life: An Expert Consensus.

The first 1000 days of life constitute a critical phase that will determine the optimum growth and development of a child. An important factor in this phase of life is the perinatal mental health of mothers and children. Mental health awareness is an important public health issue with significant impacts on mothers, spouses, and families, as well as the long-term emotional and cognitive development of children as well. However, the awareness and promotion of mental health within the realms of reproductive health, maternal health, and infant health, i.e., the first 1000 days of life, do not receive high prioritization in Indonesia. Nonetheless, Indonesia, with its existing primary healthcare system, has the potential to raise awareness of and promote the importance of perinatal mental health for its citizens. This experts' consensus proposes several strategies to maximize the usefulness of primary healthcare facilities in Indonesia, including Community Health Centers and Integrated Healthcare Posts, to support perinatal mental health awareness and promotion during the first 1000 days of life. The success of this program, in return, will improve the health status of women and children in Indonesia.

Effect of altitude zone exposure on visuospatial function in military aircrew member.

Introduction: visuospatial is a type of high-level visual perception necessary for identification, information integration, analysing of visual and spatial forms, details, structures and spatial relation. These functions are required in order to successfully complete aviation-related tasks, such as analysing movement, distance perception, and spatial navigation. The aim of this study is to examine whether hypobaric hypoxia can significantly influence changes in visuospatial function, thus increasing the risk of accident or serious incident during flight operation. Methods: this study is a quasi-experiment of pre-post study including before and after hypobaric hypoxia simulated through an altitude chamber. In this study, 42 military aircrews were exposed to different altitude zones at ground level, 10,000 ft (ft) and 25,000 ft respectively, for five minutes. At each altitude zone, the participants were instructed to complete a clock drawing test as a measurement for visuospatial function. The results were analysed using the McNemar non-parametric test. Results: among the 42 subjects, six show impaired visuospatial function at 10,000 ft and 26 participants show it at 25,000 ft. There were significant increased on the proportion of impaired visuospatial function between the ground level to 10,000 ft (p=0.031), 10,000 to 25,000 ft (p=0.0001) and ground level to 25,000 ft (p=0.0001). Conclusion: hypobaric hypoxia may have a significant influence on visuospatial function, starting from as early as 10,000 ft to 25,000 ft. This decrease of visuospatial function could affect human cognitive performance when flying and increase the risk of aviation accidents.

Noncommunicable diseases risk factors and the risk of COVID-19 among university employees in Indonesia.

INTRODUCTION: Noncommunicable diseases (NCDs) are still a major public health problem in Indonesia. Studies have shown that risk factors of NCDs are associated with coronavirus disease 2019 (COVID-19) severity and mortality. However, it is unclear whether NCD risk factors are also risks for new COVID-19 cases. This study aimed to obtain an NCD risk profile among university employees and its associations with contracting COVID-19. METHODS: A cross-sectional study was conducted in October 2021. Participants were administrative employees of Universitas Indonesia (UI), Depok City, West Java. Assessment of NCD risk factors was based on the World Health Organization STEPwise approach to NCD risk factor surveillance (WHO STEPS). Demographic, working, and medical-history data were obtained electronically by using a Google Form. Physical and laboratory examinations were done in the Integrated Post for NCDs. Risks were expressed as adjusted odds ratio (ORadj) and 95% confidence interval (CI) in multivariate analyses. RESULTS: A total of 613 employees were enrolled. Men were predominant (54.8%), and about 36% of them work in shift as security personnel. About 66.7% were overweight or obese and 77.8% had hypertension. There were 138 (22.8%) employees who had COVID-19. Nearly all (95.6%) had been fully vaccinated against COVID-19. At-risk waist circumference (ORadj 1.72, 95% CI 1.15-2.56, p = 0.008) and total cholesterol level of 200-239 mg/dL (ORadj 2.30, 95% CI 1.19-4.44, p = 0.013) were independent risk factors, but shift work (ORadj 0.52, 95% CI 0.34-0.80, p = 0.003) was protective against COVID-19. CONCLUSION: The prevalence of NCD risk factors among university administrative employees was high, increasing the risk of contracting COVID-19. A behavioral intervention program to manage NCD risk factors at the university level is urgently needed according to the Health Promoting University framework.

Assessment of the obesogenic environment in primary schools: a multi-site case study in Jakarta.

BACKGROUND: Childhood overweight and obesity have increasingly been recognized as a significant global public health crisis, including in Asia. This study aimed to assess the obesogenic environment in primary schools in Jakarta, Indonesia. METHODS: A qualitative, multi-site, case study design was used to capture different elements of the school environment and policies related to obesity, with a focus on nutrition and physical activity. An adaptation of the Primary School Environmental Assessment tool was used. Six primary schools in Jakarta were purposively selected based on their location, socioeconomic status, and type (public or private). In addition to direct observation at each school, interviews were conducted with the principal, physical education teacher, canteen staff, street food vendors, and students. RESULTS: Among the six schools, two were private and four were public. The most popular foods consumed by students were unhealthy, such as deep-fried foods and sugar-sweetened beverages. Students had easy and constant access to unhealthy foods, whereas only limited variation of healthy foods were available in the school canteen. Some schools also allowed the student to have access to street food vendors. School policies related to healthy eating and physical activities had been implemented, mainly in the form of teaching these topics as part of the school curriculum. However, promotion of healthy eating and physical activities by the schools was still limited. CONCLUSIONS: This study showed the usefulness of the Primary School Environmental Assessment tool in identifying obesogenic factors in urban area of Indonesia. Effective implementation of guidelines to foster good nutritional practices and healthy lifestyles at school should be prioritized to improve the health and nutritional status of the students.

