Study of neutrophil-lymphocyte ratio (NLR) in recent onset type 2 diabetes mellitus

Introduction: The prevalence of type 2 diabetes mellitus (T2DM) is increasing steadily, assuming an epidemic proportion throughout the world. Most of this increased burden will come from developing countries. Studies show an increasing role of inflammation in the pathophysiology of diabetes. Estimation of neutrophil-lymphocyte ratio (NLR) could be a simple, inexpensive marker to stratify at-risk diabetes patients. This study aimed to estimate the NLR and CRP levels as a measure of systemic inflammation in diabetics compared to healthy controls. We also investigated if NLR was lower in diabetics with good glycemic control. 

Methods: A cross-sectional comparative study, conducted in a tertiary hospital on 60 patients with T2DM and 69 healthy controls after voluntary informed consent. Anthropometric parameters, fasting plasma glucose, Lipid profile, CBC, CRP, and HbA1c were measured for all participants. 

Results: The diabetic group showed significantly higher waist circumference(p=0.007) mean TG (p=0.003), VLDL-c (p=0.001), LDL-c (p=0.010), TG/HDL-c (p=0.001), HbA1c (p=0.00001), MPV (p=0.002), NLR (p=0.006), and CRP (p=0.004) values and lower HDL-c values (p=0.039) as compared to the control group. No significant difference was seen in BMI, Waist -Hip ratio, total cholesterol, and total cholesterol/HDL-c values between the two groups. Among the diabetics, only HDL-c (p=0.018) and TG/HDL-c ratio (p=0.049) differed significantly with glycemic control.

Conclusion: Diabetics had higher inflammatory markers (NLR, CRP) as compared to controls. Dyslipidemia (high TG, low HDL-c with high TG/HDL-c) and a higher waist circumference were seen in diabetics. Diabetics with fair control of glycemia (HbA1c < 7%) did not demonstrate lower NLR levels indicating that meticulous glycemic control may not ameliorate the chronic inflammation seen in diabetics until dyslipidemia is corrected. 

Vitamin D Receptor (VDR) Apa1 gene polymorphism increasing the risk of breast cancer women in Bali, Indonesia

Background: Breast cancer is the most common cancer diagnosed in women. It basically caused by a progressive accumulation of genetic disorders. Vitamin D and its receptor (VDR) have been shown to have an effect on the carcinogenesis of breast cancer. Several studies have shown VDR Apa1 polymorphisms became the most prevalent polymorphism of other polymorphism variants of breast cancer. There are still lack of studies that review the relationship of VDR gene polymorphisms, especially Apa1 on breast cancer risk among Balinese woman.

Method: This study was a case-control design- analytic study to see the relationship between Vitamin D receptor Apa1 gene polymorphism and breast cancer risk in Balinese women. There were 42 venous blood samples from breast cancer women and healthy women in Bali. This study was carried out at the Faculty of Medicine Integrated Biomedical Laboratory. DNA isolation was done for sequencing to determine the sequence of gene bases. Then the data were analyzed using SPSS 16.

Results: Univariate analysis showed the characteristics of the subject and research variables. Bivariate analysis showed that the presence of VDR Apa1 polymorphism in Balinese women increased the risk of breast cancer by 5,846-fold higher compared to women without polymorphism (CI95%:1.065- 32.082; P = 0.03). Multivariate analysis confirmed that the VDR Apa1 polymorphism independently influence and increase the risk of breast cancer without being influenced by other variables (95% CI: 1.065-32.082; P = 0.042).

Conclusion: In this study has shown VDR Apa1 polymorphism significantly associated and increased the risk of breast cancer in women in Bali.

Liver resection profile in Prof. dr. R.D. Kandou General Hospital: 1-year experience

Background: The role of liver surgery is increasing for primary and secondary liver tumors. One of the most feared complications of liver surgery is Post-Hepatectomy Liver Failure (PHLF). The authors would like to present their experience in a year for liver surgery with morbidity and mortality, including PHLF as evaluation parameters.

Methods: This is a prospective study from July 2019-2020 in a single-center, in which patients with pre-existing liver pathology were assigned to receive liver resection. Types and duration of liver resection, duration of Pringle maneuver, and blood loss were measured. PHLF was evaluated using the ISGLS classification, and morbidity was evaluated using Clavien-Dindo and FABIB classification. The energy device used varies from the harmonic scalpel, ligature, and Thulium-doped fiber laser (TDFL). Data were processed descriptively with IBM SPSS 25 (SPSS Inc., Chicago, USA). Data are presented in descriptive frequency tables as medians and means.

Results: A total of 17 procedures were performed, including minor hepatectomies (58.82 %) and major hepatectomies (41.18%). The mean duration of operation 5.3 hours, the duration of parenchymal transection 91.5 minutes, and the estimated blood loss 1638.2 cc. Vascular occlusion method using Pringle maneuver with mean duration of 31.67 minutes. PHLF incidence found were grade B (5.88 %) and grade C (11.7%), while morbidities by Clavien-Dindo mostly are grade 2 (38.2%) and FABIB classification mostly are Bleeding (45%). The mean postoperative ICU is 3.06days, and the mortality rate is as high as 23.52%.

Conclusion: Liver resection in our center is quite fair judging from the low incidence of PHLF, although the mortality rate is at 23.52%. Due to that, surgical technique and teamwork between units involved need to be improved even further.

