Urine neutrophil gelatinase-associated lipocalin (NGAL) as an initial biomarker of acute kidney injury (AKI) in an intensive care unit (ICU) patients: a preliminary study

Background: Acute kidney injury (AKI) is one of the complications in critical patients that can increase morbidity and mortality. The condition of AKI is reversible and must be detected as early as possible. One of a potential marker for early detection is urine Neutrophil gelatinase-associated lipocalin (NGAL). This study aims to evaluate urine NGAL as an early AKI detection marker among critically ill patients.

Methods: This is an observational prospective cohort study involving 39 patients who were admitted to the Intensive care unit (ICU) of Dr. Sardjito General Hospital Yogyakarta during June-August 2018. The inclusion criteria were ICU patients with age>19 years old, and exclusion criteria were chronic renal failure and kidney transplantation. The AKI established based on an increase in serum creatinine levels ≥0,3 mg/dl in 48 hours or urine volume <0.5 ml /kg/hour in 6 hours. Mann Whitney test, Spearman correlation, and Chi-Square were used for statistical analysis. Data were analyzed using SPSS version 17 for windows.

Results: The results showed that there were no significant differences between the urine NGAL levels of AKI and non-AKI patients (130 (85-177) ng/dL; 56.65 (2.8-1500) ng/dL, p=0.407). In this study, only 3 cases of AKI were obtained from 39 subjects. Further analysis was carried out by looking at the correlation between urine NGAL levels and urine leukocyte count. The results showed a moderate correlation between them (r=0.6, p=0.001). The proportion of patients with elevated urine NGAL levels was greater in the group of patients with elevated urine leukocyte counts compared to the group with normal urine leukocyte counts (86,7%; 13,3%, p=0,008).).

The comparison of ion exchange-high performance liquid chromatography (IE-HPLC) and capillary electrophoresis (CE) for HbA1C measurement

Background:HbA1c is a glycosylated hemoglobin that routinely performed in patient with Diabetes Mellitus. There are several methods for HbA1c measurement. One of them are based on the molecular charge such as High Performance Liquid Chromatography(HPLC) and Capillary Electrophoresis (CE). Each method has its own advantages and disadvantages. Thus, the selection of HbA1c measurement method is an important thing. This study was aimed to compare HbA1c measurement with HPLC and CE method.

Methods:HbA1c measurement was done by HPLC and CE methods in 110 patient samples which have data of average blood glucose level during three months. We investigate the correlation of HbA1c results with average blood glucose level during three months,precision, methods comparison and interference including Hb varian. This study was conducted in Central Laboratory of dr. Saiful Anwar  Hospital during March–August 2018. Correlation analysis were done by Pearson analysis while precision test and methods comparison were done by Bland Altman Plot and Passing-bablok Regression analysis.

Results:There were correlation between estimated Average Glucose from HbA1c (eAGHbA1c) calculation with average blood glucose level during 3 months in both methods.From precision test we found intra-assay coefficient of variation in normal level (HbA1c ±5%) by HPLC vs CE was 1,7% vs 0.63% and in high level (HbA1c ±11%) was 0,59% vs 0,61% and inter-assay coefficient of variation by HPLC vs CE was 2,47% vs 2,17%. Method comparation results showed strong correlation on both method. The results of HbA1c in group without Hb variant by CE method was slightly lower than HPLC. In Hb variant group, CE method was slightly higher than HPLC, but it was not significant for HbA1c interpretation.

Conclusion:HbA1c measurement by HPLC and CE method are comparable and there is no significant difference in the results obtained.

The incidence of Clostridium Difficile infection in diarrhea patients after receiving antibiotics at Dr. Soetomo Hospital Surabaya

Introduction: Improper use of antibiotics is a risk factor for C. difficile infection. The increasing incidence of C. difficile infection is one of the indications of failure in infection prevention and control in hospitals. The aim of this study was to analyze the incidence of C. difficile infection in diarrhea patients after receiving antibiotics in the ICU and internal medicine ward of Dr. Soetomo Hospital Surabaya.

Results: The average age of respondents was 48.94 (21 – 86) years old. In addition, based on demographic data, it was predominant by females (65%), diabetes mellitus and fever (16%), and ceftriazone usage (22%).  The results showed one sample (3%) with positive results and 30 samples (97%) with negative results for both A/B toxins and GDH enzyme.

