Clinical presentation, management, and outcome of suspected central nervous system infections in Indonesia: a prospective cohort study.

BACKGROUND: Little is known about the etiology, clinical presentation, management, and outcome of central nervous system (CNS) infections in Indonesia, a country with a high burden of infectious diseases and a rising prevalence of HIV. METHODS: We included adult patients with suspected CNS infections at two referral hospitals in a prospective cohort between April 2019 and December 2021. Clinical, laboratory, and radiological assessments were standardized. We recorded initial and final diagnoses, treatments, and outcomes during 6 months of follow-up. RESULTS: Of 1051 patients screened, 793 were diagnosed with a CNS infection. Patients (median age 33 years, 62% male, 38% HIV-infected) presented a median of 14 days (IQR 7-30) after symptom onset, often with altered consciousness (63%), motor deficits (73%), and seizures (21%). Among HIV-uninfected patients, CNS tuberculosis (TB) was most common (60%), while viral (8%) and bacterial (4%) disease were uncommon. Among HIV-infected patients, cerebral toxoplasmosis (41%) was most common, followed by CNS TB (19%), neurosyphilis (15%), and cryptococcal meningitis (10%). A microbiologically confirmed diagnosis was achieved in 25% of cases, and initial diagnoses were revised in 46% of cases. In-hospital mortality was 30%, and at six months, 45% of patients had died, and 12% suffered from severe disability. Six-month mortality was associated with older age, HIV, and severe clinical, radiological and CSF markers at presentation. CONCLUSION: CNS infections in Indonesia are characterized by late presentation, severe disease, frequent HIV coinfection, low microbiological confirmation and high mortality. These findings highlight the need for earlier disease recognition, faster and more accurate diagnosis, and optimized treatment, coupled with wider efforts to improve the uptake of HIV services.

Effectiveness of transcranial direct current stimulation (tDCS) as adjunctive treatment for chronic headache in adults with clinically stable systemic lupus erythematosus (SHADE): a randomised double-blind multiarm sham controlled clinical trial.

BACKGROUND: Chronic headache is a 'silent' neuropsychiatric systemic lupus erythematosus symptom with heterogeneous prevalence, potentially reaching 54.4%. It may reduce quality of life by increasing the likelihood of depression and sleep disturbance. While pharmacotherapy remains the first-line treatment, the current management is still challenging and needs other non-invasive modalities. An effective, tolerable and disease-specific treatment modality including transcranial direct current stimulation (tDCS) is considered to reduce the frequency of chronic headaches, including in SLE. Until recently, there was no standard protocol for tDCS in treating headaches. METHODS AND ANALYSIS: SHADE is a single-centre randomised double-blind multiarm sham-controlled trial for adults with clinically stable SLE, chronic headaches and without history of traumatic brain injury, brain infection, stroke or brain tumour. Random allocation is conducted to 88 subjects into 3 treatment groups (administration at primary motor, primary sensory and dorsolateral prefrontal cortex) and control group in 1:1:1:1 ratio. The primary endpoint is reduced number of headache days after adjunctive tDCS. The secondary endpoints are reduced headache intensity, increased quality of life, increased sleep quality, decreased depression and reduced analgesics use. The outcome is measured monthly until 3-month postintervention using headache diary, 36-Item Short Form Survey, Chronic Headache Quality of Life Questionnaire, Pittsburgh Sleep Quality Index and Mini International Neuropsychiatry Interview version 10 (MINI ICD 10). Intention-to-treat analysis will be performed to determine the best tDCS electrode placement. ETHICS AND DISSEMINATION: Ethical approval had been obtained from the local Institutional Review Board of Faculty of Medicine Universitas Indonesia. Results will be published through scientific relevant peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05613582.

Evaluation of Retinal Structure and Optic Nerve Function Changes in Multiple Sclerosis: Longitudinal Study with 1-Year Follow-Up.

