himpunan riset covid19

1. BACKGROUND identify particular care of diabetes in
The rapid spreading of COVID-19 globally specific conditions.
has extensively brought many
consequences on care particularly for 2. METHODS
patients who have comorbid conditions 2.1 Study Design
[1,2]. Diabetes ranked second as the
most prevalent comorbidities (9.7%, 95% Scoping review aims to draw key
CI 6.9e12.5%) among COVID-19 patients concepts of available literature in
after cardio-metabolic diseases [1,3,4]. underpinning a research area. This
People living with diabetes are at higher design was chosen because it provided a
risk of having COVID-19 infection and broaden scope of specific field. The
potentially experiencing more severe illness scoping review procedure proposed by
when infected [4,5]. A meta-analysis from Arksey & O’Malley was used [9]. This
China reported that COVID-19 patients with pro- cedure suggests five steps for a
diabetes had twice the risk of intensive care rigorous review;1) identifying clear
unit (ICU) admission [6] and it makes research aims and searching strategies,
diabetes as independent predictor of ICU 2) identifying appropriate research
admission or invasive mechanical papers, 3)selecting research paper,4)
ventilation in COVID-19 pa- tients [3,7]. A extracting and charting the data, 5)
recent systematic review also identified that summarizing, analyzing and presenting
COVID- 19 patients with diabetes is the outcomes on report.
related to an increased risk of ICU
admission (OR: 2.79, 95% CI 1.85e4.22, 2.2 Literature Search Strategy
I2 46%, p <0.0001) and higher mortality Literature search was conducted
rate (OR 3.21, 95% CI 1.82e5.64, I2 16%, extensively by searching in several
p < 0.0001) [3]. Maintaining good glycemic databases. Two authors (ALW and NSH)
control is an effective approach to prevent performed independently search on
COVID-19 transmission in diabetic patients PubMed, Science Direct, Directory of Open
[7,8]. However, in many countries, diabetes Access Journal (DOAJ), and Microsoft
control becomes challenging because of Academics databases for lit- eratures
the imposing government policy to control published between January 1 and April 17,
transmission such as social distancing and 2020. The keywords were adopted from
lockdown. Most diabetic people could Medical Subheading (MESH) and used
experience barriers in accessing Boolean to improve sensitivity. The
measures for controlling their glycemic following search terms adopted from MESH
level such as limited access to were used: (“COVID-19” OR “severe acute
healthcare, limited avail- ability of fresh respiratory syndrome coronavirus 2”) AND
food, and limited physical activity “Diabetes Mellitus”. Only English literatures
because of confinement [7].The COVID- were included for review. Non-scientific
19 during pandemic affects diabetes publication, correspondences, news and
management. Diabetes educators, commentary were excluded.
physicians, nurses and other health care
providers, need appropriate and accurate 2.3 Identification And Selection Relevant
information to facilitate diabetic patients Articles
in taking care of their diabetes amid the The outcome of two independent
COVID-19 pandemic. Therefore, the aim searches was compared. Difference
of this paper is to provide a review on the finding were communicated and
appropriate diabetes management during discussed until the same numbers of
the COVID-19 pandemic for people living articles were reported. Duplicated articles
with diabetes. In addition, this review will were removed. Excel spreadsheet was
used to short-list the articles during

selection procedure. Seven articles were from Asian region (57.14%, n4) followed by
included for review after screening and European and American region (28.57%, n
checking eligibility. The preferred 2; 14.29%, n 1, respectively). All articles
reporting item for systematic review and discussed diabetes management domain
meta-analysis (PRISMA) was used as and only 71.43% provided information for
guidance in reporting the searching specific consideration domain. Fig.2 shows
process (Fig.1) [10]. the subdomains iden- tified in the articles.
Most articles focused on medication
2.4 Data Extraction (71.43%) and only 1 article (14.29%)
Included articles were compiled and discussed about COVID-19 preventive
extracted in an Excel worksheet. The action for diabetes patients. In terms of
extracted data included title, authors and specific consideration domain, most articles
date of publication, country and region, focused on emergency or critical care
research objective, study design, target (42.86%). Most articles used review or
of study, sample size, study setting, data unclear study design (42.86%, n 3 for both).
collection, key findings, research domains The majority of study targets were patients
and subdomains. (57.14%, n 4) and located in hospital and
community setting (57.14%, n 4). Most
2.5 Summarizing the findings included studies did not reported sample
All the included articles were categorized size (71.43%,n5,Table 1).
into two domains i.e. diabetes
management and specific consideration. 3.2 Data Extraction Of The Included Articles
Diabetes management refers to all Information of data extraction is available
actions to treat, manage and cope with in Table 2. All included articles covered
disease process of diabetes. Specific research domains and subdomains
consideration concerns on such particular through presenting main findings.
situation that requires thoughtfulness of Although some included articles did not
care. Diabetes management domain was provide detail information of study design,
further classified into six sub domains i.e. sample size, and data collection; the
glycemic control and monitoring, dietary articles were analyzed and presented
intake, physical activity, medication, since it covered the research aims.
education, and prevention. Specific
consideration was classified into sub 4. Discussion
domains of diabetes in children and 4.1 Diabetes Management
adolescents, pregnancy, older people,
and emergency or critical care. According to The American Diabetes
Methodological characteristics of the Association standard of diabetes care for
articles were also evaluated using Excel patients and health care workers,
spreadsheet. Each article will be diabetes care should includes
assessed about the study design, target comprehensive medical assessment of
of study, sample size, and setting. Then, comorbid- ities, lifestyle management,
the data were classified and presented in glycemic control, medication, obesity
the percentage. management, risk reduction, and
prevention of diabetes complication
3. RESULTS [14e16]. Diabetes management will be
3.1 Characteristic Of Published Articles discussed according to these standards
of care: glycemic control and monitoring,
Most articles were published in journal of dietary intake, physical activity,
diabetes and meta- bolic diseases (85.71%, medication, education, and prevention of
n6) followed by medical virology journal COVID-19 infection in the context of
(14.29%, n1).The majority of articles were COVID-19 pandemic.

4.1.1 Glycemic Control And Monitoring
All diabetic patients must maintain glycemic control and monitoring during the pandemic. Patients
with diabetes could potentially find difficulties for glycemic control and monitoring during the
lockdown or quarantine. They could have problem on getting an access to medicine and
glycemic monitoring materials, including glucose strips, glucometers, and needles. Thus, it is
recommended for diabetic patients to early purchase the glycemic monitoring materials

and medicine through online [2,7,8]. A Glycemic monitoring using capillary blood
tailored glycemic monitoring for diabetic test is acceptable for people living with
patients could be adjusted by considering diabetes during pandemic [2,7]. All
age, existing comorbidity, clinical hospitalized COVID-19 patients with
manifestation, and other risk factors [8]. diabetes should undergo closed glycemic

control and routine blood glucose less than 125 mg/dl or HbA1c less than
monitoring. Previous research indicated or equal to 6.5%) could be performed
that COVID-19 patients with diabetes were once or twice a week. Meanwhile, for
associated with the poor outcomes of diabetes patients who administer insulin
health [3,7]. When they are discharged, with poor outcomes or intermittent
blood glucose monitoring is highly hypoglycemia, blood glucose should be
recommended amid a 4-week follow up checked at least four times a day i.e.
after discharge and they have to avoid fasting, pre-lunch, pre-dinner and
exposure to infection [8].Timing for bedtime. Any sign or symptom of
glycemic control and monitoring can be occurring hypoglycemia is reason to
adjusted for particular occasion. During immediately check capillary blood
pandemic, fasting and postprandial blood glucose. All blood glucose checking
glucose in diabetes patients who should be recorded for a minimum of
consume oral anti diabetic agent(s) with consecutive three days and
tolerable outcomes (i.e. stable blood communicated to health care providers
glucose record or fasting blood glucose through teleconsultation [2,7].

Fig. 2. Research subdomains of the published articles. Note: Percentage in this figure was not
summed up to 100% due to possibility of multiple subdomains in one article.

4.1.2 Dietary Intake 4.1.3 Physical Activity
Lockdown during COVID-19 pandemic Social distancing, lockdown and home
could affect patient’s dietary habit. Patients confinement require patients with diabetes
with diabetes may find limited access to to limit their activities or regular exercise.
fresh fruits and vegetables [2,7] and However, they could still have limited
consume canned or packaged foods that access to indoor and outdoor physical
are high in calories and/or fats [2]. Healthy activities [2]. Home exercise such as
and balanced diet should be emphasized treadmill, stationary cycling or jogging and
and encouraged by dietician to diabetic resistance training should be recommended
patients during the consultation [7,13]. The [2,7,13].
recommended calorie intakes for obese Tailored physical activity while quarantine
and non-obese diabetes patients are 20 should be practiced about 60 min/day. The
kcal/kg and 22e25 kcal/kg of ideal body intensity and type of activities could be
weights with sedentary lifestyle, adjusted regarding individual patient’s
respectively. Dietary advice should include condition. The recom- mended physical
low carbohydrate intake, low fats intake, activity is classified into three exercises i.e.
and optimal protein intake with no meal aer- obics, flexibility workout, and strength
skipping [13]. Daily diet should be divided muscle exercises. Aerobic exercise with
into three meals and a snack.Variation of moderate intensity i.e. brisk walking,
food composition is recommended, treadmill, sta- tionary jogging or cycling,
consisting of 50e60% complex dancing, jumping, sport aerobic, and
carbohydrates, 25e45% fibers, up to 30% gardening, is suggested for a minimum of
fats, 1 g/ kg/day (general patients) or 0.8 30 min/day [7,13]. If this is unachievable,
g/kg/day (nephropathy and macro- patients could take two or three times
albuminuria) of proteins. The use of oils in small portion of aerobic exercise (10e15
should be no more than 3 teaspoons a day min). Climbing stairs, household routine
and less than 5 g/day for sodium intake. activities [7] or yoga practice as stretching
Patients could also use the diabetes plate technique [13] for 15 min/day is
method i.e. half plate of vegeta- bles, one- recommended as flexibility training [7,13]. A
fourth of proteins, and one-fourth of 11 steps of yoga pranayama for chronic
complex carbohy- drates. Alcohol, smoking, condition could be imple- mented to
and sugary sweetened foods should be enhance pulmonary function [17]. A 15 min
avoided [7]. of squats, push-ups, sit-ups, forward flexes
or small weight lift as muscle training
exercise every day is recommended as

muscle training exercises [7,13]. A physical antidiabetic agents in the context of
activity for diabetes patients with heart treatment for COVID-19 patients with
diseases or hypoglycemia history should be diabetes though some antidiabetic agents
noticed as particular circumstance [7]. indicate positive outcome of glycemic
control. The application of angiotensin
4.1.4 Medication converting enzyme (ACE) inhibitors and
Health care providers need to assess angiotensin receptor blockers (ARB) is
patient’s adherence to medication hypothetically useful to treat COVID-19
through tele-consultation using valid but patients, however, there is still no data to
brief tools. They also should make sure support it. Currently, the Association of
that all diabetes patients have sufficient European and American Cardiology and
medication stocks and prescribe enough Hypertension recommend ACE inhibitors
medication because of limited access to and ARB to treat COVID-19 although it
clinic during the pandemic [7]. lacks of evidence to support [2].
To date, there is no robust evidence of











