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"Latar Belakang: Rendahnya ketepatan kultur bakteriologis dan kurangnya fasilitas pencitraan terutama di daerah perifer, mendiagnosis meningitis tuberkulosis (MTB) pada anak menjadi suatu tantangan.Tujuan: untuk membentuk sistem skor yang terdiri dari manifestasi klinis dan pemeriksaan laboratorium sederhana untuk membantu diagnosis MTB pada anak.Metode: Studi retrospektif menggunakan model prediktif diagnostik multivariabel dengan anak usia 3 bulan hingga 18 tahun terdiagnosis meningitis, dirawat inap selama periode Juli 2011 hingga November 2021 di rumah sakit tersier.Hasil: Dari 10 variabel yang memiliki signifikansi statistik dengan TBM, diperoleh 8 variabel untuk membangun model prediksi untuk mengidentifikasi TBM. Variabel ini dibagi menjadi dua bagian skoring yang keduanya memiliki diskriminasi dan kalibrasi yang baik, sistem skoring sistemik (4 parameter, batas nilai skor ³3, sensitivitas 78,8%, spesifisitas 86,6% dengan AUC 89,9% (p<0,001) ) dan sistem skoring neurologis (4 parameter, batas nilai skor ³2, sensitivitas 61,2%, spesifisitas 75,2% dengan AUC 73,3% (p<0,001). Sistem skoring ini bila digunakan bersamaan dan memenuhi batas nilai skor masing-masing, dapat memprediksi diagnosis TBM pada anak dengan baik (sensitivitas 47,1%, spesifisitas 95,1%, dan nilai prediksi positif 90,9%).Kesimpulan: Sistem skoring klinis yang terdiri dari dua bagian, skor sistemik dan skor neurologis, memiliki kemampuan yang baik dalam memprediksi diagnosis TBM pada anak.

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Due to the low accuracy of culture techniques in bacteriological confirmation and the lack of brain imaging facilities especially in peripheral areas, diagnosing tuberculous meningitis (TBM) in children become a challenge

Objective : to establish scoring systems consisting of clinical manifestations and simple laboratory examination to help diagnosing TBM in children.

Method: Retrospective study using a multivariable diagnostic predictive model with children diagnosed as meningitis aged 3 months to 18 years, hospitalized during July 2011 until November 2021 period in a tertiary hospital.

Result: From 10 variables that have statistical significance with TBM, 8 variables were obtained for establishing the predictive model to identify TBM. These variables divided into two scoring parts which both had good discrimination and calibration, the systemic scoring system (4 parameters, total cut-off score ³3, sensitivity of 78.8%, specificity of 86.6% with AUC of 89.9% (p<0.001)) and the neurological scoring system (4 parameters, total cut-off score ³2, sensitivity of 61.2%, specificity of 75.2% with AUC of 73.3% (p<0.001)). Furthermore, these scoring systems when used together and met the cut-off score respectively, can predict the diagnosis of TBM in children well (sensitivity 47.1%, specificity 95.1%, and positive predictive value 90.9%).

Conclusion: a clinical scoring systems consist of two parts, systemic score and neurological score, have good ability in predicting the diagnosis of TBM in children."

"Latar Belakang: Mycobacterium tuberculosis merupakan penyebab tuberkulosis pada paru dan organ lain, seperti meningen meningitis tuberkulosis . Meningitis tuberkulosis dapat merupakan komplikasi tuberkulosis primer, yang bersifat laten/asimptomatik, namun risiko reaktivasi meningkat pada penurunan sistem imun/malnutrisi. Disfagia, defisit kognitif, hemiparese, dan ketidakmampuan makan mandiri juga dapat menyebabkan malnutrisi, sehingga akan meningkatkan lama rawat dan mengganggu perbaikan kapasitas fungsional. Tatalaksana nutrisi diperlukan untuk meminimalisasi kehilangan berat badan, mendapatkan imbang nitrogen positif, dan menyediakan nutrisi untuk membangun system imun. Pada pelaksanaannya, pemberian nutrisi harus memperhatikan kondisi klinis serta komplikasi berupa peningkatan tekanan intrakranial dan defisit neurologi yang terjadi. Metode: Laporan serial kasus ini menguraikan empat kasus meningitis tuberkulosis dengan tuberkulosis paru. Semua pasien datang dengan penurunan kesadaran dan telah terdiagnosis tuberkulosis paru sebelumnya, namun pasien minum obat tidak sesuai dengan anjuran dokter. Status gizi keempat pasien adalah malnutrisi ringan dan berat, obes 1 dan normal. Selama dirawat, tatalaksana nutrisi diberikan sesuai pedoman terapi nutrisi untuk penderita tuberkulosis. Asupan makronutrien diberikan meningkat bertahap sesuai kondisi klinis dan toleransi pasien. Suplementasi mikronutrien juga diberikan. Pemantauan meliputi keluhan subjektif, hemodinamik, analisis dan toleransi asupan, pemeriksaan laboratorium, antropometri, keseimbangan cairan, dan kapasitas fungsional. Hasil: Dua orang pasien menunjukkan perbaikan klinis, kapasitas fungsional, hasil laboratorium, toleransi asupan, dan outcome, sedangkan dua orang lainnya mengalami perburukan dan meninggal pada hari perawatan ke-44 dan ke-24. Kesimpulan: Dukungan nutrisi infeksi tuberkulosis pada paru dan susunan saraf, dapat memberikan manfaat untuk pemulihan pasien.