Knowledge, attitude, and practice related to the COVID-19 pandemic among undergraduate medical students in Indonesia: A nationwide cross-sectional study.

INTRODUCTION: The potential role of medical students in raising awareness during public health emergencies has been acknowledged. To further explore their potentials as public educators and role models for the communities during the coronavirus disease 2019 (COVID-19) pandemic, this study aims to assess the knowledge, attitude, and practice of these students toward COVID-19. METHODS: An online cross-sectional survey was conducted among undergraduate medical students in Indonesia. Socio-demographics characteristics, social interaction history, information-seeking behavior, as well as knowledge, attitude, and practice toward COVID-19 were collected through a self-reported questionnaire. A p-value of <0.05 indicated statistical significance. RESULTS: Out of 4870 respondents, 64.9% had positive attitude and 51.5% had positive practice toward COVID-19, while only 29.8% had adequate knowledge. Knowledge was slightly positively correlated with attitude and practice (ρ = 0.074 and ρ = 0.054, respectively; both p<0.001), while attitude was weakly correlated with practice (ρ = 0.234, p<0.001). Several factors including age, sex, place of residence, institution type, academic level, family income, history of chronic illness, prior volunteering experience, and perceptual awareness on COVID-19 were significantly associated with either knowledge, attitude, and/or practice toward COVID-19. Furthermore, health institution's and the government's press releases, as well as health expert opinions were deemed as the most reliable sources of COVID-19-related information-yet trivially none of these sources were associated with knowledge, attitude, and practice in the study population. CONCLUSION: Many undergraduate medical students in Indonesia had positive attitude and practice against COVID-19, yet only a few had adequate knowledge. This warrants further interventions to keep them updated with COVID-19 evidence to maximize their potentials in raising public awareness on COVID-19.

Retinal abnormalities in universal eye screening of healthy, full-term newborn infants in Jakarta. The incidence and its risk factors: a pilot study.

AIM: To screen for ocular abnormalities in healthy full-term newborn infants using wide-field digital imaging and to analyze factors associated with the findings. METHODS: A total of 1208 full-term newborn infants at a tertiary eye hospital (Cipto Mangunkusumo National Referral Hospital) and a district hospital in Jakarta (Koja Hospital) were enrolled to the study. All eligible newborns underwent fundus examination within 48 h after birth using the RetCam shuttle (Natus Medical Incorporated, USA). Retinal findings were documented and analyzed according to obstetric and neonatal risk factors. RESULTS: Of the 1208 newborn infants enrolled, ocular abnormalities were found in 150 infants (12.4%). Retinal hemorrhage (RH) was the most common finding (88%) in which 2.67% involved the macula, followed by chorioretinitis (4.67%). Univariate analysis showed caesarean section (C-section) (OR 0.27, 95% CI 0.18-0.41, p < 0.001) was a protective factor against RH, while prolonged labor increased the risk of developing RH (OR 1.84, 95% CI 1.24-2.72, p = 0.002). Further multivariate analysis showed similar protective association between C-section and risk of RH (OR 0.29, 95% CI 0.19-0.44, p < 0.001), while other risk factors were not. CONCLUSIONS: Our study showed that universal eye screening in healthy neonates is beneficial in the early diagnosis, monitoring and treatment of ocular abnormalities such as retinal hemorrhage, chorioretinitis and retinoblastoma. Retinal hemorrhage is the most common ocular abnormality and is associated with the delivery method and the duration of labor. Universal eye screening is visual-saving and life-saving for neonates with chorioretinitis, retinoblastoma as well as other abnormalities and should be mandatory in newborn screening.

Willingness to volunteer and readiness to practice of undergraduate medical students during the COVID-19 pandemic: a cross-sectional survey in Indonesia.

