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Background: Low back pain (LBP) is one of major health problems experienced by 80-85% of patients in their lifetime. Spondyloarthritis (SpA) has become one of the leading causes of chronic LBP but is often undiagnosed. General practitioners (GP) have an essential role in the early diagnosis of SpA. Aim: To explore the knowledge of GP about SpA from clinical diagnosis and early management and elaborate on each GP’s clinical perspective and practice performance. Methods: A qualitative study that involved 12 GP. All was consented to participate in an in-depth interview with the experts by online meeting with 15-20 minutes duration. Analysis was focused on the definition, classification, clinical manifestation, diagnosis, and early management of SpA in primary care. Results: All GP were interviewed (12 GP, 9 men, and 3 women; mean age 29.42) with average years in clinical practice was 3.8 years. All GP could describe the definition of SpA. Only a few subjects are aware of the subtype of SpA. Most of the GP could mention chronic back pain as the main SpA symptom, some GP mentioned extra-articular manifestation, but incomplete. All GP understood the current treatment in clinical practice. Conclusion: GP is aware of SpA, but not all could completely mention the type and clinical entities. In addition, a limited resource for investigation makes a diagnosis of SpA difficult. Current early treatment has been acceptable in clinical practice. A comprehensive understanding of diagnosis and effective early treatment may reduce delayed diagnosis and improve patients' quality of life.

BACKGROUND: Cytokine storm is a condition that typically develops during severe COVID-19 viral infection and contributes cause of death. Bryophyllum pinnatum is a herbal medicinal that has an impact as an anti-inflammatory agent. B. pinnatum may be used as a therapeutic agent for cytokine storms. AIM: We were investigating the molecular interactions of B. pinnatum active compounds with cytokines involved in COVID-19 infection. METHODS: We did the molecular docking approach using the active chemicals from Bryphyllum pinnatum, which was available on the PubChem website. Meanwhile, the protein utilized is retrieved from the protein databank. Pyrx 9.5, Pymol, and Discovery Studio software were used to evaluate and visualize the interaction results between ligands and the proteins formed. RESULTS: Bryophyllin B has the strongest affinity to IL-6, whereas Bryotoxin A had the highest binding to Gly-ACE and TNF alpha. Pharmacokinetic predictions indicate that Bryophyllin B has a good pharmacokinetic profile but a low toxicity profile due to a reproductive effect. On the other hand, Bryotoxin A has a poor pharmacokinetic profile but is safe for human use. CONCLUSIONS: Bryophyllin B and Bryotoxin A show potential as a therapy for the cytokine storm of COVID-19 infection. However, further study is required to examine the effectiveness and toxicity of these compounds.