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Objective: Mycobacterium tuberculosis is the cause of tuberculous in the lung and other organs, such as the meninges tuberculous meningitis . Tuberculous meningitis can be a complication of primary tuberculous, latent asymptomatic, but the risk of reactivation increases to a decrease in the immune system malnutrition. Dysphagia, defisit kognitif, hemiparese, and inability to eat independently can also cause malnutrition, thereby increasing the length of stay and interfere with the functional capacity improvement. Management of nutrients needed to minimize the lose weight, get a positive nitrogen balance, and provide nutrients for building the immune system. In practice, the nutrition must consider the clinical condition and the complications in the form of increased intracranial pressure and neurological deficits that occur.

Methods: This case series report outlines four cases of tuberculous meningitis with pulmonary tuberculous. All patients present with loss of consciousness and have been diagnosed with pulmonary tuberculous before, but patients taking the medicine does not comply with doctor's advice. Nutritional status of the four patients was mild and severe malnutrition, obese and normal one. During the treatment, management of nutrition was given according to the guidelines of nutrition therapy for patients with tuberculosis. Macronutrient intake increased gradually given appropriate clinical condition and patient tolerance. Micronutrient supplementation are also given. Monitoring included subjective complaints, hemodynamic, analysis and tolerance intake, laboratory tests, anthropometric, fluid balance, and functional capacity.

Results: Two patients showed clinical improvement, functional capacity, laboratory results, tolerance intake, and outcome, while two other people suffered deterioration and died on the 44th and 24th day of treatment.

Conclusion: Nutritional support tuberkulosis infection in the lungs and nervous system, can provide benefit to the patient's recovery."

"Latar Belakang: Meningitis tuberkulosis (TBM) memiliki angka kematian yang tinggi khususnya pada kelompok HIV positif. Penelitian ini bertujuan untuk mengetahui karakteristik klinis dan prediktor kesintasan TBM dalam masa perawatan dan 6 bulan berdasarkan status infeksi HIV.Metode: Studi kohort retrospektif menggunakan data Indonesian Brain Infection Study bulan April 2019-September 2021 dengan diagnosis akhir TBM. Analisis faktor yang berhubungan dengan kesintasan masa perawatan dilakukan dengan regresi logistik. Estimasi probabilitas kesintasan 6 bulan dan prediktor yang berperan dinilai menggunakan kurva Kaplan-Meier dan uji regresi Cox.Hasil: Sebanyak 133 subjek TBM dimasukkan ke dalam studi (HIV positif 39,8%, TBM definite 31,6%). HIV positif memiliki temuan TBM definite yang lebih rendah, peningkatan sel dan protein cairan serebrospinal (CSS) yang lebih rendah, penurunan rasio glukosa CSS:serum yang lebih rendah, dan temuan TB milier yang lebih tinggi. Kesintasan dalam masa perawatan secara umum adalah 73,7% (HIV positif 67,9% vs. HIV negatif 77,5%, p=0,2), dipengaruhi oleh TBM probable dan TBM derajat 3. Estimasi probabilitas kesintasan 6 bulan adalah 57,9% (HIV positif 54,7% vs. HIV negatif 60%, p=0,4), dipengaruhi oleh waktu inisiasi obat antituberkulosis (OAT) dan TBM derajat 3. Tidak didapatkan perbedaan prediktor kesintasan masa perawatan dan 6 bulan berdasarkan status HIV.Kesimpulan: Kelompok HIV positif memiliki gambaran inflamasi CSS yang lebih rendah namun cenderung memiliki kesintasan rawat inap dan 6 bulan yang lebih rendah. TBM stadium lanjut berperan pada kesintasan jangka pendek dan panjang, sementara penundaan inisiasi OAT sejak admisi berhubungan dengan kesintasan jangka panjang.