Fractional erbium: YSGG laser compared to the combination of fractional erbium: YSGG laser and topical autologous platelet-rich plasma for treatment of atrophic acne scars: a case report

Background: Acne scar is the most common complication in acne that occurs in about 49% of acne individuals. Fractional resurfacing lasers such as CO₂ laser and erbium-doped yttrium aluminum garnet (Er: YAG) have been widely used for acne scar treatment and give satisfying results have complications such as pain, hyperpigmentation, infection, prolonged erythema, and scarring. Fractional erbium: yttrium scandium gallium garnet (Er: YSGG) laser solves previous laser techniques' disadvantages. It has an ideal wavelength of 2790 nm, which balances the epidermis layer's vaporization and thermal damage in the dermis's superficial layer. Platelet Rich Plasma (PRP) is an autologous concentration of human platelets in a small plasma volume that secreted various growth factors that can speed up the scar healing process.

Case report: A-24 years old male student came with a chief complaint of acne scars on his face four years before the examination. The patient's condition is classified as moderate-severe acne scarring based on Goodman and Baron's criteria (qualitative global acne scarring system). Acne scars treatment plan was single fractional erbium: YSGG laser for the left side of the face and combined fractional Er: YSGG laser with topical autologous PRP on the right side. This procedure was performed in 2 sessions with an interval of 4 weeks, the final evaluation at 12 weeks after the first procedure. Clinical improvement of acne scars was assessed using qualitative and quantitative scales based on Goodman and Baron's, patient and observer scar assessment scale (POSAS), quartile grading scale, and patient satisfaction level.

Conclusion: In the final evaluation, there was an improvement on the entire grading scale on the right side of the face (Er: YSGG laser + PRP) and the face's left side (Er: YSGG laser only). Post-treatment erythema was found on both sides of the patient's face but disappeared within three days on the face's right side and five days on the face's left side.

Characteristics of non-genital warts in the dermato-venereology department of Mangusada Badung General Hospital during in 2019

Background: Non-genital warts are a very common and benign skin disease caused by low-risk Human Papilloma Virus (HPV) infection. Common warts, flat warts, and plantar warts are common clinical manifestations of non-genital warts and are caused by many different types of HPV. Data on the prevalence or incidence of non-genital warts in Bali is still very limited. Therefore, it is important to identify the incidence and prevalence as a reference for conducting further studies on non-genital warts cases. This research studied the incidence, distribution, and characteristics of non-genital warts at Mangusada Badung General Hospital.

Methods: Descriptive cross-sectional retrospective study, using secondary data from outpatient clinic's patient register book and medical records in a period of 1 year, from January 1 - December 31 2019. Variables that included are types of non-genital warts, age and sex. Data were analyzed with SPSS 18 for Windows.

Results: The number of patients in this research was 3086. The incidence of non-genital warts was 88 cases (2.85%). Common wart was the most frequent findings, with 82 cases (93.2%) and flat wart with 6 cases (6.8%). Non-genital warts frequency was highest among age 11-20, with 31 cases (35.2%). Based on sex, non-genital warts are more frequent in males than females (56.8% vs. 43.2%). The most frequent non-genital warts cases in the male population occur at age 11-20 (20 cases), while in female populations, 11-20 and 21-30 share the same incidence of non-genital warts (11 cases).

Conclusion: Non-genital warts most likely to affect a male compare to the female population. It tends to occur more frequently in children and young adults. The common wart is the most frequent findings in non-genital warts.

DNA barcoding in molecular identification and phylogenetic relationship of beneficial wild Balinese red algae, Bulung sangu (Gracilaria sp.)

Background: Bulung sangu (Gracilaria sp). is wildly widespread Rhodophyta in Bali and usually consumed as vegetable. Bulung sangu is reported for its bioactive compound scientifically proven as antioxidant, anti-inflammatory, and anti-hypercholesterolemia. Likewise, Bulung sangu as Rhodophyta is a potential source for food, fertilizer, cosmetic and pharmaceutical industry. Bulung sangu production is highly fluctuating and unable to meet its demands. Proper and correct cultivation methods based on molecular information are expected to increase the availability of Bulung sangu in Bali. Complete taxonomy is required to design the proper cultivation method. Meanwhile, Bulung sangu taxonomy is limited to the genus level. More information on Bulung sangu strain is needed, either does its relatedness.

Methods: Fresh Bulung sangu was collected from Serangan coastal area, Bali. DNA extraction was applied followed by PCR amplification using six combinations of COI primer sequence. DNA sequences obtained was evaluated to determine pairwise distance, percent of similarity and phylogenetic relationship compared to Gracilaria species registered in GenBank.

Results: PCR amplification produced 730 base pairs amplicons. Genetic distance and percentage of similarity obtained exhibit relatedness to Gracilaria gracilis with 0.487 of pairwise distance and 49.04% of similarity. The phylogenetic tree produced seven clades in which Bulung sangu and Gracilaria gracilis were in the same clade.

Conclusion: Bulung sangu showed closest relatedness to Gracilaria gracilis.

Patients’ characteristics following reoperation after Modified Blalock-Taussig Shunt (MBTS) in Cardiac Centre National General Hospital Cipto Mangunkusumo from 2018-2020

Background: Modified Blalock-Taussig shunt (MBTS) is a common palliative procedure for congenital heart defect to connect the systemic to the pulmonary circulation via a synthetic shunt from a subclavian artery to a pulmonary artery. However, certain postoperative complications do exist, such as blockage. Early identification of modifiable risk factors is important to prompt early intervention for better outcomes.

Material: This article is a descriptive narrative retrospective study. We gather data from the Cipto Mangunkusumo Hospital Cardiovascular Center medical report of 8 patients having undergone reoperation post-MBTS surgery as their first operation between January 2018 and October 2020. Data were analyzed using SPSS version 20 for Windows.

