E-Journal Faculty of Medicine Universitas Padjadjaran / E-Jurnal Fakultas Kedokteran Universitas Padjadjaran
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Type of Coronary Artery Plaque in Relation to Epicardial Fat Volume in Coronary Heart Disease Patients: A Cardiac Computed Tomography Scan Study
Get PDFBackground: Coronary heart disease (CHD) is a disease that raises public health concerns due to its high morbidity and mortality rates. Anatomically, epicardial fat is located around the heart and coronary system, making it important in the development of coronary atherosclerosis. This study aimed to explore the relationship between epicardial fat volume (EFV) and the type of coronary artery plaque by using Cardiac Computed Tomoghraphy (CT)-Scan.Methods: This was a cross-sectional observational analytic study on patients diagnosed with CHD aged > 20 years who had undergone cardiac CT-Scan at the Department of Radiology, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia between February and June 2019. Data collected from the CT-Scan were analyzed using the Chi-square test.Results: From 54 CHD patients, consisting of an equal number of male and female patients, with a majority of above 60 years old (31.5%), a correlation was identified between increased amount of EFV and mix and hard plaques in the right cirumflex artery (RCA) (p0.05).Conclusions: There is a significant relationship between the EFV value, EFV category, and the type of coronary artery plaque in CHD patients in RCA and LCX arteries. However, this correlation is not observed in LM and LAD arteries
Response to Chemotherapy in Patients with Gestational Trophoblastic Neoplasia in A Tertiary Hospital in Indonesia
No full textBackground: The incidence of gestational trophoblastic neoplasia (GTN) is high in Indonesia. Based on the FIGO prognostic score, GTN is classified into low-risk and high-risk categories. The high-risk group requires multidrug chemotherapy whereas the low-risk group requires single-drug chemotherapy. Response to chemotherapy would reflect the remission rate. The aim of this study was to describe the response to chemotherapy in GTN patientsMethods: This was a cross-sectional descriptive retrospective study on medical records of patients with GTN treated in Dr. Hasan Sadikin General Hospital during the period of 2016 to 2018. The inclusion criteria were GTN patients who received > 3 cycles of chemotherapy while the exclusion criteria were incomplete, inaccessible, or missing data. Data were collected on patient’s age, parity, history of previous pregnancy, pregnancy-therapy interval, tumor size, number and location of metastases, and history of failed chemotherapy.Results: Of the189 medical records of the GTN patient collected, only 88 met the inclusion criteria, (63.6% low risk and 36.4% high risk). Most patients were responsive to chemotherapy (61.4%), aged5 cm, had 4 month interval from previous pregnancy <4 months, had a history of molar pregnancy, had no metastases, and no previous failed chemotherapy.Conclusion: The chemotherapy response in gestational trophoblastic neoplasm patients is fairly good with most patients are in the low-risk groups. Specific tumor markers used in early diagnosis of GTN may play a major role
Gallic Acid Content and Antioxidant Activity of Pomegranate Peel Ethanol Extract
Get PDFEthanol extract of Pomegranate peel is proven to have the ability to inhibit the proliferation of cervical cancer HeLa cells. It was reported that this extract contains ellagic acid, gallic acid, and punicalagin which are identified as major effectors of antitumor activity. Gallic acid has been demonstrated to have an antioxidant activity that can influence cancer cell proliferation. The aim of the study was to identify the gallic acid content in pomegranate peel ethanol extract and to measure its antioxidant. This study was an experimental study performed at the Biochemistry and Molecular Biology Laboratory and Central Laboratory of Universitas Padjadjaran Bandung, Indonesia during September-December 2019. Gallic acid concentration was measured by using a high-performance liquid chromatography method (HPLC) and the antioxidant activity was measured by using 1,1-diphenyl-2-picrylhydrazyl (DPPH). The extract contained 616.97 mg/kg of gallic acid with an antioxidant activity of IC50 6.1 µg/mL. In conclusion, gallic acid has cytotoxic and antitumor effects from its ability to modulate antioxidant/pro-oxidant balance and inhibit reactive oxygen species (ROS). Therefore, both gallic acid content and antioxidant activity parameters can be used as markers in pomegranate peel extract which shows activities