Adjustment of sulfonylurea and insulin dose five days. About 80.6% patients indicated
may be necessary to prevent improvement of COVID-19 pneumonia and
hypoglycemia. All diabetes patients should none developed severe COVID-19
be provided information on adverse effects pneumonia. Among COVID-19 patients with
of anti-diabetic agents and encourage them diabetes, hydroxychloroquine works as
to report any adverse effect [13]. hypoglyce- mia agent by decreasing HbA1c
Additionally, it was reported that 44.9% and hyperglycemia [11]. COVID-19 patients
non-ICU and 72.2% ICU patients with with type 1 diabetes who receive
COVID-19 received glucocorticoid therapy Chloroquine therapy is potentially
as daily treatment. Glucocorticoid was experiencing hypoglycemia as its side
associated with hyperglycemia and induced effect. Chloro- quine agent has
more severe clinical manifestation. Recent hypoglycemia and immunomodulatory
review found that the use of glucocorticoid effects, and therefore all patients should be
was not recommended to treat COVID-19 closely monitored. In diabetic an- imals,
pneumonia and could cause harm [11]. Chloroquine causes an increase in the level
Previous reported COVID-19 patients of insulin serum by providing a signal to
obtained a hydroxy- chloroquine therapy. In cellular receptors and post-receptor
a small-randomized trial, COVID-19 pa- clearance [12]. All diabetic patients who
tients with mild sign/symptom of pneumonia receive hydroxy- chloroquine should obtain
(by CT scan), received oral education on the contraindication such as
hydroxychloroquine 200 mg twice a day for diabetic neuropathy and history of seizure

[7]. general precaution during tele-consultation.
When telemedicine or tele- consultation is
4.1.5 Diabetes Education not compatible, face-to-face clinic visit is
Because of the COVID-19 pandemic, accept- able by considering time and place
regular visit to hospital/ clinic by diabetes is for preventing transmission of Cavid19.
impeded. Type 1 diabetes patients should Telemedicine is also not doable for clinical
contact endocrinologists while type 2 examination and psychotropic/narcotic
diabetes patients are suggested to consult prescription [13].
with internal medical specialists or general
practitioners [5,7]. It is recommended to 4.1.6 Prevention Of COVID-19 Infection
conduct online or tele- consultation to keep As previously reported, patients with
in touch with the health care providers [7,8]. diabetes are at higher risk for COVID-19
Endocrinologist could provide consultation infection. In general, diabetes patients
by optimizing the use of smartphone should adhere to social distancing and
application (i.e. WeChat, WhatsApps, Line) home confinement policy as primary pre-
to share educational videos, e-books, and ventive method. They should avoid
recommendations [8]. A previous meta- contacts or exposure with confirmed
analysis showed that telemedicine COVID-19 patients as much as they can. It
practice during non-pandemic era by is recom- mended that patients with
emails, phones, and videos, for 3e60 diabetes should arrange an individual plan
months in China showed significant of diabetes management while staying at
reduction of HbA1c ( 0.37%, p < 0.001) home or getting sick. They can make a to
[18]. Another Cochrane review on do list for dietary intakes, physical activities,
telemedicine also indicated similar and stress management during
outcomes, i.e. decline in HbA1c of 0.31% (p confinement. All diabetes patients are
< 0.001) [19]. A recent review on 46 strongly recommended to keep maintaining
studies on telemedicine among type 1 their glycemic control as part of risk
(n 2052) and 2 diabetes (n 24,000) patients reduction of infection and/or prevent severe
showed significant reduction of HbA1c consequence of infection for confirmed
(0.12% to 0.86% and 0.01 to 1.13%, COVID-19 patients with diabetes [5,8]. All
respectively) [20]. A video mode of diabetes patients should visit hospital to
telemedicine is also recommended for the consult with phy- sicians or nurses when
first consultation. Patient’s privacy, they are suspected of COVID-19 infection.
confidentiality, and consent (from Fever and cough, dyspnea or pneumonia,
surrogates, caregivers or patients) should visiting a pandemic area and recent contact
be maintained. Radi- ology, laboratory with confirmed COVID-19 patients are
findings and prescription should be factors for diabetes patients to be
integrated in medical records. Previous suspected as COVID-19 infection. When
history of complaint, allergy, and hypo- patients decide to go to hospital or clinic,
glycemia are of main concern. Identification patients with diabetes should use
of any noticeable neurological deficit is facemasks. They will undergo diagnosis
applicable by requesting patients to perform procedure by taking samples from noses or
simple neurological test. Video or throat [5]. In case of home confinement,
photograph could help when suspecting patients and families should adhere to the
any lesion on foot, abscess or visible rules for affected or suspected people
wound. All patients should recognize because it could help to prevent further
sign/symptom of hypoglycemia and know transmission to other patients and/or
how to treat it. Health care providers should families. The affected people should live in
always remind patients to do hand washing, a single room with proper ventilation,
cough technique and social distancing as meanwhile other family members stay in

different room. If this is not applicable, 4.2.3 Diabetes In Elderly
make sure to always keep a minimum 1-m Elderly patients with diabetes are more
distance from the affected person, routine likely to have deteriorated glycemic control
hand washing after any contact with the as result of raised blood glucose amid
affected patient or the environment and use COVID-19 pandemic [7]. Hyperglycemia or
disposable paper towel or clean towel (and hypoglycemia could occur due to limited
replace it when it is getting wet) after hand access of care during lockdown and
wash. The affected person should use quaran- tine, which stimulate unstable
medical mask to cover nose and mouth. All blood glucose. It can lead to further serious
caregivers also need to wear full-covered complication for elderly patients with
medical mask when being in the same diabetes for example ketoacidosis,
room with the affected person [5]. infection, coma hyperosmolar, and cardiac
event. The drawback is more distinct
4.2 Specific Consideration among elder diabetic patients who live
Diabetes management is inevitably altered alone [2]. It is recommended to encourage
during the COVID-19 pandemic. Therefore, them and always keep in touch with health
specific condition is required for specific cir- care providers and quickly seek for help
cumstances. The following section will when needed.
discuss diabetes manage- ment in a certain
population or situation based on the current 4.2.4 Emergency Or Critical Situation
available evidences. All diabetic patients who are experiencing
drowsiness, vomit- ing, chest pain, short of
4.2.1 Diabetes In Children And Adolescents breath, limb weakness, and altered sensory
In child or adolescent with newly diagnosed should be noticed as emergency situation
type 1 diabetes, it is recommended to take [9]. In addition, diabetic patients with any
face-to-face mode of consultation. Type 1 foot lesion, gangrene, severe
diabetes patients and families should visit hypoglycemia, gastroenteritis, and any
diabetes clinic to initiate insulin other infection related to COVID-19 should
administration. Health care providers be addressed for special condition. All of
should make sure that patients and families these situations require hospital/clinic visit
receive diabetes education with highlighted or admission [13]. Health care providers
topic on insulin administration, should make sure diabetic patients
hypoglycemia and ketoacidosis understand about those signs/symptoms
sign/symptom and management. For the and take initial action to hospital/clinical
follow up of type 1- diabetes patients, appointment. For confirmed COVID-19
ketoacidosis test should be advised when patients with diabetes who receive critical
expe- riencing hyperglycemia [13]. care, intensive blood glucose monitoring
should become priority of care. Adverse
4.2.2 Diabetes In Pregnancy effect of drug reaction should be early
All patients with gestational diabetes should identified [8]. Diabetes has noticed an
undergo face-to-face consultation for insulin independent factor of ICU admission and
initiation during their first visit. Patients raised risk of mortality rate [3,7,11]. It was
should obtain tailored education related reported that COVID-19 patients with
their diabetes and current condition for diabetes comorbidity had twice the risk to
lifestyle management. Minor adjustment of be admitted ICU and receive critical care
insulin dose may be necessitated for follow [3]. Other study described that COVID-19
up gestational diabetes patients using patients with diabetes contributed to
telemedicine/teleconsultation [13]. 122.2%e58% of ICU admission due to
septic shock and acute respiratory distress
syndrome as result of blood glucose

variability and elevated blood pressure Authors’ Contribution Statement
[8,11]. The mortality risk of COVID-19 ALW, NSH, AF designed study and guided
patients with diabetes is three times higher methodology. ALW and NSH were responsible
than non diabetic patients [3]. Current for searching, selection, data extraction and
reports noted the mortality rate of COVID- wrote the first draft. AF and RBP reviewed and
19 patients with diabetes was 7.3%e7.6% discussed the manuscript. All authors approve
[8,11]. Thus, all health care providers and responsible for publication.
should more concern when caring COVID-
19 patients with diabetes during Ethic Approval And Participant Consent
hospitalization. Not applicable.

4.3 Limitation Consent For Publication
This is a scoping review to provide broader Not applicable.
scope of diabetes management and action
for particular consideration. Thus, there Declaration Of Competing Interest
was no included level of evidence and The authors declare that there is no conflict of
quality evaluation. In addi- tion, there was interest.
unclear methodological approach among
included articles (author(s) did not definitely Acknowledgments
express the method section). Three We would appreciate librarians in Universitas
included articles did not provide clear Gadjah Mada, Indonesia that facilitate our
information about study design and data review.
collection process. Five out of seven
included articles did not specify the sample REFERENCES
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COMPARISON OF SURGICAL RECORDINGS USING CAMERAS WITH AND
WITHOUT LASER POINTER FOR FOCUSING IN GASTROINTESTINAL SURGICAL

FIELD IN COVID-19 PANDEMIC: A CROSS-SECTIONAL STUDY

Yuda Handaya Adeodatus a,*, Aditya Rifqi Fauzi a, Joshua Andrew a, Ahmad Shafa Hanif a, Azriel Farrel Kresna Aditya b

aDigestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito
Hospital, Yogyakarta, 55281, Indonesia
bFaculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia

ABSTRACT Keyword: Surgical recording Laser pointer
Background: Surgical recording has become Camcorder, Action-cam, Focus surgical field
very important for digestive surgery skill
training in the COVID-19 pandemic. In 1. INTRODUCTION
addition to high quality recordings, the The Corona Virus Disease 19 (COVID-19)
directions of vantage points are also pandemic has created an obstacle for medical
important. To assist our vantage point for our education, especially in surgical skill training for
camera, we frequently use a laser pointer to clinical students, residents and trainees, due to
increase accuracy in the shooting range. the limited number of patients admitted to the
Materials and methods: We recorded surgery hospital, decreased number of surgical cases
more than 2 h with a fixed top-mounted and limited time permitted for medical students
Panasonic HC-V770 camcorder and otherwise to attend rotations in the training hospital. As a
with an action-cam Sony FDR. We installed a result, video-based study material has gained
laser Pointer TaffLED Tactical Red Dot Laser significant importance [1,2]. Surgical recording is
Gun Picatinny Mount Airsoft Rifle HJ 11. We widely increasing in this era. Recording surgical
compared focus field video recordings with and procedures has many advantages for education
without laser pointer guiding. We divided them and care purposes because ever-decreasing
into four groups: head mounted with, head opportunities and time for training due to the
mounted without, top mounted with and top lack of cases causes limited means for
mounted without. We recorded a total of five reviewing the results. Accord- ingly, video
digestive surgery cases of superficial, visceral, recording can be used for research and as a
and deep visceral procedures for each group quality control tool to assess the skills of
after adjusting the laser pointer direction to the professionals or students. They can also pro-
center of the cameras focus. vide supplementation material for demonstrating
Results: The laser pointer on camcorder procedures to improve medical students’ quality,
Panasonic HC-V770 can assist recording on efficiency, and professionalism [3–5]. During
operation fields to prevent the field of view from recordings of surgical procedures, despite the
being blocked by movement of an object cameras’ specifications or better images, we
compared to either camera without laser pointer. need a method that makes the process easier.
The head mounted Sony FDR-X3000 action- The key point when recording involves the
cam can easily depict surgeon’s eye while direction of vantage points, since when we
recording and be controlled by the slightest record the wrong direction from the beginning it
movement of the surgeon’s head by tracking will ruin the entire video. The best surgical
with a red dot. recordings can depict the view through the
Conclusion: From either mounting, the laser surgeon’s eyes. Focus of the camera is another
pointer aided in focusing the surgical field of key point, but while recording and conducting
view and could increase visibility for surgical surgical
recording.