Results: The patient’s age ranged from 3 months to 30 years old. Seven of them suffered from shunt occlusion complications, while the other suffered from the bleeding problem. The laboratory results showed that preoperative hemoglobin (18.9±4.1 g/dL vs. 16.90 (10.80-19.20) g/dL), hematocrit (58.8±12.40% vs. 42.9±14.30%), platelet counts (284.487±147.003 vs. 210.625±104.688) 10³/uL, and oxygen saturation (86.00 (75.00-89.00) vs. 70.00±17.00) levels were higher than the pre-reoperative. The coagulation markers showed that PT value has increasing trend (1.10 (0.90-2.30) vs. 1.30±0.20) while aPTT (5.90 (2.90-6.30) vs. 2.30 (1.60-5.30)) seconds and activated clotting time (ACT) (205.00±86.00 vs. 165.00 (114.00-255.00)) showed the opposite.

Conclusion: MBTS remains the first-choice bridging palliation surgery to increase the pulmonary blood flow in congenital heart defects. The cause of shunt failure remains inconclusive in this study. Other studies suggest that graft material choice, S/PA ratio, S/W ratio, operative approach, thrombus formation, and aPTT value contribute to shunt failure, thus needing a reoperation.

The correlation TNF-α gene promoter region -238G, -308G, -857, and -1031 polymorphism with psoriasis vulgaris

Background: Psoriasis vulgaris is a recurrent chronic skin disorder signed by hyperproliferation and epidermal inflammation. One of the etiology of psoriasis is genetic factors related to genetic polymorphism as disease susceptibility markers. This study was aimed to analyze the correlation of TNF-α gene promoter region polymorphism with psoriasis vulgaris.

 Methods: An analytical observational study with cross-sectional design to identify correlation TNF-region promoter polymorphisms with psoriasis vulgaris. This study included 45 psoriasis vulgaris patients and 45 non-psoriasis vulgaris patients from April to October 2016 at Immuno-dermatology Polyclinic of Dermatology and Venereology/Haji Adam Malik Hospital, Medan. We isolated DNA from the blood sample then ran into the PCR process with specific primers. PCR results were examined by electrophoresis with 2% agarose. Chi-Square test was used to test the hypothesis of a relationship between the TNF-α promoter region and psoriasis vulgaris at a significance of P <0.05.

Result: Analysis by Chi-Square test found a significant correlation of polymorphism in TNF-α gene promoter region with psoriasis vulgaris in -308G (p=0,001) and 1031 (p=0,002) loci.

Conclusion: TNF-α gene promoter region polymorphism TNF-α gene -1031 was more frequent in the case group, -308G was commonly found in the control group. Both of them were significantly correlated with psoriasis vulgaris.

Ergonomic workstation reduces electrical activity of upper trapezius muscles, erector spinae muscles, and musculoskeletal complaints in agel fiber twisting process

Background: Humans' role in small industries as a source of labor is still dominant, mostly manual work. The research was conducted on manual workers in small agel fiber industries in Yogyakarta. Manual work is related to human strength and endurance. Ergonomic problems often arise in manual labor, including neck pain, back pain, and leg pain called musculoskeletal disorders. Non-ergonomic working conditions also increase the electrical activity of muscles. This study aims to reduce electrical muscle activity and musculoskeletal complaints by repairing an ergonomic workstation in the agel fiber twisting process.

Methods: This research is an experimental study with 15 female subjects. The electrical activity of muscles is measured when working under conventional conditions (Period 1) and repairing an ergonomic work station (Period 2). The electrical activity of the muscles was measured using surface electromyography. Musculoskeletal complaints were measured before and after intervention with conventional conditions (Period 1) and ergonomic work station repair (Period 2). Musculoskeletal complaints were measured using the Nordic Body Map Questionnaire. The measurement data between the two periods were analyzed by using the paired samples t-test and the Wilcoxon signed-rank test.

Results: The results showed a decrease in the upper trapezius muscles' electrical activity by 35.46% and the erector spinae muscles' electrical activity by 22.43%. The average of musculoskeletal complaints decreased by 23.77%, measured after working in period 1 and period 2.

Conclusion: Ergonomic work station can reduce the electrical activity of the upper trapezius muscles, electrical activity of the erector spinae muscles, and musculoskeletal complaints in workers twisting the agel fiber rope.

Intravenous Wharton's Jelly stem cell increased the number of β cells pancreas and reduced the fasting blood glucose level in diabetes mellitus Wistar rat male (Rattus norvegicus)

Introduction: Diabetes mellitus is a metabolic disease characterized by hyperglycemic and disorders of carbohydrate, protein and fat metabolism due to abnormalities in insulin secretion, insulin sensitivity or both. Based on previous research, Wharton's Jelly's mesenchymal stem cells have anti-inflammatory, immunoregulatory properties that can improve metabolic control and have the ability to differentiate into pancreatic lineage cells that function as insulin-producing cells in vitro culture. The purpose of this study was to prove that administration of mesenchymal stem cells Wharton's Jelly can increase the number of pancreatic beta cells and reduce fasting blood glucose levels in male rats (Rattus norvegicus) Wistar strain of diabetes mellitus.

Methods: The research design used was pure experimental with post-test only control group design using 36 white male rats. All samples were induced with Streptozotocin and Nicotinamide. The selected samples were divided into two groups: the control group given glibenclamide + 0.9% NaCl, and the treatment group was given glibenclamide + mesenchymal stem cells from Wharton's Jelly. Calculation of the number of pancreatic beta cells and measurement of blood glucose levels were carried out after 14 days of treatment.

Result: The results showed that the treatment group had a higher number of pancreatic beta cells than the control group (105.17 ± 16.379 cells/field of view vs. 54.00 ± 11.366 cells/field of view) (p <0.001). In addition, the treatment group had lower fasting blood glucose levels than the control group (109.06 ± 16.71 mg/dl vs 122.78 ± 10.14 mg / dl) (p <0.05).