This study was aimed to explore the association of vitamin D in the risk of coagulopathy in coronavirus disease-19 (COVID-19).Clinical and laboratory findings were obtained from 50 confirmed COVID-19 patients hospitalized in Saiful Anwar General Hospital, Malang, Indonesia, from September to November 2020. Thrombotic events during hospitalization were recorded, and the ISTH disseminated intravascular coagulation (DIC) score was used to classify overt DIC. Hypovitaminosis D was defined by serum vitamin D level49.92 nmol/L.Among 50 patients, 42 (84%) had hypovitaminosis D, and 6 (12%) developed thrombotic events. Vitamin D levels were lower in patients with thrombotic events (p=0.015), D-dimer2 mg/L (p=0.006), ISTH DIC score 5 (p=0.020), admitted on ICU (p=0.002), and non-survivor groups (p=0.007). Multivariate analysis for the risk in increased D-dimer levels showed low vitamin D as the only significant risk factor with OR 1.8 (1.2-4.4), p=0.034. Low vitamin D also increased the risk for developing overt DIC with OR. 5.4 (1.0-30.2), p=0.039. Vitamin D level had negative correlations with ferritin (R=-0.316, p=0.044) and CRP (R=-0.530, p=0.000).In conclusion, a low level of vitamin D was found in most hospitalized COVID-19 patients and might be associated with the development of coagulopathy.Cilj ove studije je bio da istraži povezanost vitamina D sa rizikom od koagulopatije kod koronavirusne bolesti 2019 (COVID-19).Klinički i laboratorijski nalazi dobijeni su od 50 potvrđenih pacijenata sa COVID-19 hospitalizovanih u opštoj bolnici Saiful Anvar u Malangu u Indoneziji, od septembra do novembra 2020. Zabeleženi su trombotični događaji tokom hospitalizacije, a rezultati ISTH diseminovane intravaskularne koagulacije (DIC) korišćeni su za klasifikaciju očigledne DIC. Hipovitaminoza D je definisana nivoom vitamina D u serumu49,92 nmol/L.Od 50 pacijenata, 42 (84%) je imalo hipovitaminozu D, a 6 (12%) je razvilo trombotičke događaje. Nivoi vitamina D su bili niži kod pacijenata sa trombotičkim događajima (p=0,015), D-dimerom2 mg/L (p=0,006), ISTH DIC rezultatima 5 (p=0,020), primljenih na intenzivnu negu (p=0,002), i grupa koje nisu preživele (p=0,007). Multivarijantna analiza rizika za povećane nivoe D-dimera pokazala je nizak nivo vitamina D kao jedini značajni faktor rizika sa OR 1,8 (1,2-4,4), p=0,034. Nizak nivo vitamina D je takođe povećao rizik od razvoja očiglednog DIC-a sa OR 5,4 (1,0-30,2), p=0,039. Nivo vitamina D je imao negativne korelacije sa feritinom (R=-0,316, p=0,044) i CRP-om (R=-0,530, p=0,000).Na kraju, kod većine hospitalizovanih pacijenata sa COVID-19 utvrđen je nizak nivo vitamina D koji bi mogao biti povezan sa razvojem koagulopatije.

Vaccination is a very important measure for the prevention of various infections worldwide including the recent COVID-19 disease. However, until now the COVID-19 vaccine with various platforms has not been clinically tested on autoimmune inflammatory rheumatic disease (AIIRD) patients, due to caution against possible side effects and unknown efficacy. Several recent studies proved that there is increased risk of SARS-CoV-2 infection in AIIRD patients and moreover, those patients also have worse COVID-19 outcomes. Thus, patients with AIIRD should be prioritized for vaccination because they have an increased burden of infections, including COVID-19. Many studies showed that inactivated/non-live vaccine is safe for AIIRD patients and do not cause disease exacerbations. We conclude that benefits of vaccination greatly outweigh the risks of infection and therefore, COVID-19 vaccines can also be administered safely in stable AIIRD patients.

PUBLISHED IN WWW.SUBSTANTIVEJUSTICE.ID (July 20, 2018) In 2013 the business circle was struck by the new tax rules, namely Government Regulations PP No. 46, 2013 on taxation regulations among UKM (SME’s) / Small Medium Enterprises but the strong allegations issued PP 46 of 2013 is because the potential tax revenue from the sector of UKM has not been explored to the fullest. By the required by the taxpayer related PP. No. 46 of 2013 uses several variables, namely taxes, taxes, taxes and tax benefits. The object of this research is the perpetrators of UKM (SMEs) in Makassar City who do 40 people using quantitative analysis and quantitative analysis. The result of this research indicates that the perception of justice tax has a significant effect as well as the most dominant variable affecting taxpayer compliance, taxability perception has a significant adverse impact on taxpayer compliance, tax perception simplicity has no significant impact, taxpayer's judgment is not valid in testing. The overall coefficient of determination contributes 26.5%.

