Endovascular embolization of Spetzler-Martin Grade I brain arteriovenous malformations: A case report on patient-centered neurointervention.

Brain arteriovenous malformations (AVM) present complex treatment decisions, particularly for low-grade AVM where surgical resection is often considered the standard. This case report emphasizes the importance of patient preferences and cultural considerations in selecting endovascular embolization over traditional surgical approaches for Spetzler-Martin Grade I AVM management, highlighting the evolving practice of patient-centered care in neurointervention. A 30-year-old male presented with recurrent seizures, characterized by a sudden onset of headache followed by speech arrest, without any preceding medical history of neurological deficits. Initial physical examination revealed no focal neurological deficits. Non-contrast computed tomography, magnetic resonance imaging, and magnetic resonance angiography suggested an AVM involving the cortical-subcortical regions of the left frontal lobe, measuring approximately 1.7 × 2.6 × 1.5 cm, fed by the left middle cerebral artery M3 segment, and draining into the superior sagittal sinus. Spetzler-Martin Grade I classification was confirmed via digital subtraction angiography. Given the patient's strong preference against invasive procedures, driven by personal and cultural beliefs, endovascular embolization was selected as the treatment strategy. Post-embolization, the patient showed marked symptomatic improvement with no evidence of residual AVM on follow-up imaging, and no postprocedure complications were reported. This case highlights the importance of considering patient preferences in AVM treatment planning, illustrating that endovascular embolization can be an effective and less invasive alternative to surgery in selected patients, reinforcing the need for personalized, patient-centered approaches in neurointerventional care.

Novel Functional Food Properties of Forest Onion (Eleutherine bulbosa Merr.) Phytochemicals for Treating Metabolic Syndrome: New Insights from a Combined Computational and In Vitro Approach.

Metabolic syndrome is a global health problem. The use of functional foods as dietary components has been increasing. One food of interest is forest onion extract (FOE). This study aimed to investigate the effect of FOE on lipid and glucose metabolism in silico and in vitro using the 3T3-L1 mouse cell line. This was a comprehensive study that used a multi-modal computational network pharmacology analysis and molecular docking in silico and 3T3-L1 mouse cells in vitro. The phytochemical components of FOE were analyzed using untargeted ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS). Next, an in silico analysis was performed to determine FOE's bioactive compounds, and a toxicity analysis, protein target identification, network pharmacology, and molecular docking were carried out. FOE's effect on pancreatic lipase, α-glucosidase, and α-amylase inhibition was determined. Finally, we determined its effect on lipid accumulation and MAPK8, PPARG, HMGCR, CPT-1, and GLP1 expression in the preadipocyte 3T3-L1 mouse cell line. We showed that the potential metabolites targeted glucose and lipid metabolism in silico and that FOE inhibited pancreatic lipase levels, α-glucosidase, and α-amylase in vitro. Furthermore, FOE significantly (p < 0.05) inhibits targeted protein expressions of MAPK8, PPARG, HMGCR, CPT-1, and GLP-1 in vitro in 3T3-L1 mouse cells in a dose-dependent manner. FOE contains several metabolites that reduce pancreatic lipase levels, α-glucosidase, α-amylase, and targeted proteins associated with lipid and glucose metabolism in vitro.

Response to Neoadjuvant Chemotherapy in Invasive Breast Cancer Predicted by CD4+, CD8+, and FOXP3+ Tumor-Infiltrating Lymphocytes.