Conclusion: It was concluded that intravenous administration of Wharton's Jelly mesenchymal stem cells increased the number of pancreatic beta cells and decreased fasting blood glucose levels in male rats (Rattus norvegicus) Wistar strain of diabetes mellitus.

Comparison of skin hydration degrees based on moisturizing time in children's atopic dermatitis

Background: Atopic dermatitis (AD) is a skin disease accompanied by an inflammatory reaction influenced by heredity and environment. Atopic dermatitis commonly occurs in infants and children. Overcoming dryness of the skin is an important strategy in the management of AD. One way is by using a moisturizer (emollient) to increase the skin barrier function. This study aimed to compare the degree of skin hydration based on moisturizing time in children with AD, immediately after bathing and 30 minutes after bathing.

Methods: This analytical study's design was quasi-experimental (pre-post clinical trial) conducted in dermatology-venereology policlinic of Universitas Sumatra Utara Hospital. Subjects who met inclusion criteria were children with AD, 2-14 years who met William's criteria,  no recent use of topical preparations, and informed consent approved. The bath soap and moisturizer used were Johnson's® baby milk soap and those containing ceramide-3 (Atocalm®), respectively, applied twice a day.  Moisturizing time is given immediately and 30 minutes after bathing on the volar part of the right forearm and left forearm, respectively. The degree of skin hydration was measured by Corneometer CM 825®, taken four times on the 1st, 8th, 15th, and 21st day, and categorized into very dry skin, dry skin, and normal skin.  Test analysis using SPSS software with p<0.05 was significant.

Result: Thirty-seven children with AD followed this study. The median age was 5 (2-13) years, female sex (21 children [56.8%]). There were differences in skin hydration between these groups. There was also significant right forearm volar skin hydration measured immediately after bathing, 1st, 8th, 15th, 21st day (42.3; 48.0; 55.3; 61.3 AU (Arbitrary Unit); p<0.001), respectively. Skin hydration on the left forearm's volar part is significant between 30 minutes after bathing, respectively 1st, 8th, 15th, 21st day (42.3; 44th,7th; 47.7; 52.0 AU; p<0.001). The total amount of dry skin and very dry skin was more in the moisturizing group 30 minutes after bathing than immediately after bathing. 

Conclusion: Significant difference in skin hydration degrees found between immediately after the bathing group (on the right forearm volar) and 30 minutes after bathing (on the left forearm volar).

The correlation of blood thiamine concentrations with lactate acidosis in peritonitis patients with sepsis

Background: Vitamin B1 (Thiamine) functions as a pyruvate dehydrogenase cofactor to produce acetyl Co-A and activate the Krebs cycle in cellular metabolism. The hypermetabolic state in septic condition requires excess thiamin to keep the Krebs cycle functioning well. The thiamin level in the blood decreases and causes mitochondrial dysfunction and vice versa results in an increase in lactate levels. This study aims to evaluate the correlation of blood thiamine concentrations with lactate acidosis in peritonitis patients with sepsis

Methods: Prospective observational study in 65 adult septic patients who came to the hospital with peritonitis and underwent laparotomy. Thiamine concentration was assessed on days 1, 3, and 5 by liquid chromatography-mass spectrometry (LC-MS). The primary outcome was lactate levels. Data was analyzed using SPSS version 23 for Windows.

Results: The incidence of thiamine deficiency (TD) was 61.5% of patients. Specifically, 29 cases (44.6%) had absolute thiamine deficiency (TD) on presentation, 4 patients (6.1%) developed it on day 3, and another 7 patients (10.8%) on day 5. Thiamine was negatively correlated with lactate levels (r=-0.600; p=0.020). The relationship appeared after multivariable regression analysis controlling for sex, septic shock, and malnutrition. Overall, for the TD group, there was a significant association with septic shock, malnourishment, and Mortality (p<0.05).

Conclusion: Thiamine deficiency had significantly raised lactate levels, which might increase the risk of Mortality.

A new hope of CD133+ bone marrow stem cell for functional exercise capacity improvement in low ejection fraction coronary artery bypass graft patients: a clinical trial

Background: Patients with low ejection fraction who are undergoing coronary artery bypass graft (CABG) only have an insignificant improvement in ejection fraction. This condition will make a little hope to achieve an improvement in physical performance. But now, from a view study, CD133⁺ stem cells offer new hope for this situation. This study evaluates CD133+ bone marrow stem cells' role for functional exercise capacity improvement in low ejection fraction coronary artery bypass graft patients.

Methods: Thirty patients with ischemic heart disease who had ejection fraction <35% at the National Cardiovascular Center were randomized into 2 groups. The treatment group undergoes the CABG + CD133⁺ procedure and the control group undergoes the CABG only. All research subjects underwent follow-up before and 6 months after the procedure. Fraction ejection, scar size, wall motion score index, ventricular dimensions, myocardial perfusion measured by cardiac MRI, 6 Minutes Walking Test (6MWT) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) as an additional parameter for physical performance and quality of life. Data was analyzed using SPSS version 21 for Windows.

Results: The results of the fraction ejection parameters showed a significant improvement in the treatment group, from 25.88±5.66% to 34.57%±11.31% compared to CABG only 30.18±3.85% to 31.61±7.89% (p=0.040), in the perfusion defect showed improvement but not significant, left ventricular end-systolic volume and left ventricular end-diastolic volume showed improvement with no significant result, scar size was found to be an improvement in the treatment group 10 persons (76.92%) compared to the control group 5 persons (38, 46%) (p=0.040), the wall motion score index and 6MWT showed a significant improvement in the treatment group (p=0.003 and p=0.03, respectively). The MLHFQ parameter showed improvement but not significant.

Conclusion: CD 133+ stem cell implantation in patients with low ejection fraction who undergo CABG provides improved myocardial function and indirectly improves functional exercise capacity and patients' quality of life.

