We Need Epidemiological Study from Our Own Population.

Epidemiological data is a valuable source for decision-making in a clinical setting or from a public health perspective. It serves not only direct purposes by supporting evidence-based treatment but also indirectly contributes to guidelines and policies in healthcare services. Currently, there remains a pressing need for further epidemiological or population-based studies to be conducted in Indonesia. The availability of health data and information specifically from the Indonesian population is still limited and highly sought after. It is common for us to depend on epidemiological data from foreign countries, but this practice can introduce bias into our decision-making process due to the disparities between their conditions and our own.Indonesia possesses a distinct socio-demographic and health landscape, setting it apart from other countries. The diverse range of diseases, risk factors, healthcare access, health equity, and geographical characteristics all contribute to the uniqueness and variability of health problems within the nation. Specific regions across the Indonesian archipelago encounter health issues that are distinct to their locations. Infectious diseases, particularly tropical diseases, and nutrient deficiencies continue to present significant challenges in numerous provinces throughout Indonesia. Variations are observed across different areas and timeframes of study. These dynamic and variable factors make population studies particularly intriguing. It is the responsibility of clinicians, researchers, and epidemiologists to delve into the intricacies of the population and study its health problems comprehensively.

Success Treatment of Severe and Active Graves' Orbitopathy with Tocilizumab After Thyroidectomy and Maximum Dose of Intravenous Methylprednisolone.

We report a woman, 45th year old with Graves' disease treated with anti-thyroid drug (thiamazole). She came to our clinic with severe and active Graves' orbitopathy. We treated her with high dose intravenous methylprednisolone weekly (0.5 g weekly/ 6 weeks) and mycophenolate sodium 0.72 g daily/ 6 weeks. Because of her longterm consumption but not successful to achieve remission of anti-thyroid drugs and the size of her goiter, we decided to do total thyroidectomy. Only one week after thyroidectomy, her eye inflammation grade was reduced, but still bulging. We continue with the intravenous methylprednisolone weekly. Because of the partial response, we continue with another dose of methylprednisolone (0.25 g weekly for another 6 weeks).After 12 weeks of intravenous methylprednisolone (maximum dose for 1st course 4.5 g), there is a partial response make it to moderate to severe grade but still active inflammation. Our team decided to give her second-line treatment and we give her intravenous tocilizumab monthly for 4 weeks. After three tocilizumab infusion, the inflammation is reduced remarkably. Her overall appearance is getting better. But, because of her sight was not improved much as the inflammation reduced, we done orbital MRI and we decided to do another intravenous methylprednisolone 1 g for three days followed by orbital decompresion surgery. Shortly after the orbital decompresion, her sight was improved very well. She can now doing activities she can do previously. After recovery, we plan to give her the fourth (last) tocilizumab infusion. Overall, tocilizumab improves clinical outcome in patient with active corticosteroid-resistant moderate to severe Graves' orbitopathy. Patient's quality of life also improved.

Sight-Threatening Condition in Severe Thyroid Eye Disease: How We Should Manage.

Thyroid eye disease (TED) is an autoimmune disorder that is associated with thyroid gland dysfunction which causes muscle and orbital fat enlargement. This case report is aimed to present a case of sight-threatening TED and how we should manage this condition. We present a case of patient with chief complaint of vision loss and prominent eyes for 5 months prior to the visit to our eye hospital. Patient had sought advice from an ophthalmologist and internist. TED was eventually diagnosed 2 months after consulted with an ophthalmologist in the rural area. According to EUGOGO guidelines, TED with sight-threatening condition should be treated with glucocorticoid IV 500-1000 mg for 3 days consecutively. Although the patient was already given steroid injection for the initial treatment, the dosage was inadequate. After the inflammation process was reduced, the patient was reluctant to have an orbital decompression that was suggested. Hence, TED progressed continuously besides sight-threatening complications arising. He indeed underwent fat decompression and tarsorrhaphy as eyelid surgery to prevent corneal exposure. In follow-up, both visual acuity and corneal improvement were finally achieved. In the management of TED, collaboration between ophthalmologist and internist, who may be specialized in endocrinology, is imperative. They should be able to manage TED promptly and correctly, hence sight-threatening and other complications can be prevented and satisfactory results are achieved. Fat decompression should be considered as a good help to improve visual acuity nevertheless orbital decompression cannot be done.

Giant Recurrence Pituitary Adenoma After Three Times Transphenoidal Removal Surgery, One Craniotomy Procedure, and 30 Doses of External Radiotherapy.