that inhibit HeLa cell proliferation. Kandungan Asam Galat dan Aktivitas Antioksidan Ekstrak Etanol Kulit DelimaEkstrak etanol kulit buah delima terbukti dapat menghambat proliferasi sel kanker serviks (sel HeLa). Ekstrak ini telah dilaporkan mengandung asam ellagat, asam galat, dan punicalagin yang diidentifikasi sebagai efektor utama dari aktivitas anti-tumor. Berdasarkan pernyataan sebelumnya, pemeriksaan ekstrak akan dilakukan dengan mengidentifikasi salah satu senyawa tersebut yaitu asam galat. Aktivitas antioksidan dapat mempengaruhi proliferasi sel kanker, oleh karena itu, akan ditentukan pada ekstrak. Penelitian ini dilakukan di Laboratorium Biokimia dan Biologi Molekuler dan Laboratorium Sentral Universitas Padjadjaran periode September-Desember 2019. Kandungan asam galat diukur dengan metode kromatografi cair kinerja tinggi (KCKT) dan aktivitas antioksidan diukur dengan metode 1,1-difenil-2-pikrilhidrazil (DPPH). Ekstrak mengandung asam galat 616,97 mg/kg dan memiliki aktivitas antioksidan IC50 6,1 μg/mL. Berdasarkan aktivitasnya, asam galat mempunyai efek sitotoksik dan antitumor yang dihasilkan oleh kemampuannya untuk memodulasi keseimbangan antioksidan/pro-oksidan dan menghambat spesies oksigen reaktif. Aktivitas antioksidan yang sangat kuat dari ekstrak juga disebabkan oleh adanya asam galat; asam galat dikenal sebagai antioksidan kuat. Antioksidan mampu melindungi sel normal dengan menurunkan level ROS, sehingga memproteksi sel dari kerusakan. Dengan demikian, kedua parameter tersebut dapat digunakan sebagai bagian dari penanda untuk ekstrak kulit delima yang mempunyai aktivitas menghambat proliferasi sel HeLa
Nuclei DNA Damage Due to Extreme High-Temperature Exposure during Forensic Identification Examination
Get PDFAccurate personal identification is important in investigations because an error in the identification process may bring fatal consequences during trial. The most common identification process is the Deoxyribonucleic acid [DNA] analysis. Degraded DNA sample due to extremely high-temperature exposure may limit DNA analysis. This study aimed to analyze DNA damage patterns caused by an extremely high temperature using STR (short tandem repeat) CODIS marker. This study was conducted at the Forensic and Medicolegal Department, Laboratorium Balai Besar Kesehatan Surabaya, Ministry of Health of the Republic of Indonesia, Human Genetic Study Group of Universitas Airlangga, and Faculty of Science and Technology of Universitas Brawijaya Malang from July until October 2009. Results of PCR visualization using STR CODIS for costae demonstrated that the THO1 detection (+) in 1,2500C - 40’: 25% and the TPOX detection (+) in 1,0000C - 30’: 50% whereas the results from molar teeth showed that the THOI locus detection (+) in 1,2500C - 30’: 25% and TPOX in 1,0000C - 40’: 50%. Results for PCR visualization using mini-STR CODIS for the costae presented that the mini-THOI in 1,2500C - 20’: 50% (+) while for the molar tooth the mini-THOI in 1,2500C - 30’ : 25% (+) and mini-TPOX in 1,0000C - 40’ : 50% (+). All loci were detected on costae and second molar teeth samples of the control group. Thus, extreme high-temperature exposure significantly decreased the DNA level of second costae and second molar tooth. Sequence patterns of STR loci successfully detected were TPOX, THO1, and CSF1PO.Kerusakan DNA Inti Karena Paparan Suhu Tinggi Selama Proses Identifikasi ForensikIdentifikasi melalui DNA secara tepat penting dalam penyelidikan karena kesalahan akan berakibat fatal selama proses persidangan. Salah satu keterbatasan adalah DNA yang terdegradasi karena paparan suhu yang sangat tinggi. Penelitian ini bertujuan menganalisis pola kerusakan DNA akibat suhu sangat tinggi menggunakan penanda CODIS STR (short tandem repeat). Penelitian dilakukan di Instalasi Kedokteran Forensik, Laboratorium Kemenkes, Human Genetic Study Group, dan Universitas Brawijaya Malang pada periode Juli sampai Oktober 2009. Visualisasi PCR menggunakan STR CODIS untuk costae adalah sebagai berikut: deteksi THO1 (+) pada 12500C - 40’: 25%, deteksi TPOX (+) pada 10000C - 30’: 50%, sedangkan hasil dari gigi molar adalah sebagai berikut: THOI locus detection (+) di 12500C - 30’: 25% dan TPOX di 10000C - 40’: 50%. Hasil visualisasi PCR menggunakan mini-STR CODIS untuk costae adalah sebagai berikut: mini-THOI pada 12500C - 20’: 50% (+) dan untuk gigi molar: mini-THOI pada 12500C-30': 25% (+ ) dan mini-TPOX di 10000C - 40’ : 50% (+). Semua lokus terdeteksi pada kelompok kontrol pada sampel costae dan gigi molar kedua. Kesimpulannya, paparan suhu tinggi yang ekstrim secara signifikan menurunkan tingkat DNA kosta dan gigi molar kedua.