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Background: Tuberculous meningitis (TBM) has a high mortality rate, especially in the HIV positive group. This study aims to define the clinical characteristics, as well as to analyze the inhospital and 6 month-survival and the following predictors of TBM patients with and without HIV infection.

Methods: Cohort retrospective study using Indonesian Brain Infection Study data with final diagnosis of TBM, between April 2019 and September 2021. Logistic regression was used to determine the predictors of inhospital survival. Meanwhile, 6-months probability survival was estimated using Kaplan-Meier curves and Cox regression analysis.

Results: A total of 133 subjects were included in the study (HIV positive 39.8%, definite TBM 31.6%). HIV positive group had less TBM definite, lower cerebrospinal fluids (CSF) cells and protein increases, smaller decrease in CSF:serum glucose ratio, and more miliary TB cases. Overall inhospital survival was 73.7% (HIV positive 67.9% vs. HIV negative 77.5%, p=0.2), with predictors of TBM probable and TBM grade 3. Six-month probability survival estimates was 57.9% (HIV positive 54.7% vs. HIV negative 60%, p-=0,4), with predictors of initiation of TB drug timing and TBM grade 3. We found no significant differences of inhospital and 6-month predictors according to HIV status.

Conclusions: Despite less inflammatory profile, HIV positive group had lower inhospital and 6-month survival. Advanced stage TBM had lower inhospital and 6-month survival, while delayed TB drug initiation was more related to the 6-month survival."

"Meningitis tuberkulosis (MeTB) merupakan manifestasi klinis berat dari infeksi TB yang menyerang sistem saraf pusat (SSP) dan menyebabkan pasien mengalami penurunan asupan nutrisi karena menurunnya kemampuan makan dan selera makan. Asam amino rantai cabang (AARC) diketahui memiliki efek meningkatkan selera makan dan protektif terhadap massa otot. Pemenuhan kebutuhan AARC berpotensi memperbaiki kapasitas fungsional pasien sehingga menurunkan morbiditas dan mortalitas pasien MeTB. Empat pasien MeTB dipantau selama perawatan di Rumah Sakit Cipto Mangunkusumo (RSCM). Pencatatan asupan makanan pasien dilakukan dengan metode FFQ semi kuatitatif dan 24h dietary recall. Selama masa perawatan diberikan terapi medik gizi sesuai kondisi klinis pasien, dilakukan pemantauan harian termasuk penilaian kapasitas fungsional pasien hingga pasien selesai perawatan. Semua pasien menunjukkan tanda malnutrisi berdasarkan kriteria klinis menurut American Society of Parenteral and Enteral Nutrition (ASPEN). Belum ada rekomendasi terapi medik gizi khusus MeTB yang dapat digunakan, namun pada pasien dengan masalah infeksi disertai masalah neurologis rekomendasi tatalaksana TB paru dan stroke dapat menjadi acuan untuk tatalaksana pasien. Pemberian asupan kalori 35-40 kkal pada pasien dengan protein minimal 1,5 g/kgBB berpotensi meningkatkan kapasitas fungsional pasien dan mencegah perburukan penyakit. Tiga pasien mendapatkan asupan AARC diatas rekomendasi dan didapatkan peningkatan kapasitas fungsional dengan menggunakan indeks Barthel. Terapi medik gizi dengan pemberian protein dan AARC yang lebih tinggi dari rekomendasi IOM pada pasien MeTB dapat meningkatkan kapasitas fungsional pasien.

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Tuberculous Meningitis (TBM) has been the most severe manifestation of Tuberculosis infection attacking central nervous system (CNS) and causes the risk of malnutrition in patients due to decrease the ability of eating and loss appetite. Branched chain amino acid (BCAA) has been known having effects in appetite and protection of muscle mass. Fulfilling BCAA requirement is potential to improve patient functional capacity, furthermore lowering the morbidity and mortality of TBM patient. Four TBM patients has been observed during hospitality in Cipto Mangunkusumo Hospital (RSCM). Patient’s dietary intake was collected using semiquantitative FFQ and 24h dietary recall. During hospitality, medical nutrition therapy was administered based on patient clinical condition, daily observation including patient functional capacity was done until patient was discharged. All patients showed malnutrition signs based on clinical criteria according to American Society of Parenteral and Enteral Nutrition (ASPEN). Recommendation of nutrition therapy on TBM patient still not exist, however in patient with infection and neurological problem, guideline of nutrition therapy in TB infection and stroke can be used. Intake of 35-40 kcal/kgBW calories and 1,5 g/kgBW of protein can be potential to increase patient functional capacity and prevent further morbidity. Three patient can fulfill their BCAA beyond the requirement and there were increase in patient functional capacity using Barthel Index. Medical nutrition therapy using protein and BCAA administration above the IOM recomendation in TBM patient can improve functional capacity."

