BACKGROUND: Craniopharyngiomas, benign tumors of the sellar region, frequently disrupt hypothalamic function, leading to endocrine and neurological sequelae, including sleep disorders. CASE PRESENTATION: This case highlights the diagnostic and therapeutic challenges of secondary narcolepsy in a 19-year-old woman with craniopharyngioma. The patient presented with excessive daytime sleepiness, prolonged sleep duration, no cataplexy, and cognitive dysfunction following tumor treatment. However, CSF level of orexin/hypocretin was not measured. Diagnosis of secondary narcolepsy was confirmed through overnight polysomnography and multiple sleep latency tests. Combining methylphenidate for wakefulness and donepezil for cognitive support led to symptomatic improvement. CONCLUSIONS: This case underscores the necessity of recognizing secondary narcolepsy in patients with hypothalamic dysfunction and tailoring multidisciplinary management strategies to optimize outcomes.

BACKGROUND:Social health has been increasingly recognized as an important determinant of dementia progression and quality of life. The Social Network Index (SNI), developed by Cohen, is widely used to assess social networks as a proxy for social health. This study aimed to adapt the SNI cross-culturally and validate its psychometric properties for use among Indonesians with dementia. METHODS:A cross-sectional study was conducted at the Memory Clinic of Dr. Sardjito General Hospital, Yogyakarta, Indonesia, involving 56 individuals with mild to moderate dementia. The original 12-item SNI was translated and culturally adapted according to WHO guidelines. Construct validity was examined using Confirmatory Factor Analysis (CFA). Composite Reliability (CR) and Average Variance Extracted (AVE) were used to assess internal consistency. RESULTS:The finalized modified Indonesian version of the SNI (m-SNI-INA), consisting of 10 items (2 excluded due to low factor loadings), demonstrated strong construct validity with factor loadings >0.5 and good model fit (GFI=0.958, AGFI=0.934, CFI=1.000, RMSEA=0.000). Reliability was high (CR=0.91; AVE=0.53). CONCLUSIONS:The m-SNI-INA is a valid, reliable, and culturally adapted tool for assessing social networks in people with dementia in Indonesia. Further studies should examine its predictive validity in larger populations.

Background:SARS-CoV-2 ancestral-strain vaccines have effectively reduced SARS-CoV-2-related severe illness and death worldwide. However, waning immunity over time has warranted revaccination to boost immunity. Indonesia, like most low- and middle-income countries, has not provided regular vaccine boosters post-pandemic. This study assessed the longer-term durability of protection from ancestral-strain third- and fourth-dose boosters. Methods:We conducted a test-negative case-control study among symptomatic adults seeking SARS-CoV-2 testing at 14 purposely selected test sites in the major cities of Yogyakarta and Jakarta (March 2023-May 2024). Test-positive individuals were cases and test-negative individuals were controls. SARS-CoV-2 variants were identified using whole genome sequencing. We used multivariable logistic regression to estimate absolute or incremental vaccine effectiveness (VE) against symptomatic infection and COVID-19-related hospitalisation or death, adjusted for main confounders. Findings:Of 2439 participants (median age 35 years, 56.2% female), 388 were cases and 2051 controls. Vaccination with two primary doses, a third-dose or fourth-dose booster did not provide sustained protection against Omicron XBB/JN.1 symptomatic infection up to median 27, 20 or 13 months since administration, respectively. However, there was sustained incremental protection from the third-dose booster (administered median 20 month prior) against hospitalisation (VE 38.3% [95% CI 3.9-60.3]) and death (55.2% [17.7-75.6]) for older individuals (aged >50 years), and against death (55.2% [12.8-76.9]) for individuals with one or more comorbidities. There was also sustained incremental protection from the fourth-dose booster (administered median 13 months prior) against hospitalisation for older individuals (50.2% [10.3-72.3]) and individuals with one or more comorbidities (74.4% [49.2-87.1]). Interpretation:Ancestral-strain vaccine boosters provided durable, moderate protection against severe or fatal outcomes from Omicron XBB/JN.1 infection for older and comorbid individuals. The findings highlight the benefits of improving access to revaccination for vulnerable groups in Indonesia. Funding:US Centers for Diseases Control and Prevention.