The role of epidermal growth factor receptor as progression factor in cervical intraepithelial neoplasia and squamous cell carcinoma

Background: Cervical carcinoma is the most common cancer with a prevalence of 28.6% of all cancers in women in Indonesia and is one of the leading causes of death among gynecologic malignancies. Prevention and understanding are needed in terms of initiation and development of precancerous lesions into cervical cancer. About 90% of cervical cancers are squamous cell carcinomas that develop from intraepithelial neoplasia. Epidermal Growth Factor Receptor (EGFR) is an expression product of the proto-oncogene c-erbB-1 (HER-1), which plays a role in the proliferation, differentiation and acceleration of the transformation of malignant cells. This study aimed to prove the role of EGFR as a progression factor of cervical intraepithelial neoplasia and cervical squamous cell carcinoma.

Methods: The study design was a cross-sectional analytic observational study, with a total sample of 36, which was taken from biopsy or surgery from patients with cervical intraepithelial neoplasia (CIN) and cervical invasive squamous cell carcinoma (SCC), whose tissues were examined at the Anatomical Pathology Laboratory, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital. Histopathological diagnosis and determination of the type of malignancy were carried out by staining with Hematoxylin and Eosin (H & E). The immunohistochemical stain evaluated EGFR expression.

Results: The age range of CIN was 21-48 years and SSC 33-61 years, mean age 41.8 ± 10.55 years. A total of 16 (44.4%) showed CIN namely 9 (25%) low-grade CIN, 7 (19.4%) high-grade CIN, and 20 (55.6%) SCC. There was a significant difference in the expression of EGFR at low-grade CIN, high-grade CIN and SCC (p = 0.004). There was a significant difference in EGFR expression between low-grade CIN and high-grade CIN (p = 0.035) and between low-grade CIN and SCC (p = 0.003). There was no significant difference in EGFR expression between high-grade CIN and SCC (p = 0.441).

Conclusion: EGFR has a role as a progression factor in CIN and SCC. There was no difference in the expression of EGFR between high-grade CIN and SCC, probably because in this study, carcinoma in situ was also included in high-grade CIN.

Predicting factors for walking ability of postoperative patients with hemiarthroplasty at Wahidin Sudirohusodo Hospital in Makassar

Background: The ability to make early predictors in post-surgery includes health workers preparing patients for outpatient care. The purpose of this study is to determine the factors that influence the ability to walk postoperative hemiarthroplasty patients when patients are admitted. We hypnotized that age, sex, preoperative walking status, time interval between injury to surgery, preoperative hemoglobin level, muscle weakness, muscle atrophy, anxiety level and body mass index would be predictive factors for walking ability post hemiarthroplasty surgery.

Method: An descriptive-analytic study with a cross sectional retrospective approach was conducted at the Wahidin Sudirohusodo Hospital in Makassar 2020. Patients with fractures of the proximal femur had undergone hemiarthroplasty surgery and were over 50 years of age at admission from September 2019 to October 2020. Bivariate and multivariate with logistic regression was used

Result: 39 samples according to inclusion criteria were analyzed. Muscle atrophy has a significant correlation with p = 0,04 (p<0,05). Body mass index and muscle atrophy have the most dominant factors for predict walking ability post hemiarthroplasty (EXP (B) 7,282 & EXP (B) 0,083) eventhough not significant statistically (p = 0,116 & p = 0,073)

Conclusion: The muscle atrophy variable in this study was the most significant factor in prediction walking ability post hemiarthroplasty surgery. Also, patient with normal BMI will encourage early walk after surgery better than abnormal BMI in the same muscle-wasting condition

The dynamic of Soluble Vascular Cellular Adhesion Molecule -1 (sVCAM-1) level in Overnutritious children with Dengue Infection

Introduction: Dengue infection is still posed a significant medical challenge for pediatric population in developing countries. However, increased prevalence of overweight and obesity among children in those countries increased the possibility of the coexistence of these conditions. However, their interaction is still under investigated. Therefore, this study was aimed to study the dynamic of sVCAM-1 level as the known predictor of the severity of dengue infection with over nutritional status in children with dengue infection.

Method: An analytic observational nested case-control study was conducted in Paediatric Division Sanglah General Hospital, Bali. The children with DHF between 6 months old to 12 years old were included as the case group while control groups consisted of pediatric patients with just Dengue Fever (DF) with the same age range. The diagnosis of dengue was established using 1997 WHO criteria while nutritional status was assessed using WHO curve. The sVCAM-1 was evaluated using ELISA technique.

Results: The level of sVCAM-1 was significantly higher in patients with DHF than patients with DF only. The level was also fluctuated more in DHF patients. Likewise, the sVCAM-1 level was also significantly higher in DHF patients with overnutrition compared to normal DHF patients with a more fluctuated pattern over the course of 3 days (starting from day 4 to day 7). Finally, no significant finding was observed in sVCAM-1 level in DSS patients albeit the difference in concentration pattern.

Conclusion: Overnutrition is seems to be associated with higher concentration of sVCAM-1 and higher fluctuation of its concentration in children with DHF.

Evaluation of chronic disease management programs in developed and underdeveloped regions in Indonesia

Introduction: Chronic diseases have become a major cause of death in the world, and a major source of morbidity and misery. Approximately 80% of related deaths occur in developing countries. Chronic Disease Management Program (CDMP) is an integrative program aimed to control the prevalence of chronic diseases. Therefore, this study aimed to evaluate the interaction between context and process in CDMP services, and to determine how CDMP was implemented in developed and underdeveloped regions.