Background: Systemic sclerosis (SSc) is a chronic autoimmune disease that still poses a great challenge to clinicians. SSc is characterized by immune dysregulation and progressive fibrosis that typically affects variable internal organ involvement such as lungs. Interstitial lung disease (ILD) is a common manifestation of SSc and a leading cause of death. The immunosuppressive drug is the main treatment to suppress the inflammation process in SSc. Case presentation: In this case we report a 40-year-old female to suffer ILD-SSc. According to High-Resolution Computed Tomography (HRCT) thorax, we found that it was interstitial lung disease with aspergilloma. She got methylprednisolone 3x8 mg and azathioprine 2x50 mg. At the end of the treatment, the patient showed improvement in her clinical condition and showed no worsening condition in the HRCT evaluation for her fungal aspergilloma. Conclusion: Systemic sclerosis (SSc) is a rare autoimmune disease involving the skin and internal organs. The immunosuppressive agent is still the drug of choice for most autoimmune diseases. Immunosuppressive may promote fungal growth and have been associated with increased risk in most serious fungal diseases including aspergilloma.

Systemic Lupus Erythematosus (SLE) is a complex autoimmune disease that requires long-term corticosteroid treatment that may lead to osteoporosis characterized by low bone mass and microarchitectural deterioration of the trabecular and cortical skeletal. This study presents a severe case of thrombocytopenia in a 25-year old woman with SLE and osteoporosis who underwent routine therapy and was pregnant for the first time. The complexity of pregnancy and autoimmune conditions create therapeutic challenges that need to be considered in SLE patients with pregnancy, osteoporosis, and severe thrombocytopenia.

IgG4-Related Disease (IgG4RD) was identified by the International Classification of Diseases (ICD) in 2012. Numerous diseases, including Mikulicz’s disease, Kuttner’s tumor, Riedel’s thyroiditis, and Ormond’s disease, are pathologically associated with IgG4. Here, we present a review of the clinical presentation and pathogenesis of IgG4-associated disease. IgG4-RD term has been used to refer to a group of diseases involving multiple organs in which there is an abundant IgG4-positive lymphoplasmacytic infiltration, storiform fibrosis, obliterative phlebitis, and mild to moderate tissue eosinophilia, all of which show clinically as a tumefactive lesion, usually in more than one organ. IgG4 exhibits a unique property called an unstable disulfide bond between its heavy chain, as described by Fab-arm exchange which enables the recombination of a single IgG4 heavy chain with other IgG4 heavy chains, resulting in a bispecific antibody incapable of cross-linking and thus of forming an immune complex. IgG4-RD pathomechanism that causes serum IgG4 increase and tissue IgG4-plasma-cell deposition that is pathogenic, rather than the IgG4 itself. Genetic predisposition, autoimmunity, T-cell dysregulation, infection, and dysbiosis are just a few of the underlying pathomechanisms. Clinical symptoms are also frequently complex and may involve many organs. Confirmation of a diagnosis required a comprehensive anamnesis and examination.

Avascular Necrosis (AVN) or osteonecrosis refers to the death of osteocytes and osteoblasts. Sites such as the femoral head, the head of the humerus and the mandibular with restricted access to local blood supply are particularly vulnerable to osteonecrosis. Various traumatic and non-traumatic causes of AVN are known, including systemic autoimmune diseases. Among traumatic causes, physical trauma, decompression sickness or radiation may be cited. In the non-trauma cases, two theories are disputed: the first concerns the occurrence of an intravascular coagulation and the second one attributes the ischemia to extravascular compression. AVN has been well described in patients with autoimmune diseases such as systemic lupus erythematosus, but in systemic sclerosis (SSc) patients, there have been limited case reports and case series. We present a case of a 32-year old woman with systemic sclerosis on corticosteroid and avascular osteonecrosis and elaborating possible etiologies or mechanism of avascular osteonecrosis in SSc.