BACKGROUND: Response to neoadjuvant chemotherapy (NC) in individuals with invasive breast cancer (IBC) must be monitored, and biomarkers are needed. NC can activate an anti-tumour immune response in its microenvironment, known as Tumor-infiltrating Lymphocytes (TIL). TIL components believed to have great potential as predictors are CD4+, CD8+, and FOXP3+ TIL. This study aims to explore TIL components that can potentially be predictive biomarkers of NC pathological responses. METHODS: A sample size of 40 were analyzed based on the relationship between CD4+, CD8+, and FOXP3+ TIL expression with the Miller-Payne (MP) grading system. Age, tumour grade, PR, ER, Ki-67, and HER2 were also evaluated. CD4+, CD8+, and FOXP3+ TIL expressions were analayzed by IHC staining, while other data were collected from archives. Data was analyzed using univariate and multivariate analysis. RESULTS: Univariate analysis showed a significant relationship between CD4+ TIL and MP (p<0.001), CD8+ and MP (p=0.004), and FOXP3 with MP (p<0.001). The simultaneous integration of the three biomarkers in one model was not good enough to be a predictive model. Therefore, an exploratory analysis was conducted by testing several alternative models that combined two of the three existing biomarkers. It turned out that CD4+ TIL in model 2 (CD4+CD8+) and FOXP3+ TIL in model 4 (CD8+FOXP3+) showed significant coefficient values. Moreover, all of the threshold coefficients in model 4 are significant. CONCLUSION: This study shows that CD4+, CD8+, and FOXP3+ TIL have promising potential as predictive biomarkers. In particular, FOXP3+ is dominant in predictive models of pathological response in patients with IBC.

Predictive value of admission D-dimer levels in patient with acute ischaemic stroke and COVID-19: a second-wave prospective cohort study.

OBJECTIVES: This study aimed to evaluate the predictive value of admission D-dimer levels for in-hospital mortality in patients with COVID-19 and acute ischaemic stroke. DESIGN: Cohort (prospective). SETTING: Tertiary referral hospital in the capital city of Indonesia conducted from June to December 2021. PARTICIPANTS: 60 patients with acute ischaemic stroke and COVID-19 were included. Patients were classified into D-dimer groups (low and high) according to a 2 110 ng/mL cut-off value, determined via receiver operating characteristic analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was in-hospital mortality, with admission D-dimer levels as the major predictor. Secondary outcomes included associations between other demographic and clinical variables and the admission D-dimer value. Kaplan-Meier method was used to carry out survival analysis, with univariable and multivariable Cox regression performed to assess the association of D-dimer levels and other confounding variables (including demographic, clinical and laboratory parameters) with in-hospital mortality. RESULTS: The findings demonstrated an association between elevated admission D-dimer levels (≥2 110 ng/mL) and an increased likelihood of death during hospitalisation. The adjusted HR was 14.054 (95% CI 1.710 to 115.519; p=0.014), demonstrating an increase in mortality risk after accounting for confounders such as age and diabetes history. Other significant predictors of mortality included a history of diabetes and increased white blood cell count. CONCLUSIONS: Admission D-dimer levels may be a useful predictive indicator for the likelihood of death during hospitalisation in individuals with COVID-19 and acute ischaemic stroke.

Unraveling Light-Activated Insulin Action in Regulating Blood Glucose: New Photoactivatable Insight as a Novel Modality in Diabetes Management.

Diabetes, particularly type 2 diabetes (T2D), is the main component of metabolic syndrome. It is highly prevalent and has drastically increased with sedentary lifestyles, notably behaviors linked to ease of access and minimal physical activity. Central to this condition is insulin, which plays a pivotal role in regulating glucose levels in the body by aiding glucose uptake and storage in cells, and what happens to diabetes? In diabetes, there is a disruption and malfunction in insulin regulation. Despite numerous efforts, effectively addressing diabetes remains a challenge. This article explores the potential of photoactivatable drugs in diabetes treatment, with a focus on light-activated insulin. We discuss its advantages and significant implications. This article is expected to enrich the existing literature substantially, offering a comprehensive analysis of potential strategies for improving diabetes management. With its minimal physical intrusion, light-activated insulin promises to improve patient comfort and treatment adherence. It offers precise regulation and localized impact, potentially mitigating the risks associated with conventional diabetes treatments. Additionally, light-activated insulin is capable of explicitly targeting RNA and epigenetic factors. This innovative approach may pave the way for more personalized and effective diabetes treatments, addressing not only the symptoms but also the underlying biological causes of the disease. The advancement of light-activated insulin could revolutionize diabetes management. This study represents a pioneering introduction to this novel modality for diabetes management.