Methods: This qualitative study used the Consolidated Framework for Implementation Research (CFIR). Subjects were selected by purposive sampling from CDMP organizers in Primary Health Centers for a commitment-based capitation assessment. Transcript data were analyzed thematically by summarizing and identifying major themes based on the CFIR domains.

Results: The main activities of the CDMP (medical consultations, monitoring of health status, health educational, reminders, home visit and group activities/gymnastics) in developed regions were conducted according to the technical manual. However, in underdeveloped regions, some modifications were needed, i.e. the medical consultations, medical checkups and health education undertaken by a nurse in charge and not always conducted by a doctor; and, the services were conducted at the village meeting halls. Also, the reminders were delivered through socialization by local governments and direct invitation by team members when they met the participants on the roadway or in the neighborhood around the participants’ homes.

Conclusion: CDMP cannot fully be implemented in underdeveloped regions and some modifications were needed according to local conditions.

Correlation of low vitamin D status with atopic dermatitis severity in children

Introduction: Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disorder. Vitamin D has some roles in immunologic mechanisms. Vitamin D may influence the severity of AD. Previous studies of vitamin D correlation in children with atopic dermatitis have revealed conflicting results. This study determines the correlation between low vitamin D status with the severity of atopic dermatitis in children. 

Methods: This is a cross-sectional analytical study with a cross-sectional approach that involved DA subjects aged ≤17 years with low vitamin D status. The recording of basics data and examination of subjects included assessing the scoring atopic dermatitis (SCORAD) score and measuring 25-hydroxyvitamin D (25(OH)D) level for all subjects. Statistical analyses were performed using Pearson's correlation coefficients, with P<0.05 was considered statistically significant. 

Result: A total of 30 subjects with AD with the most extensive distribution was in the age group of 11–17 years (53.33%), sex proportions were equal both male (50%) and female (50%), all subjects have an atopic family history (100%). The mean vitamin D level was 18,02 ± 4,56 ng/ ml (deficiency), and the mean SCORAD score was 20,03 ± 5,80 (mild). There was a significantly strong negative correlation between low serum vitamin D level and severity of AD in children (r = -0.666, p = 0.001). 

Conclusion: Lower vitamin D status is inversely associated with the severity of AD in children.

COVID-19 vaccination in patients with cancer: Position paper from the Indonesian Society of Hematology and Medical Oncology (ISHMO) of Semarang

Patients with active cancer (cancer on treatment, those planning to start treatment, and those immediately post-treatment) consider getting the COVID-19 vaccine, like the other vulnerable populations, to reduce the severe risk of SARS-CoV-2 infection. We suggest patients with cancer should be vaccinated with a non-lived COVID-19 vaccine. Specific consideration belongs to the type of cancer, current treatment, phase of disease along the cancer continuum, and optimal timing for vaccination; they should talk to their hematologist-medical oncologist. Vaccination with the live-attenuated and replicating-vector vaccine is strongly discouraged in patients with active cancer receiving chemotherapy and during other immunocompromising therapies. For patients those receiving intensive chemotherapy (e.g., induction or consolidation therapy in acute leukemia), anti-B-cell antibodies, hematopoietic stem cell transplantation (HSCT), and other immunocompromised conditions, we suggest postponing SARS-CoV-2 vaccination until reaching stable lymphocyte counts due to the risk of vaccine infectivity. Cancer survivors are considered to have the same risk as other persons with matched aged and other risk factors. They also should be vaccinated as early as possible. There are various other risk factors for cancer patients which must consider related to complications of COVID-19, such as age, other comorbid diseases, demographic and social factors. All of these factors should be judged as a comprehensive evaluation of an individual patient. The use of masks, physical distancing, hygienic activities such as washing hands with soap and hand sanitizers are still needed during this pandemic. Caregivers and households should certainly be included in the vaccination strategies.

Anti-diabetic properties of Stevia rebaudiana Bertoni as sugar substitute: a mini-review

The incidence of obesity, type II diabetes mellitus, and metabolic syndrome in children and adults show an alarming increase worldwide. This increase was supported by one factor: the increasing availability of high-calorie foods and beverages, thus increasing the need for sweeteners. Researchers are driven to find a sweetener that can replace sugar. One of the natural sweeteners that can be used is the Stevia plant. Stevia contains stevioside, which is a natural sweetener with 300 times sweetness compared to sucrose. Besides, stevioside can reduce blood sugar levels and show benefits for people with diabetes.

Keloid after orthopedic surgery: prevention, current therapy modalities, and emerging therapies modalities

Keloid is a benign fibroproliferative tissue growth that exceeds the initial wound margins. It is caused by the disruption in the wound healing phase with increased fibroblast activity and excess collagen deposition. Keloid usually develops after tissue trauma. Orthopedic surgery inevitably causes tissue trauma that will lead to the formation of keloids in a few patients. Keloids can cause cosmetic and functional problems, thus interfere with a person's quality of life. Keloid therapy modalities are mainly divided into three, which are prophylactic therapy modalities, current therapy modalities, and emerging therapy modalities that are being developed. This literature review aims to evaluate further prevention, current therapy modalities, and emerging therapies modalities in Keloid following orthopedic surgery.

Successful total correction of Transposition of Great Artery in Surabaya’s rural area experience: serial cases

Background: Transposition of the great arteries (TGA) is a cyanotic heart disorder characterized by the aorta being positioned to the pulmonary artery's right-anterior. Arterial switch operation (ASO) is the main surgical procedure for TGA correction that has favorable outcomes. This case report aims to explain the findings of TGA cases that were performed successfully by ASO surgery at Dr. Soetomo Hospital in Surabaya.

Case Presentation: We reported two cases of dextro-TGA, which were confirmed from anamnesis, physical examination and echocardiographic. Both cases have been successfully carried out with an arterial switch operation (ASO) procedure with a post-operative length of 14-15 days with stable hemodynamics.