BACKGROUND: Multiple sclerosis (MS) is an autoimmune disease characterized by inflammation and demyelination of the central nervous system which often involves the optic nerve even though only 20% of the patients experience optic neuritis (ON). OBJECTIVE: This study aims to compare the retinal structure and optic nerve function between patients with MS and healthy controls (HCs), evaluate optic nerve alterations in MS over 1-year follow-up, and analyze its correlations with disease duration, number of relapses, degree of disability, and different subtypes. METHODS: This is a prospective cohort study involving 58 eyes of MS patients. Optic nerve function was evaluated with best-corrected visual acuity (BCVA), contrast sensitivity, and P100 latency, while the retinal structure was evaluated from the GCIPL and RNFL thickness measured with optical coherence tomography (OCT) and fundus photography. RESULTS: The MS group had lower BCVA (p=0.001), contrast sensitivity (p < 0.001), mean GCIPL thickness (p < 0.001), and mean RNFL thickness (p < 0.001) than HC. At 6 and 12 months of observations, GCIPL and RNFL (nasal quadrant) of MS patients decreased significantly (p=0.007 and p=0.004, respectively). Disease duration and the number of relapses correlated with delayed P100 latency (r = -0.61, p < 0.001 and r = -0.46, p=0.02). GCIPL and RNFL in the SPMS subtype were thinner than in RRMS. CONCLUSIONS: The retinal structure and optic nerve function of MS patients are worse than those of normal individuals. GCIPL and RNFL thinning occurs at 6 and 12 months but do not correlate with disease duration, the number of relapses, and degree of disability.

Increasing Traumatic Brain Injury Incidence during COVID-19 Pandemic in the Emergency Department of Cipto Mangunkusumo National General Hospital-A National Referral Hospital in Indonesia.

OBJECTIVE: Evaluating the TBI incidence during the COVID-19 pandemic era compared with similar period in previous year. BACKGROUND: The emergence of SARS-CoV2 influenced the evolution of governmental and hospital policy worldwide, which might eventually impact many aspects. The incidence of many diseases in the Emergency Department (ED), especially traumatic brain injury (TBI), has been an area of interest. DESIGN/METHODS: Retrospective study comparing TBI incidence before and during COVID-19 pandemic era starting from the declaration of national pandemic date (March 16, 2020) until June 14, 2020 with the comparison of the same period in the previous year. RESULTS: There was an increase in admission rate due to TBI during COVID-19 pandemic compared with the previous year (157/752 (20.9%) vs 106/766 (13.8%), p < 0.001, respectively). While the range of age was similar between COVID-19 and non-COVID-19 era (37.9 ± 14.8 vs 38.6 ± 15.4 years, p = 0.712), male was higher in percentage to experience the injury (131/157 (83.4%) vs 67/106 (63.2%), p < 0.001). During the pandemic era, road traffic injury (97/157 (61.8%) vs 56/106 (52.8%), p = 0.149) as well as moderate-to-severe brain injury tended to increase (30/157 (19.1%) vs 17/106 (16.0%) p = 0.524) albeit statistically insignificant. Although the mortality rate was similar (12/157 (7.6%) vs 9/106 (8.5%), p = 0.804), higher hospitalization rate was observed in the pandemic era (81/157 (51.2%) vs 37/106 (34.9%) p = 0.008). CONCLUSIONS: TBI incidence remained increasing despite entering the COVID-19 era. These phenomena required further investigation and analysis that may possibly be unrelated with the COVID-19, but due to the change of the government policy and its impact, such as the more quiet road after national social distancing.

Validity and Reliability of Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) in Indonesia and the Correlation with Quality of Life.

INTRODUCTION: Multiple Sclerosis (MS) can affect cognitive function that might interfere with quality of life. Processing speed and memory are the most common area of cognitive impairment. Cognitive evaluation in daily practice is often difficult to be performed since it needs neuropsychological expert and is time-consuming. Brief International Cognitive Assessment for MS (BICAMS) is valid and practical for cognitive evaluation. This study aims to validate BICAMS in Indonesian MS patients and healthy controls (HC) and to analyse the effect of cognitive impairment on quality of life. METHODS: BICAMS, which composes Symbol Digits Modalities Test (SDMT), California Verbal Learning Test-Second Edition (CVLT-II), and Brief Visuospatial Memory Test-Revised (BVMT-R), was translated and cross-culturally adapted to Indonesian from the original BICAMS and then administered to 40 Indonesian MS patients and 66 HC matched by sex, age, and education. Test-retest reliability was performed on 16-MS patients and 42 HC. Quality of life was measured using Multiple Sclerosis Quality of Life (MSQOL-54) instrument. RESULTS: The SDMT, CVLT-II, and BVMT-R score in MS patients were significantly lower than those in HC (effect size, r: 0.61, 0.36, and 0.47, respectively). Test-retest reliability for all tests was satisfactory with correlation coefficient for SDMT, CVLT-II, and BVMT-R in MS subjects 0.86, 0.81, and 0.83, respectively. Using 5th percentile of HC score as cut-off, 15% MS subjects had impairment in one test, 27.5% in two tests, and 40% in three tests. BICAMS was moderately correlated with EDSS but was not correlated with disease duration and relapse rate. SDMT score correlated with physical function and physical and mental role limitation. CONCLUSION: BICAMS is valid and reliable for assessing cognitive function of Indonesia MS patients.