"How is social media used for learning?": relationships between social media use by medical students with their self-regulated learning skills.

BACKGROUND: Social media is widely used by medical students, including for learning purposes since it facilitates their involvement in the communities of inquiry where they can share, express, and engage in the development of knowledge. Navigating the use of social media requires self-regulated learning (SRL) skills. Hence, studies on the relationships between social media use and SRL skills are necessary. AIM: This study aims to investigate the relationships between social media use and students' SRL skills. METHODS: A cross-sectional study was conducted using two validated questionnaires: the Social Networking Sites for Medical Education questionnaire (SNSME, 19 items) and the Motivated Strategies for Learning Questionnaire (MSLQ, 81 items). Cross-cultural adaptation and exploratory factor analysis (EFA) were also completed for the SNSME questionnaire, followed by descriptive and bivariate analysis. RESULTS AND DISCUSSION: The SNSME questionnaire is valid for use in the current setting and consists of three subscales: (1) attitudes towards the use of social media for learning and knowledge development, (2) the use of social media for information sharing and interaction, and (3) the use of social media for knowledge development and research. Among 1,122 respondents, male students presented lower scores than female students in the total score of social media for learning (80 vs. 82, p 0.007), and public medical students showed higher scores in terms of attitudes towards the use of social media for learning and knowledge development compared to private medical students (83 vs. 81, p 0.007). The differences in SRL scores for different education stages and among students from public and private medical schools were statistically significant (426 vs. 418, p 0.003, and 436 vs. 418, p < 0.001, respectively). Levels of correlation between social media use and SRL scores were low to moderate (R 0.195-0.462, p < 0.001). CONCLUSIONS: The adapted SNSME questionnaire in the current setting is valid and the use of social media for learning is influenced by gender and the learning environment. This study highlights the importance of supporting students in using social media for learning purposes as well as using social media as a means to increase their SRL skills.

Self-Efficacy and Self-Care as Risk Factors for Ischemic Stroke: Development and Validation of a Nomogram.

BACKGROUND: This study addresses the knowledge gap on how self-efficacy and self-care affect stroke risk as factors and develops a valuable tool for clinicians to assess stroke risk. METHODS: From January 2022 to January 2023, this nested-case control study was conducted. Medical data including gender, age, ethnicity, locality, education, marital status, employment, caregiver, social environment, blood viscosity, Barthel Index, modified Rankin Scale (mRS), stroke risk score, self-care score, and self-efficacy score were collected. Logistic regression was used to predict stroke risk, and a nomogram was developed and validated. RESULTS: 240 patients were included in the analysis. Stroke risk score (OR: 3.513; p = 0.005), self-efficacy score (OR: 0.753; p = 0.048), and self-care score (OR: 0.817; p = 0.018) were predictors of ischemic stroke. Internal validation was carried out, with a C-index of 0.774, and the Hosmer-Lemeshow test indicated a good fit (p = 0.92). The calibration plot also shows that this nomogram model has good calibration abilities. The decision curve analysis (DCA) results show a threshold probability range of 10-95%. CONCLUSION: A nomogram has been developed with good validity, calibration, and clinical utility, including self-care and self-efficacy as risk factors for predicting ischemic stroke.

Correlation of Before and After Invasive Breast Cancer Neoadjuvant Chemotherapy for NFkB, Cyclin D1, and Survivin Expression.