Conclusion: TGA is a congenital heart defect with a rapid worsening of clinical signs if not detected early. The early correction will improve post-correction outcomes in patients.

Right hepatic artery pseudoaneurysm after choledocoduodenostomy: a case report

Background: Pseudoaneurysm of right hepatic artery is a rare complication after bile duct injury (BDI) repair. An unidentified rupture of pseudoanuerysm will lead to mismanagement of this fatal complication. Massive haemorrhage can present and causes high mortality

Case Description: We report a 60-year-old female who suffered jaundice and massive upper gastrointestinal bleeding two weeks after cholodocoduodenostomy bypass surgery in rural hospital. That procedure was done because of BDI after laparoscopic cholecystectomy. Embolisation was carried out after identifying an pseudoaneurysm of right hepatic artery to stop bleeding. Bleeding was transiently stopped, and rebleeding occurred several weeks later. Surgery was performed because of repeated bleeding after third embolization in Kariadi hospital. Ruptured pseudoaneurysm to choledocoduodenostomy anastomosis was found. Pseudoaneurysm was resected and right hepatic artery was sutured. Choledocoduodenostomy was closed. Continuity of biliary tract was maintained by re-reconstruction choledoco-jejunostomy roux n Y. Upper gastrointestinal bleeding symptom was disappeared, and bilirubin level was returned to normal at outpatient follow up after operation.

Conclusion: This patient had a hemobilia because of ruptured right hepatic artery pseudoaneurysm. Triad Quincke which consist of right upper quadrant pain, jaundice and upper gastrointestinal bleeding, occurs in 30% of patient with hemobilia. This sign of hemobilia after biliary tract procedure must be managed quickly and accurately. Angiography is main diagnostic procedure. Arterial embolisation is first line intervention to stop the bleeding. Surgery is preserved in case where rebleeding occurs. Good anatomical knowledge can prevent this complication.

The change of cell biometric and its nucleus on cervical-squamous-epithelial-cell with GA genotype of Fas-promoter-670 gene, high-risk human papillomavirus and Candida species infection: a case report

Background: Cervical samples of patients with human papillomavirus (HPV) infections show positive results in HPV DNA testing. HPV infection can alter cervical squamous epithelial cells (CSECs) to be abnormal. Epigenetically, CSECs that change to be abnormal are affected by Fas-promoter-670 gene polymorphism. High-risk HPV (hr-HPV) patients can be infected by other microbes, for example, Candida species (Candida sp.). The present study's purpose was to show CSEC biometrics based on epigenetics of the Fas-promoter-670 gene polymorphism in Indonesian women with hr-HPV and Candida sp. infection. Biometric quantification was performed based on the following analysis of CSECs.

Case report: Indonesian hr-HPV women at the age of 28 years, with Candida sp. infection, underwent a Pap smear examination on April 21^st, 2016, using the ThinPrep method, and a blood test was also performed using the cubital vein. Blood and ThinPrep samples were examined for the Fas-promoter-670 gene polymorphism. Epigenetically, the subjects had the GA genotype of the Fas-promoter-670 gene in the blood and ThinPrep samples. Patients with Candida sp. infection in the early stages were characterized by the appearance of polymorphonuclear leukocytes (PMN), whereas those in advanced stages presented without PMN on the hyphae. CSEC biometric measurements were performed quantitatively using mononuclear CSECs (mn-CSECs) and binucleated CSECs (bn-CSECs).

Conclusion: Biometric measurements of the CSECs were performed quantitatively and assessed the length, width, area and perimeter of the cell and its nuclei. Cell length, cell width, nucleus area, nucleus perimeter and nucleus length index were significantly different between the mn-CSECs, the 1^st nucleus of bn-CSECs and 2^nd nucleus of bn-CSECs (P<0.05).

Simultaneous resection on the patient with synchronous colorectal liver metastasis: two cases report

Background: Colorectal cancer (CRC) is ranked as the third most common cancer worldwide.One of the leading causes of death in CRC patients is due to its metastasis. The liver is the most common site of metastasis. The best treatment to achieve long-term survival and cure patients with CRC liver metastasis is surgery, whether it’s sequential, delayed, or simultaneous resection.This case study aims to evaluate the simultaneous resection on the patient with synchronous colorectal liver metastasis.

Case Presentation: From January-June 2020, in Prof. Dr. R. D. Kandou General Hospital, Manado, 2 patients were treated with simultaneous resection for CRC with resectable synchronous liver metastasis. Blood loss, bile leak, ascites, and post hepatectomy liver failure (PHLF) were observed as outcome parameters.

Conclusion: Simultaneous resection is safe and exhibits advantages in the long-time survival of patients. However, the incidence of complications and mortality are higher in simultaneous resection than in staged resection.

Radiofrequency ablation for management of thyroid nodules: a case report

Background: Thyroid nodules constitute a frequently seen clinical problem and the incidence of thyroid nodules has increased with the recently increased use of thyroid ultrasonography. Radiofrequency ablation (RFA) is an effective and safe method for treating benign thyroid nodules and recurrent thyroid cancers.

Case Presentation: A 48 years old woman came to the surgical oncology clinic with the presence of a getting bigger, moves when the patient swallows, and painless mass on her neck since 20 years ago. The physical examination measured 5x5 cm mass, mobile on swallowing, no pain on palpation, and the laboratory examination shows a euthyroid state.  The ultrasound result has revealed an enlargement of the right and left thyroid with increased echo intensity of parenchyma and increased vascularisation. This mass was concluded as struma nodus bilateral. The FNAB was follicular neoplasm, Bethesda system class 4. The patient underwent a single session RFA. RFA was performed employing transisthmic access using a 7 cm 18 gauge electrode-needle with a 1 cm active needle tip. The patient well tolerated the procedure and no adverse events were noted.