Differences in Bleeding Episodes in Severe Hemophilia A Based on Nutritional Status
Get PDFBackground: Hemophilia A is a congenital bleeding disorder caused by the deficiency of coagulation factor VIII and is characterized by joint bleeding, especially in weight-bearing joints. An excess weight may cause bleeding in hemophilia due to increased joint tension. This study aimed to determine the differences in bleeding episodes between severe hemophilia A patients with and without excess weight.Method: A comparative observational analytic study was conducted in March-November 2019 using a cross-sectional design. Subjects were patients with severe hemophilia A registered in the Indonesian Hemophilia Society Association in West Java and had had severe hemophilia A for at least two years old with complete data on date of birth, height, weight, and bleeding intensity. Subjects were divided into groups with excess weight (excess weight) and without excess weight (non-excess weight). Nutritional status in adults was determined based on age-specific percentile BMI. Bleeding episodes were determined as frequency of bleeding in one year. The Mann-Whitney statistical test was used to observe the difference between groups.Result: Of 226 severe hemophilia A patients registered, only 155 patients were included. Of these, 121 patients did not have excess weight and 34 had excess weight. The median bleeding episodes of in the non-excess weight and excess weight groups were 24(1-48) and 24(8-48), respectively (p=0.761).Conclusion: There is no difference in bleeding episodes Between severe hemophilia A patients with excess weight and without excess weight. However, good nutrition education needs to be provided to these patients since excess weight may increase bleeding in joints
Elderly Quality of Life and Its Predictors in Chronic Disease Management Program: Indonesian Version of WHOQOL-BREF and WHOQOL-OLD
Get PDFIndonesia is currently experiencing increasing proportion of older population, which also increases the prevalence of chronic diseases that may decrease the quality of life (QoL). The Indonesian Social Security Agency develops a program to control chronic diseases, which is referred to as the Chronic Disease Management Program (Program Pengelolaan Penyakit Kronis, PROLANIS) for the National Health Insurance participants. Its goals is to control chronic diseases in order to improve participants’ QoL. To evaluate the QoL of the elderly, the World Health Organization (WHO) has developed two questionnaires, namely WHOQOL-BREF and WHOQOL-OLD. The objective of this study was to analyze the differences in the QoL of the elderly between PROLANIS and non-PROLANIS participants using the Indonesian-verson of WHOQOL-BREF and WHOQOL-OLD as well as the QoL predictors. A cross-sectional study was carried out to 84 elderly PROLANIS participants (n=42) and non-PROLANIS participants (n=42). Respondents were sampled consecutively from 6 public health health centers (Pusat Kesehatan Masyarakat, Puskesmas) in Bangka District, Indonesia in 2018. Mann Whitney test or the unpaired T test were used to statistically analyze the difference between the two groups. A multiple linear regression test was then carried out to determine the predictors of the QoL. This study discovered that no difference was observed in the QoL of the elderly between PROLANIS and non-PROLANIS participants. Disease status and depression were the predictors of the QoL. Therefore, PROLANIS has not been proven to be able to improve the QoL of the elderly. Kualitas Hidup Lanjut Usia dan Prediktornya pada Program Pengelolaan Penyakit Kronis: Versi Indonesia dari WHOQOL-BREF dan WHOQOL-OLD Peningkatan proporsi penduduk lanjut usia (lansia) di Indonesia meningkatkan prevalensi penyakit kronis sehingga dapat menyebabkan penurunan kualitas hidup. Badan Penyelenggara Jaminan Sosial mengembangkan Program Pengelolaan Penyakit Kronis (PROLANIS) bagi peserta Jaminan Kesehatan Nasional dengan tujuan agar penyakit kronis tersebut