Fig. 1. (A) Side view laser pointer TaffLED Tactical Red Dot Laser Gun Picatinny Mount Airsoft Rifle
HJ11 (B) Front view, there is vertical and horizontal axis to adjust laser direction (C) laser pointer
installed on head mounted action-cam. (For interpretation of the references to color in this figure
legend, the reader is referred to the Web version of this article.)

Fig. 2. (A) Camcorder with laser pointer (B) action-cam with laser pointer (C) record process with
camcorder (D) record process with action-cam.

Fig. 3. (A) With laser pointer, blocked recording surgical field by head, can be prevented move the head
or blocking object (B) Without laser p0inter, blocked recording surgical field by head, cannot be
prevented.

procedures, the surgeon often cannot fully firearms, we adopted this concept to enhance
attend to the recording pro- cess and in the our recording method. In this paper, we discuss
limited resource hospitals, there are usually not our innovation and the advantages of adding a
available the properly trained nurses who can laser pointer to our camera when we record our
help with the recordings. surgeries.
Since the laser pointer is widely used to
increase accuracy for shooting targets with

2. MATERIALS AND METHODS

The inclusion criteria of this study were the 3. RESULTS

patients who agreed to undergo surgery Laser pointers are cheap, safe, and easy to

recording, signed informed consent forms, and install to any type of camera. In this study we

were confirmed COVID-19 free from screening installed it on a camcorder and an action-cam,

and examinations. All equip- ment used in this and they were useful for assisting in designating

study were disinfected with 70% alcohol prior to the center point of the camera while recording.

entering the operating room. The recording vantage point was easily directed

We used a Panasonic HC-V770 camcorder and by the appearance of the pointer. Using laser

Sony FDR-X3000 action cam and installed in pointer can definitely help surgeons while

the camera body a Laser Pointer TaffLED recording their procedures to direct the cameras,

Tactical Red Dot Laser Gun Picatinny Mount head position, and body position. It was easier

Airsoft Rifle HJ 11a (Fig. 1), specifications to direct focus to depict surgeon’s vision using

were shown below in Table 1. We installed one of head mounted action-cam with laser pointer

the laser pointers with its mounting toward the even when the surgeon moved their head. It will

camcorder by modifying the shape of also help surgeons direct their head for

microphone clip with solder to make it suitable accuracy. The laser pointer can be used as an

with the laser pointer mount (Fig. 2A). For the indicator in top mounted camera (Fig. 3). If it was

action-cam, we were able to clip the laser disappeared from sight, we interpreted it as

pointer mount toward its case directly above the blockage of the focus point by the surgeon’s

lens (Fig. 2B). We compared video recordings head, hand or instrument. Laser pointer can be

from these two cameras (Fig. 2): inverted L used to be a sign if our recording field was

shaped rod top mounted camcorder, head blocked by its red dot. This will help the operator

mounted action- cam with and without laser make sure that the vantage point was clear. As

pointer guiding. The Panasonic HC-V770 shown by examples above, red dot from laser

camcorder as a fixed camera was used for pointer will help surgeon direct their action-

procedures more than 2 h, while for shorter cam and can be used for a pointer while

procedures we used the head mounted Sony editing the videos for educational purpose,

FDR- X3000 action cam due to its greater focusing to some object or perforation,

comfort. We recorded five digestive surgery bleeding point, point to cut, incision point and

cases of superficial, visceral, and deep visceral suture points (Fig. 4).

procedures for each group after adjusting the

laser pointer direction to the center of the 4. DISCUSSION

cameras’ lens that coaxial with surgeon’s eye. Laser pointers for the head mounted action-cam

We qualitatively assessed the convenience of can help the recording to be coaxial with the

the operator to direct the vantage point of the surgeon eyes and make the video observer’s

recording and compared the recording results view similar to the surgeon’s view. The fixed top

whether there was a hindrance or any mounted camera usually used for long duration

obstruction of the centre point of the image. This and major surgery will give the video observers

study has been reported in line with the a clear third person view.

STROCSS criteria [6].

Fig. 4. (A) Superficial shooting (internal the camera is mounted to prevent the result

hemorrhoid grade 4 surgery), central focusing from being blurry or choppy [7]. This problem

on hemorrhoid, recorded with head mounted can be minimized with assistance of the laser

action-cam (B) Visceral shooting (adhesion pointer, which can help the sur- geon to direct

intestinal surgery), central abdominal field with their head to record with the head-mounted

red dot directed to adhesion site, recorded action-cam and keep clear the centre vantage

with camcorder (C) Deep visceral Shooting point of the top-mounted camcorder. Limitation

(Liver Surgery), red dot directed to ligation of the use of laser pointer in this study is there

process of Left hepatic vein, recorded with are no dedicated laser pointer camera mounting

head mounted action-cam. (For interpretation available to date. All the mountings used in this

of the references to color in this figure legend, study were custom made and each were made to

the reader is referred to the Web version of one specific camera. We hope there will be a

this article.) universal laser pointer camera mounting, a

dedicated laser pointer camera mounting, or

With diverse types of anatomical variations and even a build in laser pointer camera that suitable

cases, medical students and residents might not for surgical recording.

be exposed to enough cases of digestive surgery

during training. These recordings can help them 5. CONCLUSION

to have a better understanding in handling these Laser pointers can aid in making clear focused

cases. Moreover, the digestive surgery is a field view of the surgical field in surgical recording

in which various cases might require different and to aid the camera to depict the surgeon’s

widths of operation field. Superficial surgeries, point of view.

for instance in visceral and peri- anal cases,

require a detailed visualization, especially with Declaration of interest

the intricate details, which may be helped with No potential conflict of interest relevant to this

the use of a laser-pointed camera. Post record article was reported

editing for teaching materials can be difficult if

handled by non-medical editors. The laser Funding

pointer can be used to provide direction for The authors declare that this study had no

video sequencing and for video editing. We funding source

used an inexpensive laser pointer due to its price

(approximately $3 USD), easy to use, and the Ethical Approval

red dot pointer can be use under any type of This study was approved by Institutional Review

overhead operation theater light, compared to Board of Faculty of Medicine, Public Health and

the commonly avail- able headlamps in the Nursing Universitas Gadjah Mada.

market. The red dot of laser pointer able to point

small structures while recording and direct Author contribution

surgeon head to record, while if we choose to Adeodatus Yuda Handaya conceived the study.

use headlamp, the headlamp will have to project Aditya Rifqi Fauzi, Ahmad Shafa Hanif, and

the head movement by a circle of illumination Joshua Andrew drafter the manuscript, and

which has 12 cm illumination spot size, uniform Azriel Farrel Kresna Aditya critically revised the

light illumination, visualize small structure in manuscript for important intellectual content. All

any ambient overhead light, and can distinguish authors facilitated all project-related tasks.

red – blue color on anatomical structure [8].

The headlamp used to meet these criteria will Registration of Research Studies

be more expensive than the laser pointer. 1 Registry used: Research Registry.

Apart from the type of camera used, the final 2 Unique Identifying number or registration ID:

quality of the video depends on the operator’s researchregistry6193

ability to become motionless, such as 3 Hyperlink to your specific registration:

minimizing movement of head and neck where https://www.researchregis try.com/browse-the-

registry#user- Education during an emergency: a guide

researchregistry/registerresearchdetails/5f9e012 based on the responses to the COVID-19

9dc4a190018589a28/ pandemic, MedEdPublish 9 (2020).

3 A.M. Fry, R.L. Orr, A. Patterson, P. Doyle,

Guarantor Use of eyewear for high definition video

Adeodatus Yuda Handaya recording in surgical training [Internet], Br. J.

Oral. Maxillofac. Surg. 52 (10) (2014) 983–

Consent statement 984,

Written informed consent was obtained from all https://doi.org/10.1016/j.bjoms.2014.08.010.

of the patients for publication of study and Available from:.

accompanying images. A copy of the written 4 A. Nair, S. Kamal, T. Dave, K. Mishra, H.

consent is available for review by the Editor-in- Reddy, D. Rocca, et al.,Surgeon point-of-view

Chief of this journal on request. recording: using a high-definition head-

mounted video camera in the operating

Declaration of competing interest room, Indian J. Ophthalmol. 63 (10) (2015)

No potential conflict of interest relevant to this 771–774.

article was reported. 5 K.R. Henken, F.W. Jansen, J. Klein, L.P.S.

Stassen, J. Dankelman, J.J. Van

Acknowledgements DenDobbelsteen, Implications of the law on

The authors are very grateful for the support to video recording in clinical practice, Surg.

anesthesiologists and nursing staff of the Endosc. 26 (10) (2012) 2909–2916.

Hospitals. 6 R. Agha, A. Abdall-Razak, E. Crossley, N.

Dowlut, C. Iosifidis, G. Mathew, for the

Appendix A. Supplementary data STROCSS Group, The STROCSS 2019

Supplementary data related to this article can guideline: strengthening the reporting of

be found at cohort studies in surgery, Int. J. Surg. 72

https://doi.org/10.1016/j.amsu.2020.12.006. (2019) 156–165.

7 A. Ortensi, A. Panunzi, S. Trombetta, A.

Provenance and peer review Cattaneo, S. Sorrenti, V. D’Orazi,

Not commissioned, externally peer-reviewed. Advancement of thyroid surgery video

recording: a comparison between two full HD

REFERENCES head mounted video cameras [Internet], Int.

1 P.S. Goh, J. Sandars, A vision of the use of J. Surg. 41 (2017) S65–S69, https://

technology in medical education after the doi.org/10.1016/j.ijsu.2017.03.029.

COVID-19 pandemic, MedEdPublish 9 (2020) Available from:.

1–8, https://doi.org/10.15694/ 8 J.A. Forrester, K. Torgeson, T.G. Weiser,

mep.2020.000049.1. Minimum specifications for a Lifebox surgical

2 M.H. Taha, M.E. Abdalla, M. Wadi, H. headlight for resource-constrained settings,

Khalafalla, Curriculum delivery in Medical JAMA Surg. 154 (1) (2019) 80–82.