BACKGROUND: The question to involve or restrict medical students' involvement in the coronavirus disease 2019 (COVID-19) pandemic response remains contentious. As their state of preparation and perceptions in volunteering during this pandemic have yet to be investigated, this study aims to evaluate Indonesian medical students' willingness to volunteer and readiness to practice during the COVID-19 pandemic. METHODS: A web-based survey was conducted among undergraduate medical students throughout Indonesia. Socio-demographic and social interaction information, in addition to willingness to volunteer and readiness to practice, were obtained using a self-reported questionnaire. The significance level was set at 5%. RESULTS: Among 4870 participants, 2374 (48.7%) expressed their willingness to volunteer, while only 906 (18.6%) had adequate readiness to practice. Male students, students with prior volunteering experience in health or non-health sectors, and students from public universities or living in Central Indonesia (vs Java) had higher scores of willingness and readiness to volunteer. Students from Sumatra also had better preparedness (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.15-2.12, p = 0.004), while the opposite occurred for students from Eastern Indonesia (OR 0.63, 95% CI: 0.44-0.89, p = 0.002)-when compared to students from Java. In addition, compared to students with high family income, students from lower-middle income families were less willing to volunteer (OR 0.76, 95% CI: 0.59-0.98, p = 0.034), though those with low family income had better readiness (OR 1.51, 95% CI: 1.10-2.08, p = 0.011). Shortage of medical personnel, sense of duty, and solicitation by stakeholders were the main reasons increasing the students' willingness to volunteer; whereas contrarily fear for own's health, absence of a cure, and fear of harming patients were the primary factors diminishing their willingness to volunteer. CONCLUSION: Our findings indicated that many Indonesian medical students are willing to volunteer, yet only few of them were ready to practice, indicating that further preparations are required to maximize their potentials and minimize their exposure to hazards. We suggest that their potentials as a firm support system during the pandemic should not be overlooked, and that the integration of relevant courses to the medical curricula are imperative to prepare for future public health emergencies.

The benefits of varicocele repair for achieving pregnancy in male infertility: A systematic review and meta-analysis.

INTRODUCTION: Varicocele is one of the most common treatable causes of male infertility. However, the decision to perform varicocelectomy before starting a fertility program remains controversial. This study aimed to thoroughly review and analyze the benefit of varicocele repair and its impact on the success rate of a fertility program. MATERIALS AND METHODS: A systematic literature search was performed using MEDLINE, Cochrane Library, and Wiley Library. The primary outcome was the pregnancy rate, and the secondary outcomes were live birth rate and surgical sperm retrieval success rate. Outcomes were compared between men who underwent treatment for a varicocele and those that did not. The pooled analysis data are presented as odds ratios with 95% confidence intervals. RESULTS: A total of 31 articles were included in the meta-analysis. The pregnancy rate was significantly higher in the treated group (odds ratio = 1.82; 95% confidence interval: 1.37-2.41; P < 0.0001) along with the live birth rate (odds ratio = 2.80; 95% confidence interval: 1.67-4.72; P = 0.0001). The further subgroup analysis revealed a higher pregnancy rate in treated men with azoospermia, subnormal semen parameters, and normozoospermia (P = 0.04, P = 0.0005, and P = 0.002, respectively), while the live birth rate was only significantly higher in the treated men with subnormal semen parameters and normozoospermia (P = 0.001 and P < 0.0001). Treated varicocele also led to a higher sperm retrieval rate in azoospermic patients (odds ratio = 1.69; 95% confidence interval: 1.16-2.45; P = 0.006). CONCLUSIONS: Varicocele repair increased the pregnancy and live birth rates regardless the semen analysis result, along with the sperm retrieval success rate in azoospermic men. Thus, varicocele repair may be beneficial prior to joining a fertility program.

Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis.

BACKGROUND: The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas. METHODS: Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect sizes, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. RESULTS: The search yielded 19 studies involving a total of 28,496 subjects, comprising of prehospital and in-hospital telestroke interventions in the form of mobile stroke units and hub-and-spoke hospitals network, respectively. Telestroke successfully increased the proportion of patients treated ≤3 hr (OR 2.15; 95% CI 1.37-3.40; I2  = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63; I2  = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49; I2  = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42; I2  = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87; I2  = 0%). GRADE assessments yielded low-to-moderate certainty of body evidences. CONCLUSION: Telestroke implementation in rural areas was associated with better clinical outcomes as compared to usual care. Its integration in both prehospital and in-hospital settings could help optimize emergency stroke approach. Further studies with higher-level evidence are needed to confirm these findings.

The implementation of community-based diabetes and hypertension management care program in Indonesia.

Since 2010, Indonesian government has initiated a chronic disease management program, Prolanis (Program Pengendalian Penyakit Kronis) targeted for diabetes and hypertension. The program is continued at the commencement of universal health coverage (UHC) in 2014. "This study aimed to report the utilization and cost of the implementation of Prolanis in Indonesia from 2014 to 2016, or two years since the commencement of Indonesian universal health coverage." Secondary data analysis was performed using publicly available data and data obtained from the national health insurance agency (BPJS); while data on disease prevalence were collected from basic national health survey. There was an increase trend of Prolanis participants, from around 11,000 participants in 2014 to more than 250,000 in 2016. More than 70% of participants were adults living in Java, however, the acceptance rate was very low in other area. Across different activities in Prolanis, physical activity was the most participated ones. In comparison to other regions, regions in Java were the most active area. The total expenditure for Prolanis program in 2016 increased almost triple from the annual cost in 2014. However, the cost per person was actually decreased more than 50%. Within two years of UHC implementation, there were increase covered participants and total costs, but cost per individual was decreased and there was significant difference in of cost between Java and outside Java. Further study and routine monitoring-evaluation process by health authority is needed to assess whether the cost difference would affect the service quality.