terkontrol dan lansia dapat hidup berkualitas. World Health Organization (WHO) mengembangkan instrumen untuk mengukur kualitas hidup, yaitu WHOQOL-BREF dan WHOQOL-OLD. Penelitian ini bertujuan menganalisis adanya perbedaan kualitas hidup lanjut usia antara bukan peserta PROLANIS dan peserta PROLANIS menggunakan kuesioner WHOQOL-BREF dan WHOQOL-OLD versi Bahasa Indonesia dan faktor yang berpengaruh. Penelitian potong lintang dilakukan pada 84 lansia yang terbagi menjadi 2 grup masing-masing 42 responden, yaitu bukan peserta PROLANIS danpeserta PROLANIS. Responden berasal dari 6 Puskesmas di Kabupaten Bangka Provinsi Bangka Belitung Indonesia pada tahun 2018 yang dipilih sesuai kriteria inklusi dan dengan metode consecutive sampling. Data yang terkumpul dilakukan analisis menggunakan Uji Mann Whitney atau uji T tidak berpasangan. Uji regresi linier multipel dilakukan untuk menentukan prediktor dari kualitas hidup. Hasil penelitian menunjukkan bahwa tidak ada perbedaan kualitas hidup lansia antara bukan peserta PROLANIS dan peserta PROLANIS. Status penyakit dan depresi merupakan prediktor kualitas hidup. Simpulan, PROLANIS belum terbukti dapat meningkatkan kualitas hidup lansia
The Characteristics, Knowledge, and Attitude of Pregnant Women Regarding Early Breastfeeding Initiation on the Fourth Antenatal Care Visit
Get PDFBackground: Early breastfeeding initiation within one hour after birth can reduce maternal and neonatal mortality. One of the interventions given on the fourth antenatal care (ANC) visit is providing information regarding breastfeeding initiation, however, the implementation is low. Many factors may influence breastfeeding initiation, including knowledge and attitude. The aim of this study was to analyze the relationship among the characteristics, knowledge, and attitude of the pregnant women on the fourth ANC visit regarding early breastfeeding initiation in Jatinangor.Methods: An analytic cross-sectional study was conducted in September 2013. A total of 61 pregnant women registered for the fourth ANC visit (K4) in Jatinangor Public Health Center were involved in this study. Data were collected from questionnaires. Data on the number of gestation, level of education, source of information regarding breastfeeding initiation, knowledge and attitude about early breastfeeding initiation were collected and analyzed using chi-square.Results: There was a significant relationship between a number of gestation, level of education, source of information and knowledge also attitude, as well as between age and attitude (p0.05).Conclusions: Number of gestation, level of education, and source of information have a significant relationship with both knowledge and attitudes about early breastfeeding initiation
Relationship between Calcification on Mammography and Human Epidermal Growth Factor Receptor 2 (HER-2) Expression in Breast Carcinoma
Get PDFBackground: Breast carcinoma shows over-expression of Human Epidermal Growth Factor Receptor 2 (HER-2) in 18 to 20% of the cases. This type of cancer is very progressive and has a poor prognosis. This study aimed to determine the association between the calcification on mammography with HER-2 expression in breast carcinoma as a marker of breast carcinoma aggressiveness.Methods: This was an analytic observational study with a case-control design. Patients with breast carcinoma at the Department of Radiology and Department of Anatomical Pathology of Dr. Hasan Sadikin General Hospital Bandung from July–September 2019 were enrolled in this study. Samples were consecutively collected. The association of calcification on mammography and HER2 expression was analyzed using the Chi-square test.Result: In total, 40 patients were included, consisting of 20 individuals with HER-2 positive and 20 individuals with HER-2 negative. The youngest was 40 years old and the oldest was 73 years old. Statistical test results showed that there was a significant association between calcifications in mammography and HER-2 expression (p-value = 0.0001, OR 13.22; 95% CI 2.7–62.6).Conclusions: There is a significant association between calcification on mammography and HER-2 expression in breast carcinoma, suggesting that positive calcification mammography was 13.22 times higher in patients with HER-2 positive compared to patients with negative calcifications