Background & Objective: Patients undergoing neoadjuvant chemotherapy (NC) for invasive breast cancer (IBC) therapy need biomarkers to track their progress. Because of the relationship between NFkB, Survivin, and Cyclin D1 with NC resistance, the different expression levels of each of these biomarkers can be different between pre- and post-NC in IBC. However, no research has examined the correlation between these biomarkers before and after the NC expression. This study aimed to determine the correlation among them. Methods: Biomarkers expression (low and high) was used to classify 30 samples. ER, PR, HER2, Ki-67 status, tumor grade, age, and NC response were assessed. The amounts of Survivin, Cyclin D1, and NFkB were evaluated using immunohistochemistry, and the samples were classified based on the cut-off. Chi-square and linear regression were used to evaluate the data. Results: No significant association was found with the changes in the expression of Survivin, Cyclin D1, and NFkB, both before and after the NC. Significant moderate correlations were shown between before and after the NC Survivin expression (r = 0.513) and Cyclin D1 expression (r = 0.543). The correlation between expression of NFkB before and after the NC was not significant. Conclusion: The high potential of these proteins as prognostic indicators was demonstrated by the strong positive association between the expression of Survivin and Cyclin D1 before and after the NC. This upregulation of biomarkers indicates chemoresistance in developing IBC in the presence of NC.

Clinical utility and diagnostic value of tumor-educated platelets in lung cancer: a systematic review and meta-analysis.

Background: The review addresses the knowledge gap concerning the diagnostic value and clinical utility of tumor-educated platelets (TEPs) in adult patients with lung cancer. Methods: We searched twelve databases: PubMed, CENTRAL, EMBASE, CINAHL, MEDLINE, Scopus, ProQuest, MedRxiv, BioRxiv, SSRN, Clinicaltrials.gov, and CNKI up to 24 March 2023, to include any diagnostic study regarding TEPs and LC. TEPs diagnostic value was evaluated from pooled sensitivity and specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the curve (AUC). QUADAS 2 was used to assess the risk of bias. Heterogeneity analysis was assessed using the receiver operating characteristic (ROC) plane, Galbraith plot, bivariate boxplot, sensitivity analysis, and meta-regression. TEPs clinical utility was evaluated from Fagan's nomogram. Results: 44 reports from 10 studies, including 7,858 events and 6,632 controls, were analyzed. The pooled sensitivity, specificity, PLR, NLR, and DOR were 0.80 (95% CI 0.79-0.80), 0.69 (95% CI 0.69-0.70), 2.92 (95% CI 2.50-3.41), 0.26 (95% CI 0.21-0.32), and 12.1 (95% CI 8.61-16.76), respectively. In addition, the AUC of the Summary ROC curve was 0.85 (95% CI: 0.81-0.88). The overall risk of bias was low. Heterogeneity may result from cancer stage, cancer control, measuring equipment, and RNA types across studies. There was no apparent publication bias (p=0.29) with significant positive (79%) and negative (22%) post-test probability, according to Deeks funnel plot asymmetry test and Fagan's nomogram. Conclusion: TEPs could be a moderately effective candidate biomarker for LC diagnosis.

Evaluation of safety and effectiveness of remdesivir in treating COVID-19 patients after emergency use authorization study.

Background: This study aimed to determine the real-world safety and effectiveness of remdesivir in hospitalized adult COVID-19 patients with moderate-to-critical disease in Indonesia. Methods: A multicenter, retrospective cohort study was conducted at four COVID-19 referral hospitals in Jakarta. A total of 587 patients were included, of whom 243 received remdesivir within 72 h of admission. The safety endpoints were the proportions of patients with any adverse event (AE), any grade 3 AE, and AE of each system organ class. The effectiveness endpoints were ICU admission >24 h from baseline, live discharge and mortality at day 14, live discharge and mortality at day 28, and virologic conversion. Patients who received remdesivir within 72 h of admission were considered the treatment group, and those who did not were the control group. Multivariate adjustments were performed using a modified Poisson regression. Results: The study found no significant differences in safety endpoints between the two groups. However, the effectiveness endpoints showed that remdesivir was associated with a decreased risk of ICU admission >24 h from baseline (RR 0.71, 95% CI 0.52-0.96), an increased probability of live discharge at day 14 (RR 1.37, 95% CI 1.08-1.74), and an increased probability of live discharge at day 28 (RR 1.28, 95% CI 1.05-1.57). The rate of virologic conversion was not significantly different between the two groups. Conclusion: The study concludes that remdesivir is safe and effective in the treatment of moderate-to-critical COVID-19 in a real-world setting in Indonesia.