Validation of the Indonesian version of multiple sclerosis quality of life-54 (MSQOL-54 INA) questionnaire.

BACKGROUND: Quality of life assessment of patients with multiple sclerosis (MS) is not routinely performed in Indonesia due to the unavailability of the validated Indonesian version of a specific instrument. The objective of this study was to transculturally adapt and validate the Indonesian version of the MSQOL-54 (MSQOL-54 INA) questionnaire. METHODS: The transcultural adaptation was conducted by performing a standardized forward-backward method. Psychometric analysis was performed by assessing the reliability (Cronbach α), internal validation (item internal consistency and item discriminant validity), and external validation by measuring the correlation with a clinical factor such as EDSS and other demographic factors. RESULTS: Reliability test with Cronbach α showed good internal consistency (> 0.7) at each component, except for health perception (0.665) and social function (0.433). Construct validity using computation of correlation coefficient showed internal consistency in accordance with the original MSQOL-54 standard dimension, except for energy and role limitation due to emotional problems components. External validation with EDSS showed negative correlation on almost all components, except for sexual function, but both composite scores were statistically significant. CONCLUSION: MSQOL-54 INA questionnaire has good internal reliability and is proven to be valid and well-accepted by Indonesian MS patients. Therefore, it can be used by Indonesian clinicians for more comprehensive MS management.

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 substansially be evaluated in NMO. Comprehensive diagnosis and providing appropriate immuno-suppressant might prevent further disability and relapse.

Proceedings of the Inaugural Strategy Meeting for the Establishment of a Southeast Asia Regional Therapeutic Plasma Exchange Consortium for Neurological Disorders.

In conjunction with the third regional Southeast Asian (SEA) therapeutic plasma exchange (TPE) conference in Kuala Lumpur, Malaysia, 25 clinicians and researchers from SEA and South Asian countries attended the inaugural strategy meeting for the establishment of a regional TPE consortium for neurological disorders. The primary objective was to establish regional collaboration to improve delivery of TPE services in SEA. A pre-meeting survey was conducted to gather insights on disease spectrum, contextual practice challenges, and the need for a regional TPE consensus. Challenges identified include limited healthcare funding in support of diagnostic workup, TPE therapy, as well as development of clinical infrastructure and expertise capacity building. There was favorable interest in developing a working plan contextualized to this region. Strategies to overcome challenges were discussed. This included the need for a comprehensive referral system and network of regional TPE centers suited to local needs, supported by innovative TPE delivery programs.

Low vitamin D-25(OH) level in Indonesian multiple sclerosis and neuromyelitis optic patients.

BACKGROUND: Vitamin D deficiency is commonly found in multiple sclerosis (MS) and Neuromyelitis Optic (NMO) patients and can impair the immunological status. As a tropical country, Indonesia has a lot of sunshine throughout the year as a source of vitamin D. The aim of this study was to evaluate and compare the serum vitamin D-25(OH) level in Indonesian MS and NMO patients to healthy individuals. METHODS: A cross-sectional study was conducted in Dr. Cipto Mangunkusumo General Hospital Jakarta from November 2016 to May 2017. Forty-eight patients (29 MS and 19 NMO) and 33 healthy controls were enrolled. We assessed the dietary recall, vitamin D supplementation, sunshine exposure, medication, annual relapse rate, and Expanded Disability Status Scale (EDSS). Vitamin D level was measured using direct competitive chemiluminescence immunoassay. RESULTS: Vitamin D deficiency was found in 48.4% of MS and 56.2% of NMO patients. The serum vitamin D level in MS and NMO groups was not significantly different from the healthy controls. Vitamin D level was not associated with EDSS and the annual relapse rate. Positive significant correlation was observed between sunshine exposure and vitamin D level in healthy control, but not evident in MS and NMO groups. MS and NMO subjects who still treated with corticosteroid had lower vitamin D level. CONCLUSION: Vitamin D deficiency is commonly found in Indonesian MS and NMO patients, but not associated with EDSS and annual relapse rate. Despite living in a country with adequate sunshine exposure, the physician should anticipate low serum vitamin D level, especially in MS or NMO patients who received corticosteroid.