COMPARISON BETWEEN CAMCORDER, FRONTAL HEAD AND TEMPORAL
MOUNTED ACTION-CAM IN DIGESTIVE SURGERY: DOCUMENTATION AND

EDUCATIONAL ALTERNATIVE DURING COVID-19 PANDEMIC

Adeodatus Yuda Handaya a,*, Aditya Rifqi Fauzi a, Joshua Andrew a, Ahmad Shafa Hanif a,Azriel Farrel Kresna Aditya b

a Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito
Hospital, Yogyakarta, 55281, Indonesia
b Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia

ABSTRACT 1. INTRODUCTION
Objective: COVID-19 pandemic has made Surgical recording is widely increasing in this era.
impact both in clinical and educational Recording surgical procedures has numerous
settings. The number of sur- geries has advantages. In clinical settings, surgery
decreased; thus, the surgery videos of all recording may give the ability to review the
cases are important for both documentation surgery process and results, aid in future
and education. This study aimed to compare management planning and referral, act as
three kinds of cameras in recording digestive objective evi- dence if needed, serve audit
surgery. purposes, and aid in the implementation of good
Methods: We compared three cameras: medical practice. For surgeons, the ability to
Panasonic HV-770 Full HD Camcorder, Sony record procedures from their point of view offers
FDR-X3000 Action-cam, and Ordro EP7 Hands- opportunities to analyze surgical per- formance
Free FPV Camera. Each camera was used in and provide objective feedback for appraisal and
several recording for superficial and visceral assessment [1]. In education settings, surgical
digestive surgeries and we compared the procedure recording can help stu- dents to
following: operation field, image focus, surgeon’s understand text-based materials and actual
comfort, practicality, and record settings. three-dimensional surgical field of view,
Results: Camcorder needs 10–15 min to set demonstrating surgical procedures, assessing
up and longer dismounting time, has steady surgeons’ and students’ skills to improve service
vantage view and focus, good image quality, quality, providing unique opportunity to see rare
can be zoomed, but the recording may be surgical cases, and act as research tools and
obstructed by the surgeon’s head. Action visual supplements to medical journals. For
camera needs 5–10 min to set up and the patients, surgical videos may help the
dismounting time was equal between understanding of their body and condition [1–7].
Camcorder and Ordro. Action camera depicts The Coronavirus Disease 2019 (COVID-19)
surgeon’s vision, however, zoom could not be pandemic settings since 2020 have required
applied while recording. Sony FDR-X3000 health protocol, physical distancing, and even
used in this study had good image quality, but total lock down period all over the world and in
the use of this camera in a long surgery may all sectors, including edu- cation, and as a
generate neck stiffness due to its weight. result, surgical recording can aid in shifting from
Ordro EP7 was comfortable in any surgery but con- ventional learning process to online
it had inferior image quality compared to the teaching [5,8]. In surgical recordings, the
others. camera type is a major factor to consider.
Conclusions: Panasonic HC-V770 and Sony Recording cameras are widely available in the
FDR X3000 had good image quality, where market, and the one most used in surgery is the
camcorder excelled in longer surgeries due to camera built into a head lamp. This camera has
its comfort, action-cam excelled for shorter
surgeries due to ease of use and settings.
Ordro EP7 was the most comfortable among
all but has lowest image quality.

Abbreviations

FHD Full high-definition
HMD head mounted display

good video quality but is not suitable for all head shows the three cameras’ specifications.
lamp types, expensive, difficult to install, limiting Physical comparison of the cameras can be seen
surgeons’ movement, and needing moni- toring in Figs. 1–3 (see Table 2).For the Panasonic
in recording. The use of other types of cameras HC-V770, we used an inverted L-shaped stand
such as action camera with or without with the tip fixed on the operating table and the
modifications have been reported recently. Many other end mounted with a flexible arm and
surgeons choose Full High Definition (FHD) camera mounting. We connected it with a power
cameras with wireless remote to monitor vantage bank with an extended cable to anticipate if the
points. In this study, we compared three surgery took more than 2 h. Our Sony FDR-
cameras: one camcorder and two action-cam, X3000 and Ordro EP7 action camera were
with three different record position that are widely mounted on the operator’s head and connected
used in surgical recording to determine the best to the power bank for medium and long surgery.
camera types and ways for surgery recording in We modified the head mounting for Sony FDR-
various settings. X3000 by adding a clip to the inner shell of the
construction helmet that was in- tegrated with
2. MATERIALS AND METHODS the head mounting to give more stability to the
The inclusion criteria of this study were: the cameras. Ordro EP7 action camera was ready
patients agreed by signed informed consent to to use with a headband that was provided in the
undergo digestive surgery recording in elective retail package. We recorded 30 surgeries, from
surgery cases, and the patients were confirmed 10 patients for each camera in total for 5
COVID-19 free from screening and superficial and 5 visceral surgery procedures.
examinations. We exclude patients with The Institutional Review Board of Faculty of
emergency surgical cases. All equipment used Medicine, Public Health and Nursing approved
in this study were disinfected with settings this study (KE/FK/0796/EC/2018).
before the operation and after surgery. Table 1





Fig. 1. a) Physical appearance of the Panasonic HC-V770 when mounted; b) Physical appearance
of the Panasonic HC-V770 when unmounted.

Fig. 2. a) Physical appearance of the Sony FDR-X3000 when mounted; b) Physical appearance of
the Sony FDR-X3000 when unmounted.

Fig. 3. a) Physical appearance of the Ordro EP7 when mounted; b) Physical appearance of the
Ordro EP7 when unmounted.

3. RESULTS 4. Discussion
All patients who agreed to have their surgery This study compared three types of cameras,
recorded on our computer system namely Panasonic HC- V770 Full-HD
were offered the opportunity to see highlights of Camcorder, Sony FDR X3000 Action Camera,
their surgery recorded simultaneously on the and Ordro EP7 Hands-free Head-wearing Mini
digital video recorder. The comparison of the DV Camera. The most popular cameras in this
three cameras is shown in the following table. market are GoPro Action Cameras (several
Sample images of all cameras during superficial models), Contour HD Helmet Camera,
organ surgery can be seen in Figs. 4a, 5a and Panasonic HX-A100 POV Camcorder, and
6a. While the pictures during performing deep
organ, surgery are seen in Figs. 4b, 5b and 6b.

Fig. 4. a) Picture quality of Panasonic HC-V770 during perianal fistula surgery; b) Picture quality of
Panasonic HC-V770 during laparotomy surgery.

Fig. 5. a) Picture quality of Sony FDR-X3000 during perianal haemorrhoid surgery; b) Picture
quality of Sony FDR-X3000 during laparotomy surgery.

Fig. 6. a) Picture quality of Ordro EP7 during perianal fistula surgery; b) Picture quality of Ordro
EP7 during laparotomy surgery.

Google Glass. The ideal camera to record among the three, even when the image was
surgeries should be small, lightweight, zoomed in the editing process, the fast
comfortable, user friendly, able to depict autofocus, and the ability to be mounted of
surgeon’s view, provide high definition images forehead with head band made it suitable for
and videos, has long battery life, affordable, and short to me- dium surgeries which require
enable an easy image or video management. To details, such as bile duct attachment and
this date, this ideal kind of camera does not procedures on retroperitoneal or pelvic organs.
exist. In this study, Panasonic HC-V770 Full-HD However, its weight made it not suitable for long
Camcorder needed 10–15 min for setting, Sony surgeries because neck stiffness occurred.
FDR X3000 took 5–10 min, and Ordro EP7 took Ordro EP7 is a versatile head mounted action
less than 5 min. The Panasonic camcorder camera, lightweight and convenient to use and
takes time for setting and dismounting, which set. It is comfortable for any kinds of surgery, but
made it more suitable for long surgeries, for the image quality was poor for visceral
example laparotomy, which do not need organ structures, even for super- ficial structures,
details and the procedures are done in hence zooming the image during editing was
superficial organ because it stands on external unfeasi- ble, and the autofocus was slow.
mounting. The camera being mounted on an Setting the image quality to the best option may
external stand made it the most comfort- able for aid to slightly improve the output.
the surgeon, providing steady vantage point and
focus, with good image quality, that could be Previous study using head mounted Sony
zoomed while recording, but may be obstructed FDR-X3000R for liver transplant recording,
by the surgeon’s head at times. very helpful for education supplementation due
to high image quality and easy to edit. The most
Both action cameras need shorter time to set popular camera to record surgery procedures
and dismount, able to depict surgeon’s view, today is the GoPro Hero 6, due to high
and could be controlled while recording using availability in the market and it is easy to use
iOS or Android based Smartphone application. but has limited image quality [4,12]. Another
However, neither could be zoomed, and both study modified their own camera, that met the
had limited battery life (which could be solved criteria for perfect surgical recording: narrow
by connecting common external power battery vantage point, HD image, detailed to small
similar to phone’s). Also, if initial camera structure, head mounted, controlled from
direction setting was off, the entire recording distance, can zoom, no need post record
would fail to point in the correct direction. editing and the video can be used directly
after recording, but it is expensive, heavy, less
Sony FDR X3000 Action Camera has a high comfortable and not practical [13].
resolution sensor to give the best image quality

Technology’s role in surgery is expected to Ethics approval
continue to increase, with a projected $5.1 Not applicable.
billion market for head mounted displays
(HMDs) in the health care industry within the Funding
next decade [14]. In the end, whether cameras The authors declare that this study had no
are good depends on what procedures we want funding source.
to re- cord, for example, the use of a
combination of top mounted camcorder such as Authors contribution
the Panasonic HC-V770 for fixed wide vantage AYH conceived the study. ASH drafted the
point and head mounted action-cam for moving manuscript. ARF and JA critically revised the
vantage points can be considered. This study manuscript for important intelectual content. All
had limitations as we only used one particular authors read and approved the final draft.
camera for each camera type which does not
rule the possibility of different result between Registration of research studies
cameras in the same type, we didn’t use
standardized surgical camera instead we use 1. Registry used: Research Registry
action camera although we need make a custom 2. Unique Identifying number or registration ID:
mounting for the camera and the comparation
was made by one surgeon which does not rule researchregistry6193
the possibility of different experience between 3. Hyperlink to your specific registration:
surgeons. Further study with larger sample size,
more camera types, and more evaluator needed https://www.researchregis try.com/browse-
to determine the best camera for surgery the registry#user-
recording. researchregistry/registerresearch
details/5f9e0129dc4a190018589a28/
5. CONCLUSIONS
The most important point of surgery recording is Guarantor
image quality. Panasonic HC-V770 Full-HD Adeodatus Yuda Handaya.
Camcorder and Sony FDR X3000 Action
Camera have good image quality, and the Availability of data and material
Camcorder excelled in longer surgeries due to Not applicable.
its comfort, whereas the Action Camera excelled
in shorter surgeries due to its ease of use and Consent to participate
settings. Ordro EP7 was the most comfortable Not applicable.
among all but due to its lower image quality, it
became the least favourite camera for surgery Consent for publication
recordings. Not applicable.

Declaration of competing interest REFERENCES
The authors declare that they have no 1. A.M. Fry, R.L. Orr, P.T. Doyle, Use of
competing interests.
eyewear for high definition video recording in
Acknowledgements surgical training, Br. J. Oral Maxillofac. Surg.
The authors are grateful to all anaesthesiologists 52 (2014) 983–984.
and nursing staff who helped during the study. 2. A.G. Nair, S. Kamal, T.V. Dave, K. Mishra,
H.S. Reddy, D. Della Rocca, R.C. Della
Appendix A. Supplementary data Rocca, A. Andron, V. Jain, Surgeon point-of-
Supplementary data to this article can be found view recording: using a high-definition head-
online at https://doi. mounted video camera in the operating
org/10.1016/j.amsu.2021.01.046. room, Indian J Ophtamol 63 (2015) 771.
3. K.R. Henken, F.W. Jansen, J. Klein, L.P.
Stassen, J. Dankelman, J.J. van den

Dobbelsteen, Implications of the law on video 14.R. Rahman, M.E. Wood, L. Qian, C.L. Price,
A.A. Johnson, G.M. Osgood, Head- mounted
recording in clinical practice, Surg. Endosc. display use in surgery: a systematic review,
Surg. Innovat. 27 (2020) 88–100.
26 (2012) 2909–2916.