Association between cardiovascular diseases and COVID-19 pneumonia outcome in Indonesia: a multi-center cohort study.

Background: COVID-19 is a pandemic affecting 185 countries, including Indonesia. Cardiovascular diseases (CVD) in COVID-19 patients were linked to worse clinical outcomes. However, the association remained inconclusive due to limited data in Indonesia. This study aimed to determine the association between CVD in COVID-19 pneumonia patients with its clinical outcomes. Methods: This retrospective cohort study was conducted in four Indonesian hospitals, enrolling 584 adult COVID-19 pneumonia patients from September 2020 to July 2021. Patients were categorized into two groups: non-CVD and CVD [hypertension, coronary artery disease (CAD), chronic heart failure (CHF), hypertensive heart disease (HHD), arrhythmia, cardiomegaly, left ventricular hypertrophy (LVH), mitral regurgitation (MR), and myocardial injury (MI)]. Clinical outcomes include in-hospital mortality, intensive care unit admission, ventilator use, earlier death, and prolonged hospital stay. Mann-Whitney test was used for analysis. Results: The most common CVD was hypertension (48.1%), followed by MI (10.6%), CAD (9.2%), CHF (6.8%), HHD (3.1%), arrhythmia (1.7%), and others (0.7%). The in-hospital mortality rate was 24%, and patients were hospitalized for a median of 12 days. MI was the only CVD that increased in-hospital mortality (RR 2.105). It was also significantly increased in patients with diabetes mellitus (RR 1.475) and chronic kidney disease (RR 2.079). Meanwhile, prolonged hospital stay was associated with any CVD (RR 1.553), hypertension (RR 1.511), MI (RR 1.969), CHF (RR 1.595), diabetes mellitus (RR 1.359), and cerebrovascular disease (RR 2.203). Conclusion: COVID-19 pneumonia in patients with CVD, specifically MI and hypertension, worsens the COVID-19 clinical outcomes.

Exploring the self-efficacy and self-care-based stroke care model for risk factor modification in mild-to-moderate stroke patients.

Context: The worldwide burden of stroke is projected to grow unless proper stroke education is implemented. Information alone cannot promote patient self-efficacy and self-care and reduce risk factors. Aim: This trial aimed to test self-efficacy and self-care-based stroke education (SSE) on changes in self-efficacy, self-care, and risk factor modification. Design setting and participants: This study is a single-center, double-blinded, interventional, two-arm randomized controlled trial with a 1- and 3-month follow-up in Indonesia. Between January 2022 and October 2022, 120 patients were prospectively enrolled from Cipto Mangunkusumo National Hospital, Indonesia. Participants were assigned using a computer-generated random number list. Intervention: SSE was given before discharge from the hospital. Primary outcome measure: Self-care, self-efficacy, and stroke risk score was measured 1 month and 3 months after discharge. Secondary outcome measure: Modified Rankin Scale, Barthel Index, and blood viscosity was measured at 1 month and 3 months after discharge. Results: A total of 120 patients (intervention n = 60; standard care n = 60) were randomized. In the 1st month, the intervention group showed a more significant change in self-care (4.56 [95% CI: 0.57, 8.56]), self-efficacy (4.95 [95% CI: 0.84, 9.06]), and stroke risk (-2.33 [95% CI:-3.19, -1.47]) compared to the controlled group. In the 3rd month, the intervention group also showed a more significant change in self-care (19.28 [95% CI: 16.01, 22.56]), self-efficacy (19.95 [95% CI: 16.61, 23.28]), and stroke risk (-3.83 [95% CI: -4.65, -3.01]) compared to the controlled group. Conclusion: SSE may boost self-care and self-efficacy, adjust risk factors, enhance functional outcomes, and decrease blood viscosity. Clinical trial registration: ISRCTN11495822.