"Latar Belakang. Prevalensi disabilitas pada pasien meningitis tuberkulosis (MTB) hampir setara dengan angka mortalitas mencapai 29-50%. Aspek luaran pasien MTB tidak cukup dinilai berdasarkan angka morbiditas dan mortalitasnya, namun mencakup kesehatan fisik, mental, dan sosial seperti yang didefinisikan oleh World Health Organization (WHO). Penelitian ini bertujuan untuk mengetahui kualitas hidup pasien MTB selesai obat anti-tuberkulosis (OAT) dan faktor-faktor yang memengaruhinya. Metode. Studi potong lintang (cross sectional) dilakukan pada pasien MTB, termasuk tuberkuloma selesai OAT di RSUPN dr. Cipto Mangunkusumo periode Mei 2019-Juni 2023. Karakteristik demografis, klinis, diagnosis, tatalaksana pasien dinilai dari data rekam medis dan wawancara. Luaran kualitas hidup pasien dinilai menggunakan kuesioner SF (Short form)-36. Analisis statistik dilakukan dengan SPSS versi 19.0, yaitu Mann-Whitney dan Kruskal-Wallis untuk data kategorik, Spearman untuk data numerik. Hasil. Dari 53 subjek penelitian dengan median usia 30 (IQR 25,5-39) tahun, didapatkan median skor SF-36 yaitu, 86,5 (IQR 74,9-92,8). Median (IQR) skor pada aspek fisik (PCS) dan mental (MCS) kualitas hidup serupa, yaitu 85 (IQR 69,4-94,85) dan 88,1 (IQR 74,1-95,3). Faktor yang berhubungan dengan kualitas hidup pasien MTB selesai OAT antara lain penghasilan (p=0,033), kejang (p=0,028), kelemahan motorik (p=0,023), dan mRS saat pulang perawatan (p=0,007). Faktor yang berhubungan dengan skor PCS adalah pekerjaan (p=0,012), penghasilan (p=0,007), kelemahan motorik (p=0,024), dan mRS saat pulang perawatan (p=0,01). Faktor yang berhubungan dengan skor MCS adalah usia (p=0,006) dan kejang (p=0,025). Kesimpulan. Kualitas hidup pasien MTB selesai OAT berdasarkan skor SF-36, PCS, dan MCS tergolong baik. Faktor yang memengaruhi kualitas hidup lebih tinggi pada pasien MTB selesai OAT adalah berpenghasilan, tanpa klinis kejang atau kelemahan motorik, dan mRS saat pulang perawatan 0-2. Faktor yang memengaruhi aspek fisik lebih tinggi adalah pekerjaan, berpenghasilan, tanpa klinis kelemahan motorik, dan mRS saat pulang perawatan 0-2, sedangkan aspek mental lebih tinggi adalah usia ≥30 tahun dan tanpa klinis kejang. Kata kunci. Kualitas hidup, meningitis tuberkulosis, selesai OAT, SF-36<