This is a case of 42nd year-old woman with history of sight loss in her both eyes. She experienced headache and visual field decrease gradually since 2014. After several laboratory and imaging examinations, from her dynamic pituitary magnetic resonance imaging (MRI), it is concluded that she had a giant adenoma of the pituitary gland which compressed to her optic chiasm. From her pituitary laboratory hormone panel, it is revealed that the tumor is a non-functioning pituitary adenoma. From the neuro-ophthalmology (campimetry) examinations, she had papillae atrophy in her both eyes and also bilateral temporal hemianopia.

A Call for Preventive Medicine Attention for Indonesian Physicians.

The year of 2020 teaches us to prevent is always better than to cure. It is an old phrase that is being used for decades, but it is never been implemented cordially by our society nowadays. Covid-19 is a good lesson that reminds us to carefully prevent the spread of coronavirus which is now a pandemic worldwide. People now wash their hands more often and clean, wear a mask everywhere - everytime, do physical distancing, do healthy lifestyle such as physical activity, healthy diet, and consume multivitamins. They obey the cough and sneeze etiquette. Prevention awareness is never been such popular like todays.For internal medicine specialist, the role for prevention is very broad. Besides we still have a role in primary prevention, we can take our part in both secondary and (of course) tertiary prevention. Primary prevention can be defined as an action not allow a disease to occur, for examples vaccination (for internal medicine specialist more specific as adult vaccination), smoking cessation, physical activity (exercise) and healthy diet. Health promotion and prevention is the core of primary prevention. Secondary prevention aims to detect the disease as early as possible, in at risk population, such as mammography for breast cancer, swab test for Covid-19, colonoscopy for colon cancer in high risk patients. Last, tertiary prevention propose to hamper the progress of clinical disease and prevent more severe complications of the disease, for examples cardiac rehabilitation, or medications for prevent chronic kidney disease in patients with diabetes or hypertension. It is overlapping the curative or treatment strategies as it is states "to cure is to prevent". In 2020, in which each underlying conditions require effective treatment and each disease should be prevented. We are now facing the era of preventive medicine. As an internal medicine specialist, we need to put in mind a philosophy of prevention in every of our action towards patient's care and services.

COVID-19 and Thyroid Diseases: How the Pandemic Situation Affects Thyroid Disease Patients.

Patients with thyroid diseases need special attention during this COVID-19 pandemic. There is a paucity of publications that review the effect of coronavirus infection on thyroid disease patients, such as those with hyperthyroidism, hypothyroidism, thyroid nodules and cancer. This article aims to collect reviews and statements about how the COVID-19 pandemic has affected the management of thyroid disease patients.

Current Diagnosis and Management of Graves' Disease.

Graves' disease is an autoimmune disorder which affect thyroid gland. Graves' disease is the most common cause of hyperthyroidism and thyrotoxicosis. Understanding of disease pathophysiology, diagnostic and treatment strategies, and prevention of disease relapse are important for all clinicians especially internal medicine specialist to give optimal and comprehensive management for Graves' disease patients. This article highlights clinical points to treat Grave's disease patients from reviews and latest guidelines from American Thyroid Association (ATA), European Thyroid Association (ETA), and Japan Thyroid Association/ Japan Endocrine Society.

Thyroid Dysfunction in Type 2 Diabetes Mellitus Patients.

BACKGROUND: thyroid dysfunction is more likely to occur in diabetes mellitus patients than general population. Until now, no study has been done to find prevalence of hypothyroidism and hyperthyroidism in Indonesian diabetics. This study aimed to find the proportion and characteristics of thyroid dysfunction in Indonesian type 2 diabetes mellitus patients. METHODS: a cross-sectional study was conducted in Endocrine and Diabetes Polyclinic, Department of Internal Medicine, Cipto Mangunkusumo Hospital from July to September 2015. This study include type 2 diabetes mellitus patients, age ≥ 18 year-old, willing to undergo thyroid laboratory testing. In this study, hypothyroidism defined as TSH more than 4.0 mIU/L, while hyperthyroidism is defined as TSH less than 0.4 mIU/L with eCLIA. RESULTS: from 364 subjects who were recruited from Endocrine and Diabetes Polyclinic, Cipto Mangunkusumo Hospital, 303 subjects underwent this study until analysis. Two hundred and three (273) subjects (90.1%) were euthyroid, 7 subjects (2.31%) were hyperthyroid, and 23 subjects (7.59%) were hypothyroid. Majority of the patients had subclinical hypothyroidism (56.5% based on Zulewski and Billewicz Score and 65.2% based on fT4 laboratory result), while 42.9% and 71.4% subjects had clinical hyperthyroidism based on clinical appearance and fT4 laboratory result respectively. CONCLUSION: proportion of hypothyroidism was 7.59% and hyperthyroidism was 2.31%, while the proportion of total thyroid dysfunction was 9.9% among diabetics. It is suggested that screening for thyroid dyscfunction can be done in high risk condition as a part of comprehensive management in type 2 diabetes mellitus patients.