The ability of earthworm Lumbricus rubellus extract in slowing down the activation of NFkB and TNF-α in lipopolysaccharide-induced Rattus norvegicus

Background: Earthworm (L. rubellus) contains many compounds such as Lumbricin I, G-90 glycoprotein, and polyphenols as antimicrobial, antioxidant, and hepatoprotective toward bacterial infections. Tumor necrosis factor (TNF-α) has been identified as a mediator for necrosis tumor inside animal serum treated by lipopolysaccharide (LPS). High concentrated LPS can cause tissue damage and death. The increasing number of Nuclear Factor Kappa Beta (NFkB) activation has been responded by macrophage to produce cytokines pro-inflammation TNF-α as an indicator of inflammation.

Methods: The research was conducted in the Animal Laboratory Pharmacology Unit, Biomolecular Laboratorium, Faculty of Medicine Udayana University and the Pathology Clinic Sanglah General Hospital with a post-test only control group design. Thirty-two experimental rats were made as samples and divided into four groups, which are negative control, positive control, treatment 1, and treatment 2. Treatment was performed for 14 days. The containment of NFkB and TNF-α was measured on the 16_th day using quantitative technique sandwich enzyme immunoassay (ELISA).

Results: The results of the Shapiro-Wilk test and Levene’s test showed that the data were normally distributed and homogeneous, with p > 0.05. As the data were normally distributed, the one way ANOVA was used to analyze the data, followed by the Least Significant Difference (LSD) test. There was a significant difference between the average amount of TNFα found in each treatment group p = 0.001 (< 0.05). There were also significant differences between the average amount of NFkB found in each treatment group p = 0.001 (< 0.05). Advanced test using LSD shows more significant differences by p < 0.05.

Conclusion: It can be concluded that earthworm extract (L.rubellus) raises the amount of NFkB and TNF-α in male experimental rats injected with LPS.

The relationship of lactic acid, neutrophil lymphocyte ratio and monocyte lymphocyte ratio with the outcomes of coronary arterial disease patients following coronary artery bypass surgery

Background: Coronary artery bypass surgery (CABG) is a surgical procedure for coronary arterial disease (CAD). It has a risk of postoperative complication, extending from a long length of stay in the intensive care unit (ICU) to death. CABG needs a long duration of perioperative time, which decreases tissue oxygenation. It causes increased lactic acid production and initiates the secretion of inflammatory factors. Neutrophil/lymphocyte ratio (NLR) and monocyte/lymphocyte ratio (MLR) become inflammatory signs that are caused by the failure of heart microcirculation during the operative procedure. This study aimed to determine the relationship of lactic acid, NLR and MLR with the outcomes of CAD patients following CABG surgery.

Methods: This was a prospective study including 42 CAD patients who had undergone CABG procedure at Dr. Kariadi Hospital Semarang between December 2017 and July 2018. Lactic acid data were taken using the spectrophotometer method.  NLR and MLR were taken by the calculation index. The outcomes data were ICU length of stay (LoS), complications, and death, which were obtained from the medical record. The data were analyzed using bivariate analysis.

Results: There was a significant correlation between lactic acid with ICU LoS (p = 0.001), complication (p = 0.01), and mortality (p = 0.044). There was a significant correlation between NLR with ICU LoS (p = 0.003), complication (p = 0.009), and mortality (p = 0.014). There was a significant correlation between MLR with ICU LoS (p = 0.02), complication (p = 0.027), and mortality (p = 0.017).

Conclusion: There was a significant correlation between lactic acid, NLR dan MLR with the outcomes of CAD patients (ICU LoS, complication and mortality) that have undergone CABG procedure.

Administration of pismatom juice increasing of potassium serum levels and faster of recovery in middle run athletes PASI Denpasar, Bali-Indonesia

Introduction: Intense prolonged physical exercises such as athletic need more energy. It causes fatigue and sweat excretion which is possibly related to decreasing of electrolyte and recovery delay. This research aimed to prove that administration of mix juice of banana, honey, and tomato (pismatom) increasing of potassium serum levels and faster of recovery in middle run athletes.