Functional Recovery of Rare Case of Sciatic Nerve Schwannoma with Peripheral Nerve Block and without Intraoperative Neurophysiological Monitoring
Get PDFSchwannoma are benign peripheral nerve tumors derived from the Schwann cells in the neural sheath. Sciatic nerve schwannoma in the lower extremity is uncommon, accounting for only 1% of all schwannoma cases. This report aimed to describe the functional recovery after lower limb surgery of sciatic nerve schwannoma with peripheral nerve block and without intraoperative neurophysiological monitoring (IOM) performed in Semen Padang Hospital in 2019. A 78-year-old woman presented with a complaint of pain on her slowly growing mass at the right popliteal region, which had existed for 22 years. Microsurgical resection was performed with local peripheral nerve block and without intraoperative neurophysiological monitoring. Tumor was removed en-bloc by sharp dissection using a microscope without any complication. The patient had significant pain relief without any neurologic deficit three weeks after the surgery. Penyembuhan Secara Fungsi Kasus Langka Schwannoma Saraf Sciatic dengan Blok Saraf Perifer Tanpa Pemantauan Neurofisiologis Intraoperatif Schwannoma adalah tumor saraf tepi jinak yang berasal dari sel Schwann dalam selubung saraf. Pada ekstremitas bawah, schwannoma saraf sciatic jarang terjadi, terhitung 1% dari semua schwannoma. Laporan ini bertujuan menggambarkan pemulihan fungsional dengan blok saraf perifer setelah operasi tungkai bawah schwannoma saraf sciatic tanpa pemantauan neurofisiologis intraoperatif (IOM) di Rumah Sakit Semen Padang, 2019. Seorang wanita 78 tahun datang dengan keluhan nyeri pada massa yang tumbuh perlahan di daerah popliteal kanannya selama 22 tahun. Reseksi bedah mikro dilakukan dengan blok saraf perifer secara lokal dan tanpa pemantauan neurofisiologis intraoperatif. Tumor terangkat secara en-bloc dengan diseksi tajam menggunakan mikroskop tanpa ada komplikasi. Pada minggu ketiga pascaoperasi, pasien mengalami pengurangan rasa sakit yang signifikan tanpa defisit neurologis
PLASMAFARESIS PADA PASIEN STATUS EPILEPTIKUS AKIBAT ENSEFALITIS ANTI- NMDAR DI UNIT PERAWATAN INTENSIF
Get PDFSejak tahun 2007 penyebab lain ensefalitis diketahui adalah autoimmun selain virus sebagai penyebab terbanyak (69%) dengan angka kematian di dunia 8–18,45%. Ensefalitis anti-NMDAR adalah ensefalitis autoimun akibat reaksi antibodi terhadap antigen membran ekstraseluler, subunit NR1, yaitu reseptor glutamat NMDA di sinapsis susunan saraf pusat. Kasus ensefalitis NMDAR sangat jarang dijumpai, berdasarkan penelitian yang teridentifikasi hanya 1% pasien usia 18–35 tahun yang dirawat di Unit Perawatan Intensif (UPI), namun dengan penatalaksanaan yang tepat dapat meningkatkan prognosis pasien. Pasien laki-laki, usia 36 tahun dikonsulkan ke UPI RSHS setelah 10 hari rawatan di Neuro High Care (NHC) pada bulan Agustus 2019 dengan penurunan kesadaran disertai riwayat kejang berulang dengan diagnosis ensefalitis anti-NMDAR. Kombinasi obat anti-viral, anti-epilepsi, dan metilprednisolon yang diberikan sebelumnya di ruangan tidak memberikan perbaikan klinis bermakna. Selama perawatan di UPI pasien diberikan terapi plasmafaresis dan menunjukkan perbaikan secara signifikan. Bangkitan kejang berulang dapat berupa kejang parsial, kejang generalisata dan status epileptikus. Manifestasi kejang diduga terjadi karena terbentuknya antibodi yang menyerang reseptor glutamat NMDA dengan target utama NR1. The American Society for Apheresis merekomendasikan plasmaferesis sebagai pilihan terapi utama. Simpulan, terapi plasmafaresis dalam tata laksana kasus ensefalitis anti- NMDAR merupakan pilihan tepat