4. S. Lee, J.M. Lee, K.S. Suh, S.K. Hong, J.H.

Cho, N.J. Yi, K.W. Lee, Wearable recording

video technology for surgical training in living

donor liver transplantation, Annls. Hepato

Biliary Pancreatic Surg. 24 (2020) 38–43.

5. P.S. Goh, J. Sandars, A vision of the use of

technology in medical education after the

COVID-19 pandemic, MedEdPublish 9

(2020) 1–8, https://doi.org/10.15694/

mep.2020.000049.1.

6. N. Papadopoulos, D. Polyzos, P.

Gambadauro, P. Papalampros, L. Chapman,

7. A. Magos, Do patients want to see

recordings of their surgery? Eur. J. Obstet.

Gynecol. Reprod. Biol. 138 (2008) 89–92.

8. A. Magos, I. Kosmas, M. Sharma, L. Buck, L.

Chapman, A. Taylor, Digital recording of

surgical procedures using a personal

computer, Eur. J. Obstet. Gynecol. Reprod.

Biol. 120 (2005) 206–209.

9. M.H. Taha, M.E. Abdalla, M. Wadi, H.

Khalafalla, Curriculum delivery in Medical

Education during an emergency: a guide

based on the responses to the COVID-19

pandemic, MedEdPublish 9 (2020).

10.Panasonic HC-V770, Camcoder review.

https://hdvcam.net/panasonic/panaso nic-hc-

v770-review/. Sony FDR-X3000, Digital

photography review.

https://www.dpreview.com/pr

oducts/sony/actioncams/sony_fdr_x3000.

11.Ordro EP5 headset action camera full HD

touch control - black. https://www.

gearbest.com/camcorders/pp_1308792.html.

12.L. Ganry, N. Sigaux, K.S. Ettinger, S.O.

Salman, R.P. Fernandes, Modified GoPro

Hero 6 and 7 for intraoperative surgical

recording—transformation into a surgeon-

perspective professional quality recording

system, J. Oral Maxillofac. Surg. 77 (2019),

1703-e1.

13.A. Ortensi, A. Panunzi, S. Trombetta, A.

Cattaneo, S. Sorrenti, V. D’Orazi,

Advancement of thyroid surgery video

recording: a comparison between two full HD

head mounted video cameras, Int. J. Surg.

41 (2017) S65–S69.



FIRST EXPERIENCE OF USING FAVIPIRAVIR IN THE FIRST HEALTHCARE
WORKER PATIENT WITH MODERATE CASE OF COVID-19 AT SULIANTI SAROSO

INFECTIOUS DISEASE HOSPITAL, JAKARTA, INDONESIA : A CASE REPORT

Pompini Agustina Sitompul, Nina Mariana, Adria Rusli, Titi Sundari, Rosa Marlina, Faisal Matondang,
Haruyuki Dewi Faisal, Mohammad Syahril

Sulianti Saroso Infectious Disease Hospital, Jakarta, Indonesia*

*Address Correspondence to:

Nina Mariana, Sulianti Saroso Infectious Disease Hospital, Jakarta, Indonesia Jl. Sunter Permai Raya,
Jakarta, Email : [email protected]

Abstrak
Kasus ini merupakan kasus pertama seorang tenaga kesehatan Rumah Sakit terdiagnosis COVID-19
dengan penggunaan terapi Favipiravir untuk pertama kalinya di RSPI Prof. Sulianti Saroso, Jakarta,
Indonesia. Berikut ini kami laporkan karakteristik klinis, hasil foto thorak, profil laboratorium dan proses
terapi serta hasil akhir pada kasus COVID-19 derajat sedang.

Kata kunci : Covid-19, Sars-Cov-2, Favipiravir, Tenaga kesehatan

Abstract
The case is about a first healthcare worker patient diagnosed with COVID-19 who had moderate type,
including first experience treatment with favipiravir in Sulianti Saroso Infectious Disease Hospital,
Jakarta, Indonesia. Here we reported the clinical characteristics, chest X-ray, clinical laboratory profiles,
the treatment process, and the clinical outcome of moderate type COVID-19 patient.
Keywords: Covid-19, Sars-Cov-2, Favipiravir, Healthcare worker

1. Background 2. Case report
In December 2019, an outbreak of pneumonia On April 13, a 38 years old woman was admitted
caused by a novel coronavirus occurred in to Sulianti Saroso Infectious Disease Hospital,
China, followed has spread rapidly to other Jakarta, Indonesia, with a brief (10 days) history
countries.1 As of March 2, 2020. The of intermittent fever, cough, sore throat, and
Government of Indonesia reported the first rhinorrhea, followed a 4 days history of
confirmed case and followed by the highest shortness of breath. She is a healthcare worker
mortality rate of COVID- 19 (5.3%). that had a history of taking care of patients with
In Indonesia, the health care workers is greatly COVID-19 in an isolation ward.
affected by the disease. Indonesian Medical
Association (IDI) reported that at least 27 doctors During our first clinical evaluation, physical
have died due to the disease as of May 2020 and examination revealed that the pulse rate was
others contracted the disease with mild to 110/minute, blood pressure 107/60 mm Hg,
moderate symptoms. Preventing health care respiratory rate 30/minute, the body temperature
workers infections is important for reducing 36.20C and 98 % oxygen saturation on ambient
morbidity and potential mortality, maintaining air. She required 3 L/minute of oxygen via nasal
health system capacity, and reducing secondary cannula. An electrocardiogram (ECG) revealed
transmission.2 sinus rhythm with QTc 388 ms.

We need to find a specific treatment against The patient did not report any underlying
COVID-19. Currently, there are no definite medical condition such as diabetes or
antiviral drugs. Without effective treatment, hypertension. A radiological finding in computed
moderate patients could convert into severe tomography (CT) showed ground-glass opacity,
develop acute respiratory distress syndrome and chest x-ray showed pneumonia lower zone
(ARDS) and multi-organ failure.1 bilateral (Table.1). Swab test for COVID-19 were
collected. On April 14, the real-time PCR on
Research is underway to identify therapeutics nasopharyngeal swab revealed the presence of
for COVID-19, including re-proposing SARS- CoV-2. According to the blood test
medications.3 Favipiravir, an antiviral drug results, white blood cell count was normal (5 x
targeting influenza viral RNA-dependent RNA 10^3/µL), lymphocyte count was 16 %,
polymerase (RdRP). It selectively inhibits RNA hemoglobin and platelet level were within normal
polymerase, which is necessary for viral limit, the neutrophil count was 75 %, albumin
replication.3 Chang Chen et al, showed that level was decreased to 2.8 g/L, and ferritin was
favipiravir could be considered as a treatment in slightly elevated to 85.8 ng/mL. All laboratory
moderate COVID-19 patients.1 Only a few tests evaluating liver enzymes, kidney function
favipiravir efficacy trials in COVID-19 have been were within the normal range. The other
reported in the literature to date, numerous other laboratory test showed in table 1.
favipiravir COVID-19 trials are ongoing or as yet
un reported.4 This case is about a first On April 16, the respiratory rate was increased to
healthcare worker patient diagnosed with 36/minutes, while oxygen saturation were 97 %
COVID-19 who had moderate type, including the and 5 L/minute of oxygen via nasal cannula was
use of favipiravir in Sulianti Saroso Infectious required. The second swab test was still positive
Disease Hospital, Jakarta, Indonesia. We for SARS-CoV Infection.
describe the characteristics of the vital signs, On April 18, the respiratory symptoms were
chest X-ray, clinical laboratory profiles, the improved, while the third swab test was negative
treatment process and the clinical outcome of for SARS-CoV infection. Physical examination
moderate type of COVID-19 patients who is also revealed that the pulse rate was 70/minute,
a health care worker. blood pressure of 120/60 mm Hg, respiratory
rate of 20/minute, and the body temperature of
36.20C.

She was treated with Favipiravir (1600 mg b.i.d supplemental oxygen.5 During the second stage
on the first day, and 600 mg b.i.d afterwards, for of established pulmonary disease, the patient
7 days), Hydroxyl-chloroquine (200 mg b.i.d for needs to be observed closely and managed
10 days), Azithromycin (500 mg single dose for 5 wisely. The onset of fever and respiratory
days), N-acetylcysteine (1250 mg single dose for symptoms should also be closely monitored by
10 days), Isoprinosine (500 mg q.i.d for 10 days) health care workers.5
and others of supportive treatment. Clinical
manifestation, laboratory profiles, and the The patient was treated with favipiravir tablets
treatment process showed in Table 1. combine with hydroxychloroquine in the
treatment of pneumonia COVID-19.
On April 21, the condition of the patient was Mechanisms of action of hydroxyl-chloroquine
improved and the respiratory symptoms are blockade viral entry by inhibiting
disappeared, while 12-lead ECG revealed sinus glycosylation of host receptors, proteolytic
rhythm with QTc 438 ms. The last processing and endosomal acidiffication.3
nasopharyngeal swabs were negative for SARS- Followed by Favipiravir that selectively inhibits
CoV infection. On the next day, the patients was RNA polymerase, which is necessary for viral
discharged. However, there was an increase in replication.3 In addition, other drugs supported
uric acid level to 8.2 mg/dl. as a local standard of care (azithromycin,
Isoprinosine and other supportive treatment) for
3. Discussion this infection. The time of improvement or
Health care workers experience significant recovery of respiratory symptoms and a
burden from corona virus infections, including negative swab test result was 6 days.
SARS-Cov2.2 Roger Chou et al, mentioned that
certain exposure are associated with increased However this case was the first moderate case
risk. The use of Personal Protective Equipment of covid-19 treated with favipiravir in a
(PPE) and infection control training are healthcare worker patients in April in our
associated with decreased infection risk.2 It is hospital. We know that the last update
still questionable whether the COVID-19 mentioned that hydroxyl-chloroquine had little or
infection acquired by the health care workers in no effect on overall mortality, initiation of
Indonesia was obtained in the community or in ventilation and duration of hospital stay in
the workplace, such as the hospital where they hospitalized patients.7 By November 2020, the
were on duty treating the patients. Food and Drug Control Agency of Indonesia
revoked hydroxyl-chloroquine and chloroquine
In this case, the patients initially had a intermittent authorization for Covid-19 patient treatment.
fever, cough, sore throat, and rhinorrhea which Hyperuricemia was detected in our patient.
began at approximately 10 days, and then the Chang Chen et al showed that there were 32
symptoms progress into the second stage. adverse effects cases from 116 subjects in
Siddiqi et al, showed three escalating phases of Favipiravir group. Raised serum uric acid (16 %)
COVID-19 disease progression.5 According to were common in patients of favipiravir group.1,8
Eastern Virginia Medical School (EVMS) Critical A recent review by Mishima et al revealed that
Care COVID-19 Management Protocol, the favipiravir may increase blood uric acid level due
course of COVID-19 consists of 4 phase: to the reduction in uric acid excretion into the
incubation, symptomatic, early pulmonary urine.7 The clinicians should be more cautious
phase, and late pulmonary phase.6 The initial when favipiravir was prescribed to patients with
stage which is also known as viral response a history of gout, hyperuricemia, or kidney
phase occurs at the time of establishment of dysfunction. Azithromycin, hydroxyl-chloroquine,
disease with non-specific symptoms. In the favipiravir, those agents can cause adverse
second stage, the patients develop viral effects, including QTc prolongation.9-11 In this
pneumonia and possibly hypoxia and required case, after 7 day within treatment, there was an
increase in QTc interval (50 ms). The rise in the