Method: This research was an experimental design using randomized pre-test-post-test control group design using 28 middle run athletes. Selected samples divided into two groups using random allocation technique. Treatment group was given pismatom juice before and after physical activity with 240 of volume and control group was given mineral water before and after physical activity with 240 ccs of volume during 14 days. Blood-vein measurement was used to evaluate potassium serum levels and measure of pulse recovery rate. The statistical analysis using SPSS version 20.0 for windows, comparison of electrolyte level and recovery time using t-independent test and General Linear Model (GLM).

Result: The results showed that potassium serum levels increasing significantly (p<0.05) in the Treatment Group (4.90 + 0.17 mmol/L vs 3.69 + 0.15 mmol/L). Pulse rate indicate the recovery more faster in the Treatment Group to 3^rd minute recovery pulse (RPR3) (124.21+6.61 x/mnt vs 131.57+12.49 x/mnt), to 4^th minute recovery pulse (RPR4) (120.14+8.29 x/mnt vs 126.50+12.13 x/mnt) and to 5^th minute recovery pulse  (RPR5) (111.29+6.69 x/mnt vs 123.14+12.06 x/mnt) that was significantly different (p<0.05).

The comparison of erythrocyte sedimentation rate (ESR) modify Westergren Caretium Xc-A30 and Westergren Manual in Clinical Pathology Laboratory, Sanglah General Hospital, Denpasar, Bali

Background: The erythrocyte sedimentation rate (ESR) test is one of the most widely performed laboratory test to assess acute phase of inflammation, infection, autoimmune or malignancy. The reference method for ESR measurement was introduced by Westergren. This method is generally easy, un-expensive, yet, time consuming. Automatic instrument has been introduced to decrease the measurement time. Caretium XC-A30 is automatic instrument to measure ESR; it is used in Sanglah General Hospital Denpasar without previous research. Aim of this study was to assess comparison, correlation and agreement of Caretium XC- A30 to the reference method.

Methods: A total of 35 samples in consecutive sampling were taken during August 2018 at Sanglah General Hospital, Denpasar. The samples were examined for ESR with Caretium XC-A30 and manual Westergren. Comparison, correlation and agreement were tested for both methods used.

Results: The Westergren method was the reference method and Caretium XC-A30 was the tested method. Wilcoxon signed rank test showed no difference between two methods (p= 0.439). There was a very strong correlation and excellent agreement showed by Spearman coefficient correlation r= 0.989 and kappa coefficient 0.942.

Conclusion: This study showed no difference between Caretium XC-A30 and Westergren as the reference method for ESR measurement, with very strong correlation and excellent agreement. Thus, Caretium XC-A30 has a potential use in performing ESR measurement with high throughput and lesser time than manual Westergren method.

The role of serum albumin level within the first 24-hours of hospitalization to the mortality risk in burn patients at Dr. Hasan Sadikin General Hospital, Bandung, Indonesia

Introduction: Serum albumin level may predict the mortality risk in burn patients. This study aimed to determine the mortality risk in burn patients based on serum albumin level within the first 24 hours of hospitalization.

Method: A cross sectional study was conducted reprostecively to the patient’s medical records. The subjects were burned patients who were hospitalized in Dr. Hasan Sadikin General Hospital Bandung during January-December 2017. The subjects were divided into two groups, which were dead and survived at the end of hospitalization. The mortality risk based on serum albumin level within the first 24 hours of admission was assessed using the odds ratio (OR) of two groups. Data were analyzed using SPSS version 17 for windows.

Result: The subjects were 47 patients, consisted of 9 dead subjects and 38 survived subjects. Males were predominant in both groups such as 12.8% in dead subjects and 70.2% in survived subjects. The OR value based on serum albumin level <2 g/dL within the first 24 hours of hospitalization was 14.40 (p=0.009; CI:2.1–100).

Conclusion: The subjects with serum albumin level <2 g/dL within 24 hours of hospitalization has 14 times higher mortality risk compared to the subjects with serum albumin level >2 g/dL. Therefore, burn patients need to be examined for serum albumin level within the first 24 hours of hospitalization.

Pregnant gymnastics, ANC, and IEC pregnancy lower the stress on pregnant women

Background: Psychosocial stress in pregnant women is one of the factors that cause the disorder of metabolism for pregnant women. Maintaining physical and mental health on a pregnant woman can be conducted by ANC, pregnant gymnastics, and IEC pregnancy to optimize health degrees while pregnant and expedited the process of childbirth.

Aim: This study aimed to analyze the relationship of the gymnastics, ANC, and the IEC pregnancy with stress rate on pregnant women.