Conclusion: Radiofrequency ablation for thyroid lesions is a safe and effective method for treating benign thyroid nodules and even recurrent thyroid cancers. Therefore, various factors, including serum TSH, clinical risk factor assessment, size of the nodule, ultrasound characteristics, patient preferences, and results of the FNA biopsy, should be considered to manage thyroid nodule.

Management of giant thyroglossal duct cyst in Dr. Moewardi Hospital Indonesia: A case report

Introduction: Thyroglossal duct cyst (TGDC) is a developmental abnormality in which the thyroglossal duct settles after the decline of the thyroid gland.A 57-year-old female patient presented with complaints of a lump in the middle of her neck that slowly enlarged. The lump was first realized around 10 years ago. When she swallowed, the lump also moved. The swelling was cystic, painless surrounded by healthy skin except for a small area that showed a sign of inflammation. The ultrasound and Magnetic resonance of the neck confirmed TGDC with a size of 120 x 100 x 50 mm. We performed a surgical excision on the cyst and the central part of the hyoid bone (sistrunk procedure) and sent the specimen for histopathological examination, to confirm the preoperative diagnosis. TGDC diagnosis and management are not related to age or size. Operative management standards are carried out with sistrunk procedures.

Case Description: The standard management of giant tyroglossal duct cyst is the sistrunk procedure with maximum result. The surgical procedure has been succesfully performed in this case.

Conclusion: The standard management of TGDC is the sistrunk procedure with maximum results. The surgical procedure has been successfully performed in this case. The standard diagnosis and management of TGDC are not related to the patient's age or cyst size.

Acute kidney injury in patient with djenkolism: a case report

Background: Djenkolic poisoning or djenkolism is one of the causes of acute kidney failure common in Southeast Asia. Djenkol bean or jering (Archidendron pauciflorum) is one of the foods commonly found in Southeast Asia. These seed plants are usually processed by boiling or frying, but often they are also consumed raw. Djenkolism sometimes occurs, albeit infrequently after ingesting djenkol beans. The clinical presentation of djenkolism is varied but generally presents as a spasmodic loin to groin pain and acute kidney injury (AKI), with evidence of urinary obstruction.

Case description: We report a previously healthy 40-year-old male developed AKI after consuming a large amount of uncooked djenkol beans, which was resolved with rehydration with normal saline and conservative therapy.

Conclusion: We highlight the importance of healthcare practitioners, especially in the Southeast Asian region to consider this rare cause of acute kidney injury to provide early diagnosis and prompt treatments.

The relationship between self-esteem and husband support with body image perception in post-vaginal delivery primiparous mother in independent Delima midwife practice in Denpasar

Background: Childbirth is a big, happy event for a mother. In post-partum mothers, physical changes and psychological changes can occur. It is reported that 50% to 70% of post-partum mothers experience psychological disorders, such as a mother can feel uncomfortable with body image perception changes, which result in feelings of lack of husband support. Body image perception itself can cause an effect on self-esteem. This study aimed to analyze the relationship between self-esteem and husband's support with body image perception among primiparous mothers after vaginal delivery.

Methods: An observational analytic study was conducted among 30 post-vaginal delivery primiparous mothers in independent Delima midwife practice in Denpasar. Data regarding respondents’ characteristics, self-esteem, husband’s support and body image perception were obtained using the Rosenberg self-esteem questionnaire, the Revised Dyadic Adjustment Scale (R-DAS) questionnaire Multidimensional Body-Self Relations Questionnaire Appearance Scales (MBSRQ-AS). The relationship between self-esteem and husband's support with body image perception was analyzed using SPSS version 23 for Windows.

Results: The average age of the respondents were 24.73 years old, and most of them were graduated from high school (50%), employed (53.3%) and have no conflict in their marriage (80%), have normal self-esteem (96.6%), didn’t get enough husband’s support (56.7%) and have positive perception regarding the evaluation of physical appearance (96.6%). We found a significant relationship between self-esteem and body image perception (p = 0.001), husband's support and body image perception (p = 0.001) and husband's support and self-esteem (p = 0.010) in post-vaginal delivery primiparous mother in independent Delima midwife practice in Denpasar.

Conclusion: Self-esteem, husband's support and body image perception were essentials factors that contributed to post-partum woman mental health stability that should be understood by family and health workers to avoid psychological disorder in post-partum woman.

The 4th Aceh Surgery Update 2021

Assalamualaikum Wr.Wb

Praise and gratitude we pray the presence of Allah SWT for all His grace and guidance so we can still work to help in the fields of education and humanity. With greetings and prayers we praise the prophet Rahmatan lil alamin Rasulullah Muhammad SAW who has brought us from the realm of darkness to a realm full of knowledge.

 In the fourth year it was held during the Covid 19 pandemic, 4th Aceh Surgery Update International Conference in 2021 will be held virtually on February 26-28, with theme Current Update on Covid 19; Clinical and Surgery. This virtual science event will be attended by international and national speakers who have expertise in the field of surgery and the latest information regarding Covid 19 from the Indonesia government. This scientific event felt very special with the presence of the Bali Medical Journal indexed by SCOPUS and Web of Science in scientific publications for all topics presented, both in symposium and free paper sessions.

I would like to welcome all experts who are willing to attend to be native speaker at this scientific even. I would like to thank all the committees and sponsors who have helped make this scientific webinar a success. Finally, I am also welcome all the participants and delegated, really hope you all get valuable scientific experiences in extra ordinary city of Banda Aceh.

Sincerelly Yours,

Yopie Afriandi Habibie, MD, Sp. BTKV (K)-D, FIHA, FICS, FACS

Chairman