The Potential of Expression of Cyclin-D1 on Neoadjuvant Chemotherapy in Invasive Breast Carcinoma.

BACKGROUND: Patients undergoing neoadjuvant chemotherapy (NC) for invasive breast cancer (IBC) need indicators to track their progress during treatment. The goal of this research is to learn how cyclin D1 works in conjunction with taxane and non-taxane therapy for people with IBC. METHODS: There were 31 examples divided into two groups, based on: those using a different type of NC (taxane- or non-taxane-based), and NC administration time (before or after). Tumor grade, age, PR, ER, Ki-67, HER2, and Cyclin D1 expression were among the factors considered. Using immunohistochemical labeling, we were able to categorize cyclin D1 levels according to a threshold value, and we supplemented this with data we found in our databases. To analyze the data, we used a modified linear model. RESULTS: The expression of Cyclin D1 decreased after NC delivery (p=0.086). Cyclin D1 expression was reduced in the taxane group (p=0.792). The non-taxane group also saw no differences in outcomes (p = 0.065). There was a larger decrease in Cyclin D1 expression in the non-taxane group compared to the taxane group, but the difference was not statistically significant (p=0.200). CONCLUSION: Cyclin D1 expression, even if the differences are not statistically significant, may be a prognostic indicator of NC reaction in IBC. The involvement of Cyclin D1 in NC warrants more research with bigger IBC sample sizes.

Comprehensive Management of Acute Ischemic Stroke in Psoriatic Patient.

Background: Stroke is one of the top causes of death and disability in several nations. Patients with psoriasis are susceptible to multiple comorbidities, including stroke. In addition to acute ischemic stroke, psoriasis and chronic inflammation require comprehensive treatment. Here, we present a comprehensive management case of a patient with an acute ischemic stroke and psoriasis. Case Presentation. A 42-year-old man came to the emergency department complaining of sudden left-sided weakness that started two and a half hours before being admitted to the hospital. The patient was treated with cyclosporine from 2013 to 2019 for a history of psoriasis. The patient was then treated for secondary stroke prevention using aspirin, vitamin B6, vitamin B12, folic acid, simvastatin, cyclosporine, and topical treatment. After two days of treatment, the patient's condition improved clinically, and he was discharged without further neurological deficits. As a home medication, the patient's cyclosporine was switched to the initial dose of methotrexate (7.5 mg/week) and titrated weekly to a response dose of 10 mg in the 10th week. After three months of follow-up, the patient's condition remained stable, devoid of similar symptoms or sequelae. Conclusions: Cyclosporine should only be used for a maximum of 1 year for stroke management with psoriasis and be substituted for other systemic agents such as methotrexate. In addition, anticoagulants, antihypertensive, antihyperlipidemic, vitamin B6, vitamin 12, and folic acid regimens are highly recommended for comprehensive therapy of cardiovascular comorbidities.

Exploring the Integrated Role of AKT2, CD44v6, And MT1-MMP as Predictors of Axillary Lymph Node Metastasis in Invasive Breast Carcinoma of No Special Type.