Background: Reduced level of serum BDNF in acute stroke patients is associated with poor outcomes. We aimed to identify the role of serum BDNF level as a predictor for post-stroke cognitive impairment (PSCI). Methods: This was a prospective study. We recruited acute ischemic stroke patients in Dr. Sardjito General Hospital Yogyakarta, Indonesia followed them up for 90 days (3 months). Serum BDNF was collected at day 5 and day 30 of stroke onset and measured by ELISA. Montreal Cognitive Assessment (MoCA) was used to measure the cognitive function at 90 days of follow up. ROC curve was conducted to measure the cut-off point of the BDNF level. Factors independently associated with PSCI were analyzed by using stepwise regression. Results: Among 89 patients recruited, 60 patients (67.41%) developed PSCI. The mean age of PSCI and non-PSCI patients was 62.7 ± 9.5 and 57.5 ± 8.7, respectively (p = 0.01). Patients with dyslipidemia were less likely to develop PSCI (OR 0.19, 95%CI 0.06–0.56, p < 0.05). In addition, patients with day 5-serum BDNF level < 23.29 ng/mL were five times more likely to develop PSCI compared with their counterparts (OR 5.02, 95%CI 1.67–15.04, p < 0.05). Conclusions: Among acute ischemic stroke patients, those with serum BDNF <23.29 ng/mL had a higher risk of developing PSCI, while those with dyslipidemia had a lower risk of PSCI. This study suggests that BDNF could be a predictor of PSCI, allowing for earlier detection and better preventive strategies.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

The effect of antihypertensive drug classes in reducing the risk of post-stroke cognitive impairment (PSCI) remains elusive. We aimed to investigate the association between antihypertensive drug classes and the risk of PSCI among ischemic stroke patients using data collected from a tertiary hospital in Indonesia. We carried out a retrospective analysis of data from a medical database in Sardjito General Hospital Yogyakarta, Indonesia. We identified the first-ever ischemic stroke patients hospitalized between June 2018 to May 2019 and whose serial measurements of cognitive function were available up to 90 days after stroke. The effect of antihypertensive drug classes on PSCI was measured by using multivariate logistic regression analysis. We found 71.11% patients developed PSCI at 90 days after stroke. Forty-one patients (44.09%) received no antihypertensive drugs, 14 (15.05%) with angiotensin receptor blockers (ARB), 20 (21.50%) with calcium channel blockers (CCB), and 18 (19.35%) with combination of ARB and CCB. After controlling covariates, we found that ARB reduced the risk of PSCI by 64% (aOR 0.364, 95% CI = 0.14-0.91, p<0.05), with improvement of total MoCA-INA score by 3.113 points (p<0.05). Among first-ever ischemic stroke patients, ARB showed more favorable outcome on reducing the risk of PSCI and improving cognitive performance at 90 days after stroke. These findings may contribute to assist clinicians for selecting antihypertensive drug classes in PSCI prevention.