Inflammation, Chronic Diseases and “Bone Quality”

Chest pain is a common clinical presentation in daily practice. Musculoskeletal origin is a rare etiology of chest pain, compared to a cardiorespiratory problem and often underrecognized. Fork-rib or bifid-rib is a rare anomaly which uncommonly present with clinical symptoms since in most cases fork-rib incidentally found during cadaveric dissection. Here we report a 27 years old man presenting with chest pain and radiographic examination showing bifid rib of the fifth left rib, without any abnormalities from physical examination and electrocardiography. The patient treated with intravenous painkiller and anticonvulsants. Fork-rib should be considered as a differential diagnosis for chest pain of musculoskeletal origin especially in young adults or chest pain precede with minor trauma.Â

Background: Healthcare workers (HCWs) run a high risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The HCWs are prone to the SARS-CoV-2 infection in the hospital despite being fully vaccinated. The present study aimed to address the factors associated with the coronavirus disease 2019 (COVID-19) vaccine breakthrough among HCWs. Study Design: A prospective cohort study. Methods: Participants were 184 HCWs receiving two doses of inactivated SARS-CoV-2 vaccine (CoronaVac, Sinovac Life Science). All participants were followed for six months. Confirmed COVID-19 was defined as positive SARS-CoV-2 by reverse transcription-polymerase chain reaction (RT-PCR). Before undergoing RT-PCR, questionnaires were used to obtain information on demographic characteristics, profession, contact with COVID-19 cases, personal protective equipment (PPE), health protocols adherence, exercise, and nutritional habits. Results: A number of 57 (31%) participants were COVID-19 positive. Close contact with COVID-19 cases (adjusted RR 6.82, 95% CI: 1.97, 47.98, P=0.044), being a resident doctor (adjusted RR 4.72, 95% CI: 1.11, 20.11, P=0.036), improper mask-wearing (adjusted RR 2.36, 95% CI: 1.15, 4.85, P=0.019), and lower frequency of eating fruit and vegetables (adjusted RR 2.73, 95% CI: 1.34, 5.57, P=0.006) increased the risk of vaccine breakthrough. Compared to single surgical masks, KN95 and N95 significantly reduced the risk of COVID-19 (adjusted RR 0.27, 95% CI: 0.07, 0.97, P=0.045 and adjusted RR 0.25, 95% CI: 0.07, 0.87, P=0.029), respectively. Conclusion: As evidenced by the obtained results, being a resident doctor, close contact with confirmed COVID-19 cases, health protocol incompliance, as well as the lower frequency of fruit and vegetable consumption were associated with the risk of vaccine breakthrough among HCWs. Appropriate strategies are needed to prevent the risk of SARS-CoV-2 infection among HCWs.

Kurangnya pengetahuan masyarakat tentang COVID-19, lupus, reumatik, dan alergi mempengaruhi keberhasilan terapi, penurunan angka kejadian, dan pencegahan kekambuhan. Tujuan pengabdian masyarakat adalah membangun desa-desa binaan tanggap COVID-19, lupus, reumatik, dan alergi di Malang oleh Tim Kelompok Kajian Lupus, Autoimun, Reumatik, dan Alergi (LAURA) Universitas Brawijaya. Warga desa binaan diberikan penyuluhan berupa seminar awam dan pelatihan tentang pertolongan awal pada penyakit COVID-19, lupus, reumatik, dan alergi, kemudian diminta mengisi kuesioner posttest untuk mengukur pemahaman. Desa-desa binaan diberikan thermo-gun dan wastafel untuk menerapkan protokol kesehatan. Satu bulan kemudian dievaluasi adanya kejadian COVID-19, lupus, reumatik, dan alergi di desa binaan. Hasil evaluasi menunjukkan rata-rata warga desa binaan memahami 78,3% materi yang diberikan dan menerapkan protokol kesehatan sesuai yang diajarkan saat penyuluhan. Dilaporkan tidak ada kejadian COVID-19 serta kekambuhan lupus, reumatik, dan alergi dalam satu bulan terakhir kegiatan. Kesimpulan: pembangunan desa-desa binaan di Malang meningkatkan tanggap warga terhadap COVID-19, lupus, reumatik, dan alergi.