Background & Objective: Invasive breast carcinoma of no special type (IBC-NST) is the most common type of breast cancer, which mainly causes axillary lymph-node metastasis (ALNM). Building on our previous research, we wanted to explore the optimal combination of AKT2, CD44v6, and MT1-MMP for the ALNM prediction. Methods: The presence or absence of ALNM was used to separate 46 paraffin blocks containing IBC-NST primary tumors into two groups. Age, tumor grade, tumor size, receptor status (ER, PR, HER2, Ki-67, TOP2A), and test biomarker expression were evaluated. Biomarker expressions were assessed by IHC staining and categorized according to their respective cut-offs from our previous study, while other data were collected from archives. Data was gathered and analyzed using univariate, multivariate, and AUROC models. Results: The expression of CD44v6 (OR: 12.77, 95% CI: 2.18-87.12, P=0.005) was identified as the independent variable for ALNM. Meanwhile, AKT2 expression (OR: 3.22, 95% CI: 0.36-22.41, P=0.237) and MT1-MMP expression (OR: 5.35, 95% CI: 0.83-34.54, P=0.078) did not demonstrate a statistically significant independent association in respect to ALNM. Combining AKT2 and MT1-MMP on CD44v6 increased overall accuracy by 4% compared to CD44v6 alone (AUROC 0.89 vs. 0.85). Conclusion: The combined usage of AKT2, CD44v6, and MT1-MMP revealed no significant change compared to CD44v6 alone. Due to the cost and practicality, we propose using CD44v6 as a predictor biomarker of ALNM in IBC-NST.

Coagulation and hemorheology profile of patient with stroke and COVID-19: A case series during second wave pandemic.

In 2021 the delta variant was discovered, heralding the start of the second pandemic wave. This case series aims to analyse and compare the coagulation and hemorheology profiles of COVID-19 patients diagnosed with acute stroke during the pandemic's second wave and ascertain the effect on patient outcomes. This case series reports 4 cases with their respective characteristics. Case 1 reports on COVID-19 patients without comorbidities, Case 2 with comorbidities, Case 3 with strokes in young patients, and Case 4 with strokes in elderly patients. All cases had abnormal coagulation and hemorheology factors with mixed outcomes. Coagulation and hemorheology factors tend to be higher in COVID-19 patients with acute stroke. The value of coagulation and hemorheology factors can be a prognostic outcome in COVID-19 patients with severe disease, especially in patients associated with acute stroke.

Association of coagulation factors profile with clinical outcome in patient with COVID-19 and acute stroke: A second wave cohort study.

INTRODUCTION: The second wave of COVID-19 in Indonesia occurred due to delta variant transmission with up to 2266 cases. This variant could cause higher rate of morbidities and mortalities. This study reported coagulation profile of COVID-19 patients with acute stroke and its association with patients' outcome. METHOD: This is a cohort-retrospective study conducted during the second wave of COVID-19, June-August 2021 in Cipto Mangunkusumo General Hospital. Inclusion criteria were adult patients with confirmed COVID-19 and diagnosed with acute stroke confirmed by radiological evidences. Exclusion criteria were COVID-19 patients with prior diagnosis of acute stroke. Coagulation factors were analyzed and presented with tables and graphs. RESULTS: A total of 33 patients included in this study with majority experienced ischemic stroke (84.8%), followed by ischemic with haemorrhagic transformation (9.1%), and the rest with haemorrhagic stroke. The median of fibrinogen and D-dimer was 487.1(147-8,943)mg/dL and 2,110(250-35,200)ug/L respectively. Prothrombin time (PT) ratio was 0.95(0.82-1.3) and activated partial thromboplastin time (APTT) ratio was 1.01(0.64-2.72). On observation, 33.3% died during hospitalization, D-dimer value in these patients was significantly higher with 9,940ug/L compared to those who survived with 1,160ug/L(p = 0.009). The highest D-dimer value during hospitalization was also significantly higher with the median of 14,395ug/L compared to 3,740 ug/L (p = 0.014). DISCUSSION: D-dimer value on initial assessment and its highest value during hospitalization were significantly higher in patient with poor outcome, showing that D-dimer can be one predictor of mortality in COVID-19 patients with acute stroke.

Spontaneous subarachnoid hemorrhage due to arteriovenous malformation mimicking migraine: A case report.