Background Coronavirus disease 2019 (COVID-19) surges, such as that which occurred when omicron variants emerged, may overwhelm healthcare systems. To function properly, such systems should balance detection and workloads by improving referrals using simple yet precise and sensitive diagnostic predictions. A symptom-based scoring system was developed using machine learning for the general population, but no validation has occurred in healthcare settings. We aimed to validate a COVID-19 scoring system using self-reported symptoms, including loss of smell and taste as major indicators. Methods A cross-sectional study was conducted to evaluate medical records of patients admitted to Dr. Sardjito Hospital, Yogyakarta, Indonesia, from March 2020 to December 2021. Outcomes were defined by a reverse-transcription polymerase chain reaction (RT-PCR). We compared the symptom-based scoring system, as the index test, with antigen tests, antibody tests, and clinical judgements by primary care physicians. To validate use of the index test to improve referral, we evaluated positive predictive value (PPV) and sensitivity. Results After clinical judgement with a PPV of 61% ( n = 327/530, 95% confidence interval [CI]: 60% to 62%), confirmation with the index test resulted in the highest PPV of 85% ( n = 30/35, 95% CI: 83% to 87%) but the lowest sensitivity ( n = 30/180, 17%, 95% CI: 15% to 19%). If this confirmation was defined by either positive predictive scoring or antigen tests, the PPV was 92% ( n = 55/60, 95% CI: 90% to 94%). Meanwhile, the sensitivity was 88% ( n = 55/62, 95% CI: 87% to 89%), which was higher than that when using only antigen tests ( n = 29/41, 71%, 95% CI: 69% to 73%). Conclusions The symptom-based COVID-19 predictive score was validated in healthcare settings for its precision and sensitivity. However, an impact study is needed to confirm if this can balance detection and workload for the next COVID-19 surge.

Background: Public health emergencies require integration between multiple stakeholders in different sectors to monitor the situation and carry out an appropriate response. As a country with a large land area consisting of thousands of islands, Indonesia's centralized Public Health Emergency Operation Center (PHEOC) system is currently unable to effectively contain diseases. A PHEOC system reform is required to accommodate Indonesia's circumstances, particularly at the regional level. We have outlined potential models at the sub-national level for PHEOC based on existing evidence. Policy Options and Recommendations: Based on existing evidence of PHEOC models internationally, we have formulated three policy models for regional-level PHEOC. These models (the ad hoc agency model, the independent agency model, and the Province Health Office (PHO)-based model) entail different chains of command, and each has its own benefits. Conclusion: We recommend that the Ministry of Health in Indonesia adopt the third PHEOC policy model, in which the chain of command lies under the PHO. This is the most practical approach, as the PHO has the authority to mobilize units and access resources in response to imminent public health emergencies. Further training and capacity-building are required to support the PHO as the commander of the regional PHEOC.

Background Indonesian Ministry of Health stated that around 80% of Indonesian women aged between 15-24 years are anaemic, and 30% of children are stunted. The leading cause of this problem is poor quality food, including poor micronutrient quality, low dietary diversity and low intake of animal-source foods. Preconceptional young women who are anaemic and stunted have a risk of giving birth to stunted children later in life if their nutrition is not immediately improved. This study aims to have a deeper understanding of anaemia and stunting conditions among young women in the rural setting of Indonesia.Methods Twenty young women with the anaemic and stunting condition aged between 15 - 19 years were recruited through the randomly selected patient in the outpatient department of Public Health Center (Puskesmas) in the rural area of Gunungkidul, Yogyakarta from October to November 2022. Focus Group Discussion (FGD) was conducted with the following area early marriage, cause and effect of anaemia and stunting, and women health-seeking behavior. Interviews were audio-recorded, transcribed, translated, and analyzed thematically.Results Young women with anaemic and stunting condition are having powerlessness where they are unable in determining daily diet, arise from a low-income family and have no choice in their life course. They are suffering from financial difficulties and food insecurity, resulting in inadequate nutrition and stunting. They also believe that early marriage is a viable option for their own and their children’s well-being.Conclusion This study is the evidence of young women powerlessness in the rural area of Indonesia. The understanding could contribute to develop evidence-based, effective, and efficient policies and regulations. The existing health system needs to reinforce the support for young women to reduce risks in early life and improve their health across the life course. The intervention could include promoting access to nutritious foods, good hygiene, family planning education, and access to health facilities and services.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementH and FAY was funded by National Research Priority Flagship Program for Universities under 2883/UN27.22/PT.01.03/202. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This study was approved by the Research Ethics Committee of Faculty Medicine Universitas Sebelas Maret (Approval number: 88/UN27.06.11/KEP/EC/2021).I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesThe datasets generated and/or analyzed during the current study are available upon reasonable request from the corresponding author because of ethical restrictions concerning the sharing of the study data with others without permission from the participants of this study.