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The prevalence of disabilities among tuberculous meningitis (TBM) patients almost similar with its mortality rate (29-50%). The comprehensive evaluation of long-term outcomes should encompass not only morbidity and mortality rates but also incorporate the dimensions of physical, mental, and social well-being as outlined by the World Health Organization (WHO). This study aimed to assess the quality of life (QoL) among patients with TBM following the completion of anti-tuberculosis treatment (ATT) and investigating the factors that have impacts on this particular aspect. Methods. Retrospective cross sectional study of TBM patients, including tuberculoma upon completion of ATT at dr. Cipto Mangunkusumo National Center General Hospital during May 2019-June 2023. Demographic, clinical, diagnostic, and treatment characteristics were conducted by medical records and interviews. The assessment of QoL in TBM patients was performed using Short form (SF)-36 questionnaire. Statistical analysis was performed with SPSS version 19.0 (Mann-Whitney and Kruskal-Wallis for categorical data, Spearman for numeric data). Result. The study involved 53 participants, with median of age 30 (IQR 25.5-39) years, demonstrated favorable median SF-36 score of 86.5 (IQR 74.9-92.8). Median of physical score (PCS) and mental score (MCS) almost similar, 85 (IQR 69.4-94.85) and 88.1 (IQR 74.1-95.3), respectively. The impact of various factors on QoL was assessed, revealing significant associations with monthly income (p=0.033), presence of seizure (p=0.028), motoric abnormalities (p=0.023), and mRS at discharge (p=0.007). Employment (p=0.012), monthly income (p=0.007), motoric abnormalities (p=0.024), and mRS at discharge (p=0.01) were identified as factors influencing the PCS score. Age (p=0.006) and presence of seizure (p=0.025) found to impact the MCS score. Conclusion. The evaluation of QoL in TBM patients after completing ATT utilizing SF-36 score, PCS, and MCS revealed favorable outcome. Several factors were found to significantly influence higher SF-36 score, including monthly income, absence of seizure and motoric abnormalities, and mRS at discharge of 0-2. Similarly, factors such as employment, monthly income, absence motoric abnormality, and mRS at discharge of 0-2 were associated with higher PCS scores. Furthermore, a higher MCS score was observed in patients aged 30 years or older and those without seizures. Keywords. Quality of life, QoL, tuberculous meningitis, completion ATT, SF-36"

"ABSTRAKPendahuluan : Deteksi Basil Tahan Asam (BTA) Ziehl Neelsen cairan serebrospinal (CSS) di RSUPN dr Cipto Mangunkusumo tahun 2014 tidak pernah positif. Pewarnaan Auramine-O dapat meningkatkan sensitivitas deteksi BTA. Perlu modifikasi sitosentrifugasi pada pulasan BTA, agar dapat deteksi BTA lebih banyak dan cepat.Metode: uji diagnostik pulasan BTA CSS Ziehl Neelsen metode non sitosentrifugasi, Cytospin, Cytopro serta Auramine-O Cytopro dibandingkan dengan baku emas biakan TB MGIT.Hasil: Uji diagnostik BTA Ziehl Neelsen tanpa sitosentrifugasi, tidak dapat dinilai karena BTA tidak terdeteksi di semua sampel. Uji diagnostik Ziehl Neelsen Cytospin dan Cytopro sama yaitu sensitivitas 64%, spesifisitas 85%, NPP 54%, NPN 89 %. Uji diagnostik Auramine-O Cytopro, sensitivitas 91%, spesifisitas 26%, NPP 26%, NPN 91 %.Kesimpulan: Pulasan BTA CSS metode sitosentrifugasi dapat menggantikan metode non sitosentrifugasi. Pulasan BTA CSS Auramine-O dapat me rule out diagnosis meningitis TB.

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ABSTRACT

Introduction: Detection of AFB from CSF with Ziehl Neelsen staining in 2014 at dr Cipto Mangunkusumo general hospital never gives positive result. Staining with Auramine-O smear staining can increase its sensitivity. Acid fast bacilli cytocentrifugation is needed as a modification in AFB slide preparation to gain more bacilli faster.

Methods: Diagnostic perfomance of AFB slide prepared by non cytocentrifugation, Cytospin, Cytopro with Ziehl Neelsen stain, prepared by cytopro with Auramine-O stain are compared to TB MGIT as a gold standard.

Results: Acid fast bacilli slide prepared with non cytocentrifugation method and stained by Ziehl Neelsen cannot be obtained because AFB was not detected in all samples. Acid fast bacilli slide prepared with Cytospin and Cytopro and stained with Ziehl Neelsen has sensitivity (64%), specificity (85%), PPV (54%), 89% NPV. Acid fast bacilli slide prepared with Cytopro and stained with Auramine-O has sensitivity (91%), specificity (26%), PPV (26%), 91 % NPV.

Conclusion: Detection of AFB from CSF with cytocentrifugation method can replace non cytocentrifugation method. Acid fast bacilli slide prepared cytocentrifugation and stained by Auramine-O can rule out Tuberculous meningitis."