karena terbukti efektif dan efisien dalam perbaikan klinis pasien melalui mekanisme penurunan titer antibodi terhadap reseptor NMDA. Plasmapheresis in Patients of Epilepticus Status Patients Due to Anti-NMDAR Encephalitis in Intensive Care UnitsSince 2007 another known cause of encephalitis is autoimmune other than viruses as the most common cause (69%) with a mortality rate in the world of 8-18.45%. Anti-NMDAR encephalitis (n-Methyl-D-Aspartate receptor) is an autoimmune encephalitis due to an antibody reaction to the extracellular membrane antigen, NR1 subunit, the NMDA glutamate receptor at the synapses of the central nervous system. Cases of NMDAR encephalitis are very rare, based on studies that identified only 1% of patients aged 18-35 years who were treated in the Intensive Care Unit (ICU), but with proper management could improve the patient's prognosis.Male patient, 36 years old, was admitted to ICU RSHS after 10 days of treatment at Neuro High Care (NHC) in August 2019 with decreased consciousness accompanied by a history of recurrent seizures with a diagnosis of anti-NMDAR encephalitis. The combination of anti-viral, anti-epileptic, and methylprednisolone drugs given previously at NHC did not provide clinically meaningful improvement. During treatment at ICU, patients were given plasmafaresis therapy and showed significant improvement. Recurrent seizures can be partial seizures, generalized seizures and status epilepticus. Seizure manifestations are thought to occur due to the formation of antibodies that attack NMDA glutamate receptors with the main target NR1. The American Society for Apheresis recommends plasmapheresis as the main therapeutic choice. In conclusion, plasmafaresis therapy in the management of anti-NMDAR encephalitis cases is the right choice because it is proven effective and efficient in the clinical improvement of patients through the mechanism of decreasing antibody titers to NMDA receptors.Ensefalitis memiliki angka kejadian dan kematian yang tinggi di seluruh dunia sekitar 8 – 30% dengan penyebab terbanyak virus (50%). Namun, sejak tahun 2007 diketahui penyebab lain ensefalitis yaitu yang disebabkan oleh autoimun. Ensefalitis anti NMDAR (n-Methyl-D-Aspartate receptor) adalah ensefalitis autoimun yang disebabkan oleh adanya reaksi antibodi terhadap antigen membran ekstraseluler yaitu subunit NR1, suatu reseptor glutamat NMDA di sinapsis susunan saraf pusat. Bangkitan kejang berulang berupa kejang parsial, kejang generalisata dan status epileptikus dapat terjadi pada kasus ensefalitis anti-NMDAR. Manifestasi kejang terjadi diduga oleh karena terbentuknya antibodi yang menyerang reseptor glutamat NMDA dengan target utama adalah NR1, yang merupkan sub unit dari NMDAR. Antibodi ini akan merusak reseptor NMDA sehingga terjadi penurunan jumlah reseptor NMDA, inhibisi oleh GABA dan sinaps glutamat yang mengakibatkan disinhibisi dari jalur eksitatorik, peningkatan kadar glutamat di ekstraseluler, menyebabkan kerja frontostratial terganggu dan menimbulkan gejala psikosis, katatonia, dan rigiditas. Penatalaksanaan ensefalitis anti reseptor NMDAR berbeda dari ensefalitis lainnya oleh karena manifestasi klinis berbeda. Menurut The American Society for Apheresis, terapi imunoterapi dengan plasmaferesis direkomendasikan sebagai terapi pada kasus ensefalitis anti NMDA. Immunoterapi sebagai lini pertama saat ini adalah kortikosteroid dosis tinggi 1 gr/hari untuk 5 hari, plasmafaresis, atau IVIG. Plasmafaresis diberikan pada pasien ini ketika dengan pemberian kortikosteroid tidak menunjukkan perbaikan klinis. Cara kerja plasmafaresis adalah bertujuan untuk menurunkan titer antibodi terhadap reseptor NMDA. Prognosis penyakit berkaitan dengan kecepatan penegakkan diagnosis dan ketepatan dalam memberikan terapi. Terapi plasmafaresis dalam tatalaksana terapi ensefalitis anti NMDAR pada kasus ini merupakan pilihan yang tepat ketika kombinasi obat anti viral, anti epilepsi, dan metil prednisolon tidak memberikan perbaikan klinis yang bermakn