Background: The increasing rates of Caesarean section (CS) beyond the WHO standards (10-15%) pose a significant global health concern.Objective: Systematic review and meta-analysis to identify an association between CS history and maternal adverse outcomes for the subsequent pregnancy and delivery among women classified in Robson classification (RC).Search Strategy: PubMed/Medline, EbscoHost, ProQuest, Embase, Web of Science, BIOSIS, MEDLINE, and Russian Science Citation Index databases were searched from 2008 to 2018.Selection Criteria: Based on Robson classification, studies reporting one or more of the 14 adverse maternal outcomes were considered eligible for this review.Data Collection: Study design data, interventions used, CS history, and adverse maternal outcomes were extracted.Main Results: From 4,084 studies, 28 (n = 1,524,695 women) met the inclusion criteria. RC group 5 showed the highest proportion among deliveries followed by RC10, RC7, and RC8 (67.71, 32.27, 0.02, and 0.001%). Among adverse maternal outcomes, hysterectomy had the highest association after preterm delivery OR = 3.39 (95% CI 1.56-7.36), followed by Severe Maternal Outcomes OR = 2.95 (95% CI 1.00-8.67). We identified over one and a half million pregnant women, of whom the majority were found to belong to RC group 5.Conclusions: Previous CS was observed to be associated with adverse maternal outcomes for the subsequent pregnancies. CS rates need to be monitored given the prospective risks which may occur for maternal and child health in subsequent births.

Background: Global COVID-19 outbreaks in early 2020 have burdened health workers, among them surveillance workers who have the responsibility to undertake routine disease surveillance activities. The aim of this study was to describe the quality of the implementation of Indonesia’s Early Warning and Response Alert System (EWARS) for disease surveillance and to measure the burden of disease surveillance reporting quality before and during the COVID-19 epidemic in Indonesia. Methods: A mixed-method approach was used. A total of 38 informants from regional health offices participated in Focus Group Discussion (FGD) and In-Depth Interview (IDI) for informants from Ministry of Health. The FGD and IDI were conducted using online video communication. Yearly completeness and timeliness of reporting of 34 provinces were collected from the application. Qualitative data were analyzed thematically, and quantitative data were analyzed descriptively. Results: Major implementation gaps were found in poorly distributed human resources and regional infrastructure inequity. National reporting from 2017–2019 showed an increasing trend of completeness (55%, 64%, and 75%, respectively) and timeliness (55%, 64%, and 75%, respectively). However, the quality of the reporting dropped to 53% and 34% in 2020 concomitant with the SARS-CoV2 epidemic. Conclusions: Report completeness and timeliness are likely related to regional infrastructure inequity and the COVID-19 epidemic. It is recommended to increase report capacities with an automatic EWARS application linked systems in hospitals and laboratories.