"Tingginya angka masyarakat perkotaan di Indonesia menimbulkan permasalahan kesehatan berupa tuberkulosis paru. Bakteri Mycobacterium tuberculosis yang ada di paru dapat menyerang ke meningen dan parenkim otak sehingga menyebabkan tuberkulosis meningitis. Penurunan atau kerusakan fungsi tubuh telah dilaporkan sebagai akibat dari sistem saraf pusat penderita yang terlibat. Disabilitas yang terjadi dapat mengakibatkan penurunan kualitas hidup penderita terganggu dan mengarah pada masalah psikososial gangguan citra tubuh akibat hilangnya fungsi, bentuk dan struktur tubuh. Karya ilmiah ini melaporkan analisis masalah dan intervensi keperawatan psikososial gangguan citra tubuh pada klien dengan tuberkulosis meningitis. Evaluasi hasil akhir menunjukkan adanya penurunan tanda dan gejala gangguan citra tubuh serta hasil klinis yang lebih baik. Pengembangan dan implementasi asuhan keperawatan psikososial gangguan citra tubuh perlu diterapkan di ruang rawat umum, khususnya pada klien dengan masalah kesehatan perkotaan tuberkulosis meningitis.

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The high number and one of them person's lung can tuberculous meningitis. The decrease and damage in functions have been reported as the result of the affected central nervous system. This will eventually lead to decreasing the person's quality of life and resulting in physical and psychosocial problems such as body image disturbance due to loss of form, function, and structure of the body. This paper reports the analysis of problems and psychosocial nursing interventions of body image disturbance in person with tuberculosis meningitis.

The final results showed a decrease in signs and symptoms of body image disturbance and better clinical outcomes. The psychosocial nursing care plan for body image disturbance needs to be applied in the general ward, particularly for the clients with urban health problems tuberculosis meningitis."

"Latar Belakang: Osteosarkoma merupakan keganasan tulang primer dengan beragamsubtipe dan memerlukan pendekatan multidisiplin dalam diagnosis dan tatalaksananya.Hingga saat ini belum ada alat diagnostik yang terbukti dapat mendekaticlinicopathological conference (CPC) sebagai standar baku emas. Keterbatasan fasilitas,biaya, dan antrian pemeriksaan yang panjang sering kali menunda diagnosisosteosarkoma. Penelitian ini bertujuan untuk membuat model sistem skoring berdasarkantemuan klinis, laboratorium, radiografi konvensional, dan histopatologis untukmendiagnosis osteosarkoma secara cepat dan tepat.Metode: Penelitian ini dilakukan dalam dua tahap. Tahap pertama bertujuan untukmemformulasikan sistem skoring untuk mendiagnosis osteosarkoma menggunakan datasekunder secara retrospektif di RS. Dr. Cipto Mangunkusumo tahun 2016 hingga 2020.Studi ini melibatkan semua pasien dengan suspek keganasan tulang primer dandidiagnosis akhir berdasarkan CPC. Uji analisis dilakukan secara univariat, bivariat, danmultivariat menggunakan regresi logistik backward stepwise dilanjutkan dengan ujikalibrasi dan diskriminasi menggunakan uji Hosmer-Lemeshow dan kurva receivingoperator characteristic (ROC), serta menentukan titik potong pada model. Tahap keduaditujukan untuk mengevaluasi model sistem skoring yang diformulasi pada tahap pertamasecara prospektif menggunakan data primer sejak September 2022 hingga Desember2022 di poliklinik Orthopaedi dan Traumatologi RS. Dr. Cipto Mangunkusumo.Hasil: Penelitian tahap pertama melibatkan 120 subjek dan menghasilkan dua modelsistem skoring, yaitu dengan mempertimbangkan riwayat pijat (model 1) dan tanpamempertimbangkan riwayat pijat (model 2). Dari hasil analisis multivariat, didapatkansembilan variabel yang dimasukan dalam model sistem skoring yaitu usia, indeks massatubuh (IMT), onset, riwayat pijat, lokasi tumor, kadar alkaline phosphatase (ALP), laktatdehidrogenase (LDH), letak lesi berdasarkan radiografi konvensional, serta gambaranhistopatologis berdasarkan fine needle aspiration biopsy (FNAB). Uji kalibrasi model 1dan 2 menunjukan kalibrasi yang baik (p=0,498 dan p=0,917). Uji diskriminasi padamodel sistem skoring menunjukan nilai area under the curve (AUC) 0,818 dengan nilaip<0,001 pada model 1 dan 2. Titik potong pada model 1 dan 2 berturut-turut adalah 19dan 11 poin. Penelitian tahap kedua melibatkan 34 subjek dan menunjukan sensitivitas,spesifisitas, dan akurasi model 1 dan 2 berturut turut sebesar 81,25% dan 87,5%, 100%dan 100%, dan 91,1% dan 94,1%.Kesimpulan: Didapatkan dua model sistem skoring yang mampu mendiagnosisosteosarkoma dengan cepat dan tepat dibandingkan dengan CPC. Lokasi tumor di lututdan gambaran sel pleiomorfik dengan atau tanpa matriks osteoid ganas merupakan faktoryang paling berpengaruh terhadap diagnosis osteosarkoma.