Methods: This was an observational analytical with a case-control approach. The subject of this study was the mother of a toddler as many as 390, ages 2 to 2.5 years that live settled in Klaten Regency, Karanganyar and Sragen.

Results: Stress while pregnant is significantly associated with the gymnastics pregnant (p = 0.023; CI 0.38-0.93; OR 0.69), ANC (p = 0.001; CI 0.01-0.57; OR 0.75) and IEC of pregnancy (p = 0.049; CI 0.45-1.00; OR 0.69).

Conclusion: Stress during pregnancy can be reduced by doing pregnant gymnastics and the ANC. Granting education can also be used as an alternative to reduce stress during pregnancy.

The different effects of banana juice and sport drink on lactic acid among volleyball students in Surakarta

Introduction: The response of lactic acid as a result of exercise in recent times has received considerable attention from physiologists, particularly in term of sports aspect. Lactic acid level is one of the most common measured parameter to determine the performance of athletes. Provision of supplements containing potassium for athletes is usually given such fruit juice or sport drink to prevent muscle fatigue. This study examined the effect of the banana juice and sport drinks to lactic acid in volleyball students.

Methods: The study was a randomized experimental trial using pre-post test with control group. The study populations were all volleyball students aged 15-17 years in Pundong Senior High School. The subjects divided into three equal group, 10 subjects in each group treated with either banana juice, sport drink and mineral water as a control group. Sampling was done by a double-blind method.

Results: The results of the paired sample T-Test showed a significantly difference of lactic acid levels by intervention with banana juice and sport drink compared to control group with mean difference the mean were 4.43, 3.59, 2.68 respectively (p<0.05).

Conclusions: Intervention of banana juice significantly decreased the lactic acid levels compared to sport drinks in volleyball students.

Intraarterial heparin flushing effect on motor evoked potentials in chronic ischemic stroke patients

Background: Stroke has always been a complicated disease which affects not only the patient quality of life but also the patient family. In ischemic stroke patients, one of the most complicated outcomes was the disruption of motor function. Increased motor function is a visible positive outcome of stroke patients.

Aim: This study aims to measure the motor evoked potentials values which the results might give us more insights into how this disease affects the motor neuron pathway.

Methods: This study was an experimental pre-posttest study involved 75 patients diagnosed with chronic ischemic stroke (onset of more than 30 days). The MEPs value was measured by adjusting the IAHF procedure in 2015.

Results: There was no significant difference between motor evoked potential value (amplitude, latency, central motor conduction time) pre and post intraarterial heparin procedure (IAHF) (p>0.05). Occasionally, there was a significant difference in latency value in lacunar, subcortical, and cortical-subcortical area after IAHF (p<0.05).

Conclusion: This study shows that the size and localization of the affected area might determine the results of IAHF.

The characteristics of mandibular fractures among patients attending Plastic Surgery Unit in Sanglah General Hospital, Bali, Indonesia: A preliminary study

Background: Trauma is the fourth leading cause of death in the world and occurs at all ages. The high incidence of traffic accidents is equivalent to the increasing incidence of maxillofacial trauma, especially mandibular fracture. This study aims to determine the characteristics by age, gender, mechanism of injury and anatomical site of mandibular fractures among patients attending the Plastic Surgery Unit of Sanglah General Hospital as a preliminary study

Methods: A descriptive cross-sectional study was enrolled among 45 patients attending plastic surgery who recorded in medical records from January 2014 until December 2016 as well as met the inclusion criteria. Data were analyzed using SPSS version 17 and presented in percentage regarding Age, mechanism of injury, gender, and fracture site

Results: There were 45 patients with 61 mandibular fracture sites. Most of the patients were male (84.4%). Based on age, the mandibular fracture is most common in the productive age (20-30 years old) at 22 cases (36.1%). Majority cause of fractures was road traffic accident (82.2%). Parasymphysis region was the most common site of fracture (39.3%).

Conclusion: The characteristics of mandibular fracture patients describe trauma patterns in the community. This finding is similar with some readily available literature with RTAs was the most common etiology and parasymphysis was the most common fracture site.

An Efficient Polymerase Chain Reaction (PCR) Enhancer for Highly Guanine-Cytosine (GC)-Rich DNA Sequences

Background: Polymerase chain reaction (PCR) has become a fundamental technique in molecular biology. Nