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.

The future of three-dimensional skin graft: a mini-review

Over the last few years, the development of three-dimensional (3D) skin bioprinting has increased rapidly. The concept of bioprinting involves a computer in designing using conventional 3D printing. 3D bioprinting can produce tissue structures such as skin and have the opportunity to substitute autografts, which are still the gold standard today. Network construction in bioprinting requires stages in the network structure design, selection of cell and biomaterial raw materials, and the molding process. The use of keratinocytes and fibroblasts is used as the main raw material in the manufacture of the dermis and epidermis layers. The biomimetic technique will combine these raw materials with other biomaterials (hydrogel, collagen, fibrin, gelatin, alginate, chitosan, and chitin) and growth factors (hydrocortisone, thrombin, and FGF-2) so that the physiological condition of the skin can be created. Currently, 3D bioprinting research continues to develop in response to the various shortcomings and challenges faced. The purpose of this review is to discuss the current use of 3D bioprinting technology, the principles of this technology and the prospects for 3D skin bioprinting in the future.

A 3-days old infant with neonatal soft tissue sarcoma: a case report

Background :The incidence of sarcomas occurs in less than 1% of all malignant tumors but sarcoma is the cause of 2% of total cancer deaths. Based on the National Registry the incidence of neonatal sarcomas is 2.6 per million live births.

Case Description : A baby girl aged 3 days, complaining of a mass on the patient's left thigh since birth. the mass was large from birth and there was only one on the left thigh. In the prenatal history, the mother and baby with routine ANC history to the midwife, and never having a control with an obstetrician, the mother was not sick during pregnancy and took medication during pregnancy outside of a doctor's prescription. In the perinatal history, the baby was born to mother G1P1A0, gestational age at term, was born by cesarean section, with birth weight 2800 grams, was born crying, active movement, reddish color, vomiting (-) genitalia (+) anus (+)

Conclusion : Soft tissue sarcomas (STS) require proper diagnosis and management. The results of rhomboid flap in the tumor resection area are better than skin grafts of similar shape and location and provide cosmetic advantages with very few complications.

Single Umbilical Artery (SUA) - prenatal sonography diagnosis and vascular imaging features postnatal cord: a case report

Background: Single umbilical artery (SUA) is a rare presentation in obstetrics practice, yet it comprises most of the umbilical anomaly. Despite its rare occurrence, a proper prenatal diagnosis needs to be established timely in order to prevent morbidity and mortality from commonly coexisting abnormalities. This case report presents a delayed diagnosis of SUA by prenatal sonography diagnosis and vascular imaging features postnatal cord at the third trimester of pregnancy and discusses the proper diagnosis and management of such cases.

Case Presentation: We reported a case of a 37 year old pregnant woman who found to have one artery one vein in her umbilical cord on ultrasound. This is very rare case and precise concern for us. Unfortunately we found this case in the third trimester of pregnancy (37w5d), therefore we have slightly to evaluate. Female baby was born by elective C-section. The baby cried immediately, with an Apgar score of 8-9. We didn’t find major abnormalities in the baby. Birth weight 3700 grams. There were not sign of heart diseases and kidney’s abnormality. Baby was monitoring for one weeks and the baby has good growth and development.

Conclusion: This report is expected to increase the awareness of this disease entity as a fundamental basis for developing its screening and management protocols.      

Delayed laparotomy and gastric repair in gastric perforation: a case report in the neonatal patient

Background: The incidence of gastric perforation in neonates is rare but has a high mortality rate of 15-70%. Spontaneous gastric perforation in neonates is estimated to occur in one of 2,900 live births and accounts for approximately 7% of all gastrointestinal perforations in neonates and children.

Case: We present a case of gastric perforation complicated by sepsis, anemia, thrombocytopenia, and hypoalbuminemia in a 3-day-old girl. The patient was brought to the emergency room of Dr. Soetomo Hospital Surabaya with blood vomiting complaints from 1 day. On physical examination, it was found that the general condition was weak, with an axillary temperature of 38.2° C. The abdomen looked distended from inspection of the abdominal region, with the dilated vein and periumbilical hyperemia. Its percussion revealed the loss of liver dullness. The results of laboratory examinations: Hb 10.7 g/dl, Platelet 14,000/mm³, Albumin 2,6 g/dl. Plain thoracoabdominal X-Ray study showed a pneumoperitoneum. Needle decompression was performed because there were signs of Abdominal Compartment Syndrome (ACS). After five days of optimization in the Intensive Care Unit, a laparotomy exploration and primary repair of gastric perforation were conducted.

Conclusion: Gastric perforation in neonates is a rare condition. The management principle for each patient is different depending on the patient's condition. Needle decompression is indicated when ACS is present or the patient's condition is not optimal for surgery. Definitive laparotomy can be done after the patient's condition has been stabilized. Proper selection of treatment can improve the patient's outcome and reduce the risk of morbidity and mortality.

Video-assisted thoracoscopic surgery in the treatment of empyema: a case series

Background: Empyema is a condition that can be treated depending on the etiology of the empyema and the phase of empyema development. Open thoracotomy surgery is a conventional technique commonly used in empyema that has greater risk and more extended postoperative hospital stay. This case series aims to evaluate Video-Assisted Thoracoscopic Surgery (VATS) to shorten postoperative hospital stay and lower the risk during the surgery.

Case Presentation: We describe a case series of empyema in five patients, each with a different presentation, clinical course, and outcome. All of our patients were performed VATS procedures under General Anesthesia and evaluated for postoperative hospital stays and complications that occur after the surgery. Most of the patients experienced tolerable pain on the site of surgery and only need 3 – 4 days post-operation hospital stays after VATS before being discharged. Only one patient with a poor prognosis after VATS in this case series caused the patient to be admitted to the Intensive Care Unit and using a mechanical ventilator.

Conclusion: In this case series, VATS has a promising result for the patient and can become a choice of treatment for empyema.

Penile gangrene as a priapism sequele due to Chronic Myeloid Leukemia (CML): the first report in Indonesia

Background: Priapism is defined as a prolonged erection of the penis lasting over 6 hours in the absence of sexual stimulation. Priapism is divided into two types, Low-Flow (ischemic priapism) and High-Flow (trauma). This case study aims to evaluate penile gangrene as a priapism sequele due to Chronic Myeloid Leukemia (CML) as the first report in Indonesia.

Case Presentation: A 45-years old male patient admitted at Muara Teweh hospital before referred to Ulin Hospital presented with Fournier gangrene with unconfirmed leukemia as comorbidities used in this case report. In his medical history, “Snake Maneuver Shunting” has been carried out in this patient as an indication for priapism lasting more than 24 hours.

Conclusion: Hyperleukocytosis is thought to be the cause of priapism in patients with leukemia. Leukostasis is the most common medical emergency seen on CML patients in blast crisis.

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