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Introduction : Osteosarcoma, being one of the most prevalent among the primary bone

malignancies, consists of multiple subtypes and requires a multidisciplinary approach for

proper diagnosis and treatment. Lately, there have not been a diagnostic tool that is able

to rival the accuracy of clinicopathological conference (CPC) as a gold standard in

determining the diagnosis and treatment of osteosarcoma. Limitations in budgeting, as

well as the time taken for each patient to undergo supporting examinations often leads to

a delayed diagnosis. This research aims to create a scoring system that is based on clinical

symptoms, laboratory results, conventional radiology, as well as histopathological results

to establish a quick and accurate diagnosis for osteosarcoma.

Method: This research was conducted in two stages; the first stage aims to formulate the

scoring system for diagnosing osteosarcoma by using a retrospective, secondary data

obtained from Dr. Cipto Mangunkusumo Hospital from 2016 up to 2020. This study

involved all patients with suspected bone malignancies that was eventually diagnosed

with osteosarcoma by means of CPC. The analysis was done with univariate, bivariate,

and multivariate analysis using backward stepwise logistic regression method followed

by calibration and discrimination test using Hosmer-Lemeshow test and receiving

operator characteristic (ROC) curve analysis, and determined the cut-off point in the

scoring system model. The second stage was aimed to prospectively evaluate the

previously formulated scoring system model in the first stage using primary data from

September 2022 to December 2022 at Orthopaedic and Traumatology outpatient clinic

Dr. Cipto Mangunkusumo Hospital.

Result: The first stage of the study involved 120 subjects and resulted two models of

scoring system, namely by considering massage history (model 1) and without

considering massage history (model 2). From multivariate analysis, nine variables were

included in the scoring system model, including age, body mass index (BMI), onset,

massage history, tumor location, alkaline phosphatase (ALP) levels, lactate

dehydrogenase (LDH), location of the lesion based on conventional radiography, and

histopathological finding based on fine needle aspiration biopsy (FNAB). Calibration

tests for models 1 and 2 showed good calibration (p=0.498 and p=0.917). The

discrimination test on the scoring system model showed an area under the curve (AUC)

value of 0.818 with a p-value <0.001 in both models 1 and 2. The cut-off points in model

1 and 2 were 19 and 11, respectively. The second stage of the study involved 34 subjects

with the sensitivity, specificity, and accuracy of models 1 and 2 showing 81.25% and

87.5%, 100% and 100%, and 91.1% and 94.1%, respectively.

Conclusion: This study has proposed two models of scoring systems that can be used

for a more rapid and accurate diagnosis of osteosarcoma when compared to CPC; the

location of the tumor mass in the knee joint and the appearance of pleomorphic cells, with

or without the appearance of malignant osteoids, both being significant factors in

diagnosing osteosarcoma"

"Latar Belakang: Meningitis tuberkulosis (TBM) merupakan manifestasi terberat infeksi TB dan prognosisnya bergantung pada kecepatan memulai terapi. Studi ini bertujuan mengetahui alur perjalanan pasien TBM serta faktor-faktor yang memengaruhi keterlambatan dalam mendapatkan pengobatan.Metode Penelitian: Penelitian ini merupakan studi potong lintang dari pasien TBM yang sudah mendapatkan terapi OAT dan dirawat di RSCM pada bulan Januari 2020 – April 2022. Data diperoleh melalui wawancara terhadap pasien atau pendamping dan telusur rekam medis.Hasil: Sebanyak 99 orang subjek yang memenuhi kriteria. Terdapat 6 pola alur perjalanan pasien dengan yang terbanyak adalah mengalami gejala umum diikuti gejala neurologis, mencari pertolongan kesehatan, terdiagnosis, dan mendapatkan pengobatan (52,5%). Fasilitas kesehatan pertama terbanyak dikunjungi pasien adalah praktek dokter swasta (L1b) (35,4%). Median jumlah kunjungan yang dibutuhkan pasien untuk mendapatkan pengobatan adalah 6 (4-9) kunjungan dengan durasi keterlambatan sebagai berikut: keterlambatan pasien 17 (3-33) hari, keterlambatan diagnosis 44 (16-101) hari, keterlambatan pengobatan 1 (0-1) hari, dan keterlambatan total adalah 78 (33-170) hari. Faktor yang secara signifikan berhubungan dengan keterlambatan yang lebih panjang (>78 hari) adalah jumlah kunjungan ke fasilitas kesehatan aOR=3,51 (CI95=1,36-9,10; p=0,01) dan pendidikan rendah aOR=0,30 (CI95=0,01-0,89; p=0,03).Kesimpulan: Pasien TBM di RSCM menjalani kunjungan multipel dan membutuhkan waktu 2,5 bulan sejak mengalami gejala hingga mendapatkan pengobatan dengan keterlambatan terbesar berasal dari sistem kesehatan.