Background: Identifying risk factors of incomplete immunization among children is crucial to developing relevant policies to improve immunization coverage. In this study, we investigated factors associated with incomplete immunization among children in Indonesia and elucidated differences in risk factors between urban and rural areas. Methods: The data came from a national-wide survey, the 2017 Indonesia Demographic Health Surveys. In total, 3264 children aged 12-23 months were included in the study. An incomplete immunization status was defined as a child who did not complete the ten doses of basic vaccinations, consisting of one dose of bacille Calmette-Guerin, one dose of hepatitis B, three doses of pentavalent vaccine (diphtheria, pertussis, tetanus, hemophilus influenza type B, and hepatitis B vaccine), four doses of polio vaccine, and one dose of measles vaccine. Generalized linear mixed models were constructed to examine the effects of different levels of risk factors on the incomplete immunization status. We further conducted stratified analyses by urban and rural areas. Results: About 40% of the 3264 children were incompletely immunized, among whom 45.3% were in urban areas and 54.7% were in rural areas. Eight of the 34 provinces had incomplete immunization rates exceeding 50%, and the Papua and Maluku regions had the highest rates of incomplete child immunization. The multivariate analyses showed that when women attended fewer than four antenatal care sessions and resided outside the Nusa Tenggara region, their children were more likely to have incomplete immunization in both urban and rural areas. On the other hand, having no health insurance was positively associated with incomplete immunization in urban areas, whereas having received a tetanus vaccination during pregnancy was negatively associated with incomplete immunization in rural areas. Conclusions: Results of this study suggest that tailored interventions should be developed to address significant risk factors in rural and urban areas. Copyright (C) 2020, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC.

Obesity is one of the factors associated with cognitive impairment. However, obesity may differently affect cognitive function in different age groups, and scarce data are available from low- and middle-income countries. This cross-sectional study aimed to identify the association between obesity and cognitive impairment among 143 elderly individuals in Yogyakarta. We recorded the sociodemographic factors and some comorbidities, also measured the body mass index as a parameter of obesity, cognitive function using Montreal Cognitive Assessment—Indonesia, mood condition and depression status using geriatric depression scale-short form, as well as the daily life function using Activity of Daily Living and Instrumental Activity of Daily Living. After adjustment for the sociodemographic and comorbidities, we found that subjects with older age were more likely to have cognitive impairment (odds ratio [OR] 3.544, 95%CI: 1.36–9.22, p < 0.01) and compared with elderly individuals with normal weight, obese elderly individuals were 40% less likely to have cognitive impairment (OR 0.604, 95%CI: 0.39–0.95, p < 0.05). This study suggests that obesity in elderly individuals is less frequently associated with cognitive impairment. These findings support the reverse causation mechanism related to body mass index (BMI) and cognitive impairment in low/middle-income countries.

The province of Nusa Tenggara Timur (NTT) in the eastern part of Indonesia is known for high maternal mortality ratios (MMRs) and neonatal mortality eates (NMRs). Sister Hospital is a multicenter program, which aims to lower MMRs and NMRs in the deprived areas of Indonesia by providing comprehensive emergency services for maternal and newborn care. In this study, we evaluated the impact of the Sister Hospital program on MMRs and NMRs in 2009-17. We used linear mixed-effects models to analyze the program's effects. Study results suggested that in general, the Sister Hospital program reduced MMRs by 1.14/100 000 live births after adjusting for other sociodemographic factors. This study also found that the program effects varied by island, and the highest reduction in MMRs, were found on Sumba Island in which the log of MMRs decreased from 2.23 in 2009 to 2.01 in 2017. However, no effects on NMR outcomes by the program were found. These findings suggest that the Sister Hospital program can be a practical solution for lowering MMRs in rural Indonesia.

Indonesia has one of the highest maternal mortality rates among Southeast Asia countries. Mothers’ pregnancy-related behaviors were proven to be the major determinants of maternal mortality. This study attempted to measure individual- and community-level factors that contribute to pregnancy-related health behaviors among Indonesian women. This study used representative nationwide survey samples among women aged 15 to 49 years from the Indonesian Demographic Health Survey in the years 2007 (N = 15 314), 2012 (N = 15 197), and 2017 (N = 15 300). Generalized linear mixed models were constructed to simultaneously analyze relationships of pregnancy-related health behaviors with other individual- and community-level explanatory factors. We found that women’s educational level, household wealth index, insurance status, access to health facilities, geographic location, general health condition, pregnancy intentions, and community-level socioeconomic status were significantly associated with different outcome behaviors. The findings of this study suggest that future policies should focus on both individual- and community-level factors to improve women’s pregnancy-related behaviors.