QTc interval was still within normal QTc values. 3. James MS, Marguerte L. Tomasz, James B.
However, we could not assume that there was
no potential adverse cardiac effect due to the Pharmacologic treatment for
limitations of this single case report. The intensity
of QT and arrhythmia monitoring should be coronavirusdisease 2019 (Covid-19). JAMA;
considered in the context of potential drug
benefit and safety.12-15 2020; E1-E5

4. Conclusion 4. Zarir FU,Pawan S,Hanmant B,Saiprasad
This case presented the first healthcare worker P,Shabbir R,Amol P,Jatin K,Wen W,Cynthia
patient with a moderate type of COVID-19, FC,Monika T. Efficacy and safety of
including first experience treatment with favipiravir, an oral RNA-dependent RNA
Favipiravir. We believe that a solid evidence of polymerase inhibitor, in mild-to-moderate
treatment is urgently needed because moderate COVID-19: A randomized, comparative,
patients of Covid-19 could convert into a severe open-label, multicenter, phase3 clinical trial.
or critical case. Particular attention should be International Journal of Infectious Diseases,
paid to adverse drug reactions when using 2020, 103:62–71
concomitant medication.
5. Siddiqi HK, Mehra MR. COVID-19 illness in
native and immunosuppressed states: A
clinical−therapeutic staging proposal.
Jhltonline. 2020: 405-07

Conflict of Interest 6. Eastern Virginia Medical School (EVMS)
The authors declare that they have no conflict of Medical Group. EVMS Critical Care COVID-
interset 19 Management Protocol. Available from:
https://www.evms.edu/covidcare Accessed
Funding on 2020 May 6
No funding or financial support was received

Ethical approval 7. Mishima E, Anzai N, Miyazaki M, Abe T. Uric
Informed patient’s consent has been conducted acid elevation by favipiravir, an antiviral drug.
Tohoku J Exp Med. 2020 ; 251(2):87-90.

Acknowledgment 8. Kaur RJ, Charan J, Dutta S, Sharma P,
We are grateful to our patient and other doctors, Bhardwaj P, Sharma P, Lugova H,
also nurses of RSPI Prof. Dr. Sulianti Saroso Krishnapillai A, Islam S, Haque M, Misra S.
Infectious Disease Hospital who contributed to Favipiravir Use in COVID-19: Analysis of
this case report. Suspected Adverse Drug Events Reported in
the WHO Database. nfection and Drug
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1. Chang C, Jiangying H, Zhenshun C,

Jianyuan W,Song C, Yongxi Z. et al.

Favipiravir versus Arbidol for Covid-19 : a 9. Chief Investigators of the Randomised

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32.Accessed on 2020 May 2 RECOVERY Trial n.d.

https://www.recoverytrial.net/news/statement

2. Rogers C, Tracy Dana, David B, Schelley S, -from-thechief-investigators-of-the-
Rongmei F, Annette M. Epidemiology of and
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11.Pilkington V, Pepperrell T, Hill A. A review of
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12.Ventricular arrhythmia risk due to
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cardiology/articles/2020/03/27/14/00.
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13.Ghasemiyeh P, Borhani-Haghighi A,
Karimzadeh I, et al. Major Neurologic Adverse
Drug Reactions, Potential Drug-Drug
Interactions, and Pharmacokinetic Aspects of
DrugsUsed in COVID-19 Patients with
Stroke: A Narrative Review. Ther Clin Risk
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14.Uppsala Monitoring Centre: WHO
Programme for International Drug Monitoring.
VigiBase. Accessed Nov 28, 2020

15.Uppsala Monitoring Centre. VigiBase:
signaling harm and pointing to safer use.
Accessed Nov 28 2020. https://www.who-
umc.org/vigibase/vigibase/vigibase-
signalling-harm-and- pointing-to-safer-use/.

CLINICAL PROFILE AND RISK FACTOR OF MORTALITY OF THE EARLIEST COVID-
19 CASES IN THE REFERRAL CENTER FOR INFECTIOUS DISEASES HOSPITAL IN

INDONESIA

Pompini Agustina1, Nina Mariana1, Siti Maemun, Adria Rusli1, Titi Sundari 1, Rosa Marlina1, Faisal
Matondang1 Haruyuki Dewi Faisal1, Vivi Lisdawati1, Mohammad Syahril1

1 Prof Dr Sulianti Saroso Hospital for Infectious Diseases, Jalan Sunter Permai Raya, North
Jakarta 14340, Indonesia

Corresponding Author : Nina Mariana, Jl. Sunter Permai Raya, Jakarta, [email protected]

ABSTRACT
Background: This study aims to describe the clinical profile of the earliest Covid-19 cases and to
analyze the risk factors of mortality of those Covid-19 cases.
Methods: This is a retrospective cohort study on all admitted Covid-19 patients and non Covid- 19
patients to Sulianti Saroso Hospital for Infectious Diseases, Jakarta, Indonesia between 22 January and
2 May 2020.
Results: A total of 162 patients was divided into two groups (100 Covid-19 patients and 62 non- Covid-
19 patients). Of 100 Covid-19 patients, 52 patients were males (52%) and 46 patients were 40 - 59 years
old (46%). Fifty-four percent of Covid-19 patients had a history of close contact with confirmed cases of
Covid-19. Thirty-eight percent patients had severe Covid-19. The most common clinical symptom of
covid-19 cases was cough (80%), followed by shortness of breath (59%). Infiltration on chest
radiographs were commonly found (76.8%). The mean length of stay of Covid-19 cases were 13 days.
A total of 24 (24%) Covid-19 patients died. The odds ratio (OR) analysis showed that mortality is
dependently related to the symptoms of shortness of breath (OR [95%CI]: 13.90 [1.36-142.28], p =
0.027), cough (OR [95%CI]: 6.11 [1.33-27.96], p=0.020),
gender (OR [95%CI]: 6.53 [1.49-28.69], p = 0.013), and the presence of comorbidities (OR [95% CI]:
0.07 [0.01-0.43], p = 0.004).
Conclusions: Many severe Covid-19 cases were found in our hospital in the early outbreak period.
Patients with symptoms of shortness of breath, cough, the male gender and the presence of comorbidities
were more at risk for mortality.

Keywords: Covid-19, mortality, risk factor

BACKGROUND of nasal and oropharyngeal swab specimens as
Coronavirus disease (COVID-19) is an infectious a confirmed case of Covid-19 and suspected
disease caused by a novel coronavirus. In cases which were then tested negative for
December 2019, an outbreak of pneumonia SARS-Cov-2 by RT-PCR as non Covid-19.
caused by Covid-19 occurred in China and has Data were collected from medical records and
since spread rapidly to other countries.1 Early hospital information system. We had a total
reports from Wuhan described that 26-33% of sample of 162 patients that completed the
coronavirus disease 2019 (Covid-19) patients variable of data. Categorical variables were
needed intensive care and 4-15 % died. The summarized as counts and percentages.
clinical presentation of covid-19 among patients Proportional data was analyzed using Chi-
were more often as a mild respiratory tract Square tests or Fisher’s Exact. We also
infection or mild symptoms.2,3 analysed the risk factors of mortality in Covid-19
Since January 22, 2020, all patients suspected patients. Multivariate analysis included
with Covid-19 were admitted Sulianti Saroso independent variable with p-value less than
Infectious Disease Hospital. On March 2nd 2020, 0.25. The odds ratio (OR) from logistic
the Government of Indonesia reported the first regression of variables was also analysed in this
confirmed case of COVID-19. Since then, Covid- study. All statistical analyses were performed
19 cases in Indonesia have increased gradually. using SPSS 21. This study was approved by the
At the time, Sulianti Saroso Hospital for Ethics Committee of the Research and
Infectious Diseases was turned into the first Development Agency, Ministry of Health,
covid-19 referral hospital by the Indonesian Indonesia.
Ministry of Health.
The symptoms of SARS-COV-2 include fever, RESULTS
cough, shortness of breath or difficulty of A total of 162 patients were divided into two
breathing, myalgia, fatigue, normal or decreased groups (100 Covid-19 patients and 62 non-
leukocyte counts and radiographic evidence of Covid-19 patients). As shown in table 1. Out of
pneumonia.3,4 Signs of Covid-19 infection may 100 Covid-19 patients, 52 patients were male
overlap with other viral or bacterial infections, (52%), 46 patients were 40 -59 years old (46 %),
which poses a challenge in making clinical all of Covid-19 patients were Indonesian, and
diagnosis.3 Diagnostic test based on the 54% had a history of close contact with
detection of the viral sequence by real-time confirmed Covid-19 cases.
reverse-transcription (RT)-PCR is the gold The most common clinical symptom of were
standard confirmatory test. 4 cough (80%) and followed by shortness of
In this study we describe the initial reports of breath (59 %). The majority of cases showed
Covid-19 and non-Covid-19 cases at our infiltration on their chest radiographs (76.8%).
hospital during the early period of the outbreak. Thirty-eight (38%) patients had severe Covid-19.
We aimed to describe the demography and the The mean length of stay of Covid-19 cases was
clinical profile of Covid-19 and non-Covid-19 13 days (table 2). The majority of covid-19
cases and to analyze the risk factors of mortality patients had comorbidities such as hypertension
in Covid- 19 cases. (32 patients, 32%), chronic liver disease (22
patients, 22%), diabetes (19 patients, 19%),
METHODS cardiovascular disease (13 patients, 13%),
We conducted a retrospective cohort study to asthma (7 patients, 7%), chronic renal disease (3
describe the demography and the clinical profile patients, 2%), COPD (2 patients, 2%),
of Covid-19 and non-Covid-19 cases and also to tuberculosis (2 patients, 2%), HIV/AIDS (1
analyze the risk factors of mortality in Covid-19 patients, 2%), and none had malignancy.All
cases. We identified all patients admitted patients experienced at least one complication
between 22 January and 2 May 2020 at Sulianti during their course of disease. The most
Saroso Hospital for Infectious Diseases with common complications found in Covid-19
positive result of Sars-CoV-2 by RT-PCR assay patients were ARDS (15%) and secondary