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Background: Tuberculous meningitis (TBM) is the worst manifestation of TB infection. Its prognosis is depend on timely treatment initiation. This study intend to know TBM patient pathway and factors that affect treatment delay.

Methods: This was a crossectional study of TBM patients who have received antituberculous medication and were admitted at the RSCM January 2020-April 2022. Data were obtained from interview to either patient or caregiver and medical reccord.

Results: A total of 99 subjects met the criteria. There were 6 patterns of patient pathway with the most prevalent is having general symptoms followed by neurological symptoms, first healthcare visit, diagnosed, and treated (52.5%). The first healthcare visited by most patients was private doctor's practice (L1b) (35.4%). Median number of visits before recieving treatment was 6 (4-9) visits. Delay duration are as follow: patient delay 17 (3-33) days, diagnosis delay 44 (16-101) days, treatment delay 1 (0-1) day, and total delay 78 (33-170) days. Factors that significantly associated with longer delays were number of visits to healthcare facilities aOR=3.51 (CI95=1.36-9.10; p=0.01) and lower education aOR=0.30 (CI95=0 .01-0.89; p=0.03).

Conclusions: TBM patients experienced multiple visit and had 2.5 months delay from first symptoms to treatment with the longest delay coming from the healthcare system."

"ABSTRAK Praktek klinik lanjut pada sistem neurologi dimaksudkan untuk mampu memberikan asuhan keperawatan, menerapkan Evidence Based Nursing EBN serta sebagai inovator. Peran pemberi asuhan keperawatan dilakukan pada pasien dengan meningitis TB dan 30 pasien dengan gangguan sistem persarafan menggunakan Model adaptasi Roy RAM . Perilaku mode adaptasi fisiologi paling sering mengalami perilaku maladaptif. Diagnosis keperawatan yang muncul yaitu gangguan mobilitas fisik dengan intervensi salah satunya berupa exercise therapy. Penerapan EBN Kegel rsquo;s exercise yang dilakukan dalam 1 pekan belum mampu mengatasi inkontinesia urin pada pasien stroke. Program inovasi penambahan format pengkajian neurologi berupa NIHSS, BBS, ISI, 3IQ, FAST, dan ANVPS mampu meningkatkan pengetahuan perawat mengenai format pengkajian selain dari format pengkajian yang telah ada di ruangan. Pengkajian perilaku dan stimulus pada RAM perlu diterapkan pada pengkajian pasien. Diharapkan kegel rsquo;s exericse tetap diajarkan pasien stroke yang mengalami inkontinensia urin dikarenakan perlu waktu yang cukup lama untuk mengatasi inkontinensia urin. Adanya format pengkajian neurologi tambahan dapat meningkatkan mutu pelayanan keperawatan. ABSTRACT Advanced clinical practice in the neurological system is intended to be able to provide nursing care, apply Evidence Based Nursing EBN as well as the role of an innovator. Nursing care roles were performed in patients with TB meningitis and 30 patients with impaired neural system using the Roy adaptation model RAM . The behavioral mode of physiological adaptation most often experiences maladaptive behavior. The emerging nursing diagnosis is impaired physical mobility with exercise theray intervention sould be applied. Application of EBN Kegel 39 s exercise performed on a week and showed that kegel 39 s exercise has not been able to cope with urinary incontinence. The innovation program for the addition of the neurological assessment format NIHSS, BBS, ISI, 3IQ, FAST, and ANVPS was able to increase the nurse 39 s knowledge of the assessment format apart from the existing assessment formats in the room. Assessment of behaviors and stimuli in RAM need to be applied to patient assessment. It is expected that kegel 39 s exericse still taught stroke patients who experience urinary incontinence due to long enough time to overcome urinary incontinence. The presence of additional neurological assessment formats can improve the quality of nursing services. "