Subarachnoid hemorrhage (SAH) due to Arteriovenous Malformation (AVM) is a rare emergency case, which is often misdiagnosed as migraine. Here we present a case of SAH due to AVM that mimics migraine. A 41-year-old man came with headaches that radiated to the neck, worsened in the last week, accompanied by nausea, vomiting, photophobia, and a history of intermittent headaches for the previous 2 years. Physical examination was within normal limits, initial laboratory tests showed leukocytosis, and CT scan was not typical. The patient was diagnosed with migraine. Apparently, the lumbar puncture showed very high red blood cells, suspected as SAH. CT angiography revealed an extra-axial AVM. The patient was later diagnosed as SAH due to AVM. We recommend applying 4 key points, namely headache progressivity, neck pain, neck stiffness, and leukocytosis, to differentiate SAH due to AVM from migraine, especially in areas with limited facilities.

Does Insulin Use Worsen the Prognosis of COVID-19 Patients with Type 2 Diabetes Mellitus? A Current Update.

BACKGROUND: Insulin has recently received special attention concerning its use in COVID-19 patients. Although controversial, insulin can be able to worsen the prognosis of COVID-19 patients with Type 2 Diabetes Mellitus (T2DM) through an inflammatory pathway. This uncertain aspect brings a new perspective related to insulin use in this pandemic era. OBJECTIVE: We tried to collect and analyze various studies related to this issue to provide a complete picture of the prognosis of insulin use in COVID-19 patients with T2DM. METHODS: We comprehensively searched PubMed, Cochrane CENTRAL, Embase, EBSCO CINAHL, MEDLINE, and grey literature databases for studies investigating the effect of insulin on COVID-19 outcomes, including mortality, hospitalization, disease progression, other prognostic surrogates. Records were screened against the eligibility criteria. RESULTS: 2556 articles were retrieved and were screened. A total of 8 studies were included in the final analysis. There are no studies with solid evidence supporting the effect of insulin treatment on the worsening of the prognosis of COVID-19 patients with T2DM. Although several studies have shown that insulin is associated with a poor prognosis, most studies have not considered confounders. This certainly makes it challenging to analyze the effects of insulin independently. CONCLUSION: We propose that COVID-19 patients with T2DM continue to receive insulin, but with careful observation of the risk of disease progression.

CD44 Variant Exon 6 Isoform Expression as a Potential Predictor of Lymph Node Metastasis in Invasive Breast Carcinoma of No Special Type.

BACKGROUND: Invasive breast carcinoma of no special type (IBC-NST) is the most widespread invasive carcinoma subtype causing primarily regional metastases of the lymphatic node (LNM). The capacity of CD44 variant exon 6 (CD44v6) expression as an LNM predictor biomarker in IBC-NST was explored. METHODS: We conducted a cross-sectional research with 48 paraffin blocks containing IBC-NST primary tumors that were divided into two groups by LNM. The assessment has been carried out in terms of age, tumor size, tumor grade, lymphovascular invasion (LVI), and CD44v6 expression. The expression of CD44v6 was analyzed on the grounds of immunohistochemical (IHC) staining, while other data were taken from archives. Statistical analysis is carried out by univariate, multivariate, and AUROC. RESULTS: CD44v6 exhibits a dominant expression in IBC-NST tumor cells. Univariate analysis revealed a significant association between CD44v6 and LNM status (p = 0.001). Multiple logistic regression results showed that CD44v6 expression and LVI were significantly associated with LNM with OR 10.7 (95% CI: 2.43 to 47.08) and 6.22 (95% CI: 1.4 to 27.88), respectively. CD44v6 expression was able to discriminate against LNM with AUROC 0.863 ± 0.053 (95% CI: 0.759 to 0.967) at the H-score cut-off 133.889 (75% sensitivity and 83.3% specificity). CONCLUSION: CD44v6 expression and LVI are potential predictors of LNM in IBC-NST. The H-score cut-off of the CD44v6 expression can also be used as a threshold for classification in further investigation.