infection (15%), followed by septic shock (8%), It was higher than the non- Covid-19 patients.
acute kidney injury (7%), and cardiac injury The SARS-CoV-2 intervened mainly in the lung
(2%). In non Covid-19 cases, 12.9% developed and caused pneumonia and ARDS via the
ARDS and 3.2% developed secondary infection. angiotensin-converting enzyme 2 (ACE2)
Seventy-six (76 %) out of 100 Covid-19 patients receptor.9 This infection spread through the
were discharged alive and 24 (24%) patients ACE2 receptor further to various organs
died. Fifty-eight (93.5%) non Covid-19 patients including the gastrointestinal tract.9
were discharged alive and four (6.5%) patients In our study, infiltration on chest radiographs
died. Mortality is dependently related to the were found in 76.8% of Covid-19 patients, which
following markers; shortness of breath (OR was higher than the non-Covid-19 patients,
[95%CI]: 13.90 [1.36-142.28], p = 0.027), gender suggesting the clinical diagnosis of pneumonia
(OR [95%CI]: 6.53 [1.49-28.69], p = 0.013), in Covid-19 patients.10 The study by Inui et al
cough (OR [95%CI]: 6.11 [1.33-27.96],p=0.020) reported that the lung lesions of patients with
and any comorbidity (OR[95% CI] : 0.07 [0.01- SARS- CoV-2 were present even in the absence
0.43], p = 0.004) (Table3). of clinical symptoms.11
A total of 38 patients (38%) had severe condition
DISCUSSION of Covid-19 and 19 patients (19%) had critical
During the early period of Covid-19 condition of Covid-19. A total of 7 patients had
outbreak outside of China, suspected mild Covid-19 symptoms. In contrast, a report in
cases were detected since January in Indonesia China showed that 160 cases were mild (non-
and the first confirmed case of Covid- 19 were pneumonia and mild pneumonia), while 6.168
detected on 2 March 2020. Our study identified cases were severe with the symptoms of
that almost all cases occurred among adults dyspnea, respiratory rate ≥ 30 x/minute, oxygen
(aged ≥ 18 years). Half of Covid- 19 cases were saturation ≤93%, the ratio of the oxygen partial
40-59 years of age (46 %), while more than half pressure to the fraction of inspired oxygen <
of non Covid-19 cases (56 %) were < 40 years of 300, and lung infiltration > 50%, and 2,087
age. Similar to previous study in Wuhan, China cases were critical cases of respiratory failure,
also showed that the early cases were septic shock, and/or multiple organ failure or
concentrated among adults over 40 years of dysfunction.12 Italy reported that there were
age.4,5 In this study, the data suggests that 46.1% mild cases, 24.9% severe cases, and 5%
people in productive age, including middle-aged critical cases of COVID-19.13 The proportion
adults, had high mobility related to chance of the difference in the severity of the cases may be
transmission of SARS-Cov-2 infection.6 More because Sulianti Saroso Hospital is a national
than half (52 %) of Covid-19 patients were men. referral center hospital for infectious diseases.
The proportion of Covid-19 patients who had Therefore, patients who came or referred to our
close contact with confirmed Covid-19 cases hospital generally were patients with moderate,
were 54 percent. Other than close contact with severe and/or critical condition of Covid-19.
confirmed cases, epidemiological study of Ping Our study reported the Covid-19 related in-
Yu et al also showed that it is possible for Sars- hospital mortality rate was 24 percent. It was
CoV-2 to be transmitted during the incubation higher than the non Covid-19 patients (6.5 %). In
period.7 In this study, the most common Covid-19 patients, men were found to be at a
symptom of Covid-19 cases was cough (80%) higher risk of mortality than women. One of the
followed by shortness of breath (59%). possible reason which may be responsible for
Gastrointestinal symptoms such as diarrhea, high mortality rate in males infected with Covid-
nausea, and vomiting were also found. Previous 19 is the differences in the immune or endocrine
study also showed that the earliest Covid-19 systems between men and women.14,15 Foo Y et
patients suffered from respiratory symptoms for al study reported a general pattern of suppressed
1 week before hospital admission.8 In Addition, immunity in males due to the presence of
we found that 15% of Covid-19 patients testosterone.17 In male patients, testosterone
developed acute respiratory distress syndrome. leads to lower adaptive immunity due to

suppressed function of associated type 2 and ETHICAL CONSIDERATION. This study was
type 17 T-helper cells, and hence decreases the approved by the Ethics Committee of the
antibody responses and B cell proliferation.15 Research and Development Agency, Ministry of
These conditions attributed to delayed antibody Health, Indonesia (No. LB.02.01/2/KE.335/2020)
response in males. 15
In female patients, estrogen is at a CONFLICT OF INTEREST. Authors declare that
physiologically higher concentration and thus they have no conflict of interest.
inhibits the synthesis of various pro-
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BREAST CANCER MANAGEMENT DURING CORONAVIRUS DISEASE 2019
PANDEMIC: A LITERATURE REVIEW

Andree Kurniawan1,2, Devina Adella Halim3, Angela Giselvania4, Noorwati Sutandyo5, Sonar Soni Panigoro6, Asri
Adisasmita7, Ratna Djuwita Hatma7

1 Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia

2 Clinical Epidemiology, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia
3 Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
4 Department of Radiation Oncology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia,
Jakarta, Indonesia
5 Hematology and Medical Oncology, Department of Internal Medicine, Dharmais Cancer Center Hospital, Faculty of
Medicine, Universitas Indonesia, Jakarta, Indonesia
6 Department of Surgical Oncology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta,
Indonesia
7 Department of Epidemiology, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia

ABSTRACT multidisciplinary team consisting of surgical,
Introduction Breast cancer is the most radiation, and medical oncologists, pathologist,
prevalent cancer found in women. The World radiologist, palliative care people, nurses,
Health Organization declared the coronavirus nutritionist, and others related to the field.
disease 2019 (COVID-19) as a public health Conclusion The International Oncology Society
emergency of international concern. Delaying has released recommendations for breast
treatment was associated with mortality. The cancer during COVID-19 pandemic but there is
aim is to evaluate breast cancer management still questionable-quality evidence.
during the pandemic.
Methods We searched articles evaluating the Keywords : breast neoplasms, COVID-19, drug
management of breast cancer in the midst of therapy
COVID-19 outbreak, by searching in PubMed,
PubMed Central, and Oncology Society related INTRODUCTION
websites. We only included articles discussing Breast cancer is the most prevalent cancer
adult breast cancer management in COVID-19 found in women with an estimated number of
era. The two reviewers screened the titles and new cases in the Europe community being
abstracts. 404,920, while its estimated age-adjusted
Results Around 124 articles were found through annual incidence is 144.9/100,000. Worldwide,
the searching process. Eight observational trials, in 2018, the incidence of breast cancer in female
two review articles, six guidelines or was up to 2.1 million.1 In the same year in Asia,
recommendations, and one letter to the editor newly confirmed cases kept rising with an
were included in final review. It was concluded estimated increment of more than 900,000
that breast cancer posed a risk to contract cases, constituting 43.6% of the newly reported
COVID-19. Newly suspected breast cancer breast cancer cases worldwide. On the other
could be deferred for screening or diagnosis, hand, its breast cancer death com- prised about
except for special breast cancer cases with half of worldwide mortality, reaching more than
bleeding, invasive, and complicated tumors. The 300,000 deaths.2
benefit of radiotherapy option in every case The World Health Organization declared the
should be carefully weighed against the risk of Coronavirus disease 2019 (COVID-19) as a
infection. Oral chemotherapy and hormonal public health emergency of international
therapy drugs were preferred to be given than concern. The newly discovered disease is a
intravenous chemotherapy. The scheduled chal- lenge for health care professionals. The full
chemotherapy could be adjusted to reduce impact of severe acute respiratory syndrome-
hospital visit. Each breast cancer patient is coronavirus 2 (SARS-CoV2) in our health
different, so they should be discussed in systems is yet to come and will be prolonged.

Global confirmed cases of COVID-19 had reporting items for systematic reviews and meta-
reached more than 48.5 million, with more than analyses) can be seen in ►Fig. 1. The two
1.2 million deaths, while Indonesia has reported reviewers (A.K. and D.A.H.) screened the title
429,574 cases with 14,442 deaths, as of and abstracts for 124 articles. Finally, we only
November 6, 2020.3 included articles mainly discussing breast
Timing of surgery after neoadjuvant cancer man- agement in adults during COVID-
chemotherapy, espe- cially in estrogen receptor 19 pandemic. There were eight observational
positive (ER+)/human epidermal receptor 2 trials, two review articles, six guidelines or
positive (HER2+) patients if delayed more than recommendations, and one letter to the editor.
8 weeks, would impact on decreased overall The dia- gram of search literature can be seen in
survival and disease-free survival.4 Another ►Fig. 1.
study found that delaying breast cancer
treatment of even a single modality will impact Risk of COVID-19 Infection in Cancer
on higher breast cancer-specific mortality and Patients
all-cause mortality.5 From the longitudinal COVID-19 infection data in
There is still limited data to recommend care for China reported by Liang et al,6 the incidence of
breast cancer patients in the midst of COVID-19 cancer in the COVID-19 population seems to be
outbreak, result- ing in fear of delay in treatment higher than in the overall Chinese population.
and impact on the over- all survival of patients. Breast cancer was found in 3 of 18 cancer
The aim of this study is to know the best patients (two in remission and one no
recommendation for breast cancer care during information). Cancer patients were older (63.1
COVID-19 outbreak. vs 48.7 years) and smokers (22% vs 7%). At
diagnosis of COVID-19, patients presented more
METHODS fre- quently with tachypnea (47% vs 23%) and
Search Strategies with a more severe computed tomography (CT)
A comprehensive search of the literature was pattern of infection (94% vs 75%). Cancer
conducted by searching in PubMed and PubMed groups are more likely to develop more severe
Central databases, and for guidelines or illness or death (50% vs 16%; p = 0.0008), even
recommendation by international societies of worse in those undergo- ing active treatment
surgical oncology, radiation oncology, and (75% vs 43%).6 After adjusting for the vari-
medical oncology, from January 2020 to April ables age and smoking in cancer patients, the
2020, with keyword combinations of the medical results showed an odds ratio (OR) for more
subject headings (MeSH) on April 9, 2020. The severe complications (OR = 5.34; 95%
keywords “breast neoplasm” AND “COVID-19” confidence interval = 1.8–16.18; p = 0.00026).
AND “man- agement” were used in search The risk seemed to be independent of cancer
engine. Management of adult breast cancer types.7
patients through surgery, chemotherapy, and
radiotherapy (RT) were the inclusion criteria. What Oncologist Should Do?
Articles in non-English language were excluded. Discussing the possible options for health care
Firstly, we searched the titles and abstracts. profession- als on how to deal with patients with
Then, we evaluated the full text whether it recent diagnoses/sus- pected breast cancer or
discussed breast cancer care in COVID-19 with ongoing treatment within the recent COVID-
times. 19 pandemic context should be done in a mul-
tidisciplinary team (MDT) meeting. Several
RESULT AND DISCUSSION scenarios should be considered for breast
Literature Search cancer management according to the diverse
We discovered 124 articles through the literature pandemic scenarios in different countries.8
search strategy. The reviewing process of
literature based on sys- tematic reviews and
meta-analysis (e.g., PRISMA: preferred

Preparation Screening and Diagnosis
Test all patients planned to receive elective Breast cancer screening, with mammographic
surgery and emergency surgery for COVID-19, use, should be postponed until the outbreak is
like using rapid tests. The decision needs to over. Symptomatic cases that need diagnostic
comply with local test availability, and choosing procedure should be managed according to
the proper test needs to rely on proper timing to local availability. On the other hand, considering
obtain valid test results.8 the burden

Fig. 1 PRISMA (preferred reporting items for systematic reviews and meta-analyses) search strategy.

on clinical outcomes, regular evaluation should for instance echocardiography monitoring, was
be performed in patients with unusual symptoms considered to be postponed if no cardiac
and signs.8 symptoms and no previous reduction in ejection
Initial breast cancer work-up should be fraction were observed. Alternatively, troponin
conducted only in patients with node-positive and brain natri- uretic peptide laboratory checks
breast cancer. Magnetic res- onance imaging from blood samples can be done.8
should only be done in COVID-19 nega- tive Outpatient consultation should be changed to
patients due to the risk of device contamination. telemed- icine consultation. Appointments
CT scan should be avoided whenever possible should be prioritized according to urgency using
because the prioritization is for COVID-19 high, medium, and low-priority stratification.8
positive patient evalua- tion. Other imaging use,

Further information about stratification can be retrieved from ►Table 1.

SURGERY platform. The results should be fur- ther
Ideally, team members must be reduced to deliberated with the patient and should depend
lessen the possi- bility of contacts and allow for on their desire to take the final decision.
replacement in case of get- ting contracted. All Before initiating invasive procedure, such as
booking procedures per day should be reduced, surgery, ideally all patients should be screened
regarding the time needed to disinfect carefully. for COVID-19, although asymptomatic. When
Most procedures should be technically the presence of SARS-CoV2 is detected, the
contraindicated or need to be replaced.8 patients should be treated as COVID-19 patient
All decisions to proceed with the surgical first while the procedure and/or treatment can be
procedure should be discussed in MDT meeting, resumed afterward.9
which could be held through teleconference

Table 1 Stratification of outpatient consultation appointments into priority groups8

Priority Interval Until Surgery Recommendation

Urgency <2 weeks • Patients with significant tumor burden not responding or progressing under
PST

• Pregnant patients

• Patients with complicated locally advanced tumor

High priority 2–4 weeks • Patients with early isolated locoregional recurrence (within 48 months from
pri- mary treatment)

• High-risk patients with contraindications to PST, if younger than 40 years or

node-positive, or with disease showing biological features of

aggressiveness

Medium priority 4–8 weeks • Patients treated with PST (ideally at a maximum of 4–6 weeks after
treatment completion)

• Premenopausal patients with small (<2 cm) node-negative tumors

Low priority >8 weeks • Ductal carcinoma in situ (However, high-grade ER-negative or very extensive
DCIS and/or with a palpable lump or extensive microcalcifications might fall
into the intermediate priority category, based on individual consideration of
each case)

• Postmenopausal patients with luminal A-like cancer; in these women, primary

endocrine therapy could be initiated and surgery could be postponed

Abbreviations: DCIS, ductal carcinoma in situ; ER, estrogen receptor; PST, primary systemic therapy.

All nonurgent and benign surgery indications experiences in caring breast cancer patients in
should be deferred. Outpatient surgery should the COVID-19 era. Further details of surgical
be offered to indicated patients whenever therapy priority in breast cancer have been
possible. Oncoplastic surgery, which needs provided in ►Table 2.
prolonged hospitalization, should be minimized.
In specific cases, immediate breast Radiotherapy
reconstruction was to be considered if the The role of RT in breast cancer causes
procedure remained simple and speeded significant impact on reducing locoregional
recovery. However, microsurgery procedure recurrences and improving survival. However, in
should be post- poned because of high particular patients it might have no survival
resources required.8 implications, for instance in ductal carcinoma in
situ cases. The use of breast RT has to be
Recommendation for Surgery in Breast thoughtfully evaluated in terms of its risk toward
Cancer infection, in the middle of the pandemic.11
In recent weeks there were recommendations
from the cancer working groups and country

Recommendations for RT for breast cancer in given RT for their survival benefit. Some tiers of
the COVID-19 pandemic include the changes in elevated priority have been prepared based on
framework for patient care,12 such as use of available evidence and clinical judgment. This
remote visits/teleconsultations, patient pri- ority setting should be considered by the
prioritization, method of radiation, avoidance, physician regarding the patient age,
delay or omission of RT, and the use of comorbidities, risk of exposure, and benefit
hypofractionation techniques. prediction of RT.8 Further details are available in
►Table 3.
Teleconsultations
Teleconsultations, using simple call or video Breathing Control
calls, should be implemented to replace Active breathing control technique in breast RT
outpatient visit when possible.12 Telehealth is not rec- ommended during the COVID-19
technology can also be used upon avail- ability, pandemic, since it may increase the risk of
depending on local institutional resources and aerosol contamination. Additionally, con-
legal aspects. For clinic patients or those who sideration should be taken to minimalize the use
are coming for their RT sessions, special of device requiring decontamination. To reduce
strategy should be arranged. Patients should cardiac toxicities with no supplementary
come only at their time of appointment and equipment and the risk of infection, deep
should spend the waiting time elsewhere until inspiratory breath-hold techniques with voluntary
their scheduled time. Visitor numbers should be breath hold might support.13
cut down to allow physical distancing in the
waiting room. Patients should not be not allowed Omission and Delay of Radiotherapy
to bring more than one companion. Laboratory Breast RT can be considered to be omitted in
testing should be performed with minimal certain settings when the effect on survival is not
contact to staff or other patients, and to avoid a very significant, such as in patients with
busy hospital, possibly with a drive through noninvasive disease or older patients with low-
system. Posttreatment routines, like tumor risk disease who have minimal survival benefit
marker testing, can safely be postponed for up from breast RT and much greater risk of
to 3 months.12 mortality from COVID-19.13 Experts in several
countries in the world discussed and made
Patient Prioritization several recommendations for RT in breast
Under extreme circumstances, it is essential to cancer patients
make priority setting for patients who might be

Table 2 Priorities for breast cancer: surgical oncology10

Priority Recommendation

• Breast cancer surgery complication with bleeding or indication to incision and drainage of a breast
abscess and/ or hematoma

• Complications of reconstructing surgery, for instance, ischemia

High • Surgery in patients who have completed neoadjuvant chemotherapy-based treatment (or cases with
progression of disease during neoadjuvant treatment)

• Surgery in patients with invasive cancer after discussed in MDT

• Breast cancer surgery during pregnancy (MDT decision should be according to the stage and
biology)

• Excision of malignant recurrence (depending on phenotype and extent)

Medium • Clinically low-risk primary breast cancer (e.g., stage I/II ER-positive/PR-positive/HER2-negative, low
grade/low proliferative index tumors); MDT to decide on starting neoadjuvant/preoperative endocrine
therapy according to menopausal status and delaying surgery

• Discordant biopsies likely to be malignant

• Excision of benign lesions and duct excision (fibroadenomas, atypia, papilloma)

• Surgery of noninvasive breast cancer (in situ), except for extended high-grade DCIS
Low • Discordant biopsies likely to be benign

• Breast reconstruction with autologous tissue and/or implants

• Prophylactic surgery for asymptomatic high-risk patients

Abbreviations: DCIS, ductal carcinoma in situ; ER, estrogen receptor; HER2, human epidermal receptor 2; MDT,
multidisciplinary tumor board meeting; PR, progesterone receptor.

Table 3 Prioritization of radiation for breast cancer based on treatment indication8

• Inflammatory breast cancer
• Residual node positivity after NAC
• Four or more positive nodes (N2)
High Priority For Breast RT • Recurrent disease
• Node-positive triple-negative BC
• Extensive LVI

• ER+ with 1–3 positive nodes (N1a)

Intermediate Priority For Breast • Pathology N0 after NAC
RT • LVI (NOS)
• Node-negative triple-negative BC

Low Priority For Breast RT • Early-stage ER+ breast cancer (especially elderly)
• Ductal carcinoma in situ
• Otherwise not meeting criteria for high and intermediate priority

Abbreviations: BC, breast cancer; ER, estrogen receptor; LVI, lympho-vascular invasion; NAC, neoadjuvant chemotherapy;
NOS, no other specified; RT, radiotherapy.

during COVID-19 pandemic. RT should be 16 Gy in 5 to 8 fractions. Hypofractionation is
omitted for patients aged 65 years and older (or possible in breast RT with strong supporting
with relevant comorbidities in younger age) with data. In the COVID-19 pandemic era, it is rec-
invasive breast cancer that are up to 30 mm with ommended to use hypofractionation scheme for
clear margins, grades 1 to 2, ER+, HER2- all breast/chest wall and nodal RT, such as 40
negative, and node negative planning for Gy in 15 fractions over 3 weeks.14 Extreme
treatment with endocrine therapy. hypofractionation scheme can be considered for
patients with node-negative tumors that do not
Hypofractionation require a boost, as in hypofractionated breast
Adjuvant breast RT has been established as RT for 1-week versus 3-week (FAST Forward)
part of standard treat- ment with normal trial, with options including 28 to 30 Gy in 5
fractionated regimen of 50 Gy in 25 fractions fractions weekly over 5 weeks or 26 Gy in 5
daily over 5 weeks with or without a boost of 10– fractions daily over 1 week, respectively.14

In order to reduce the number of fractions and/or postmenopausal women requir- ing whole breast
complex- ity of treatment, a boost in breast RT RT following sentinel lymph node biopsy and
should be considered to be omitted whenever primary surgery for T1, ER+, HER2-negative,
possible, unless in those with signifi- cant risk for and G1 to 2 tumors with 1 to 2 macro
local relapse, that is, 40 years old and under, or metastases.15–17 Further indications of omitting
over 40 years with significant risk factors for RT treatment are provided in ►Table 4.
local relapse. Nodal RT can be omitted in

Table 4 Radiotherapy treatments that may be omitted in breast cancer13,15

Subsite or classification Modality Comments and evidence

• Breast conservation Omission of radiotherapy to No survival benefit; small benefit in
• DCIS the whole breast locoregional recurrence

• Invasive disease Omission of radiotherapy to Endocrine therapy only sufficient in >70
• Low risk, older patients the whole breast (>65 in PRIMEII trial)

• Invasive disease Omission of radiotherapy to LUMINA, IDEA, PRECISION, PRIMETIME
• Genomic profile, low risk the whole breast trials ongoing (caution outside of trial)

• Age ≥ 50, ER+, HER2-breast Omission of boost No survival benefits
cancer without other adverse radiotherapy
pathologic features

• Postmastectomy Omit radiotherapy NSABP B-51/RTOG 1304 trials ongoing
• T1-2 N1 (node + breast cancer)

Abbreviations: DCIS, ductal carcinoma in situ; ER, estrogen receptor; HER2, human epidermal receptor 2.

Delay in RT treatment may be safely done for The preventive measures in hospitals should be
ER+ breast cancer patient for up to 5 months if improved. Daily phone calls to check symptoms
they are established on endocrine therapy and of COVID-19 in patients, who are planned for
have received prior chemotherapy.16,17 hospital treatment in the following day, should
be done regularly. Separation measures in
Systemic Therapy hospital must be implemented, for example
The objective of systemic therapy is to ensure ensuring appropriate space between seats.
appropriate cancer care and to protect patients Caregivers should not be not allowed for all in-
with cancer from the risk of COVID-19 and outpatients except in selected cases, for
infection.8 instance for children who need continuous
We should minimize the presence of cancer assistance. Surgical masks and handwashing
patients at the hospital. Patients should be with a hydro-alcoholic solution should be
encouraged to be managed at home by provided to all patients and staff at the hospital
telemedicine and phone calls. Oral entrance. MDT meetings should be done in a
chemotherapy and hormonal therapy drugs virtual setting or internally.18,19
should be preferred to intrave- nous drugs. The criteria for patient admission to hospital for
Other alternatives such as intravenous and sub- sys- temic therapy should depend on curative or
cutaneous anticancer agents can be made palliative intent, patient age, and their life
available at home. The schedule of expectancy. The prior- ity for patient admission
chemotherapy could be adjusted to decrease to hospital for systemic ther- apy should be set
hospital visit, for example every 3 weeks, in the following order: (1) patient with curative
compared to weekly basis. Patients with slowly intent treatment, favoring those with less than or
evolving metastatic cancer can break equal to 60 years or life expectancy ≥5 years;
temporarily. All the decisions should be (2) cancer patients with (a) noncurative intent
discussed by the MDT and shared with patients and less than or equal to 60 years old, (b) 5
and their families.18,19 years life expectancy or more, or (c) both and in
first-line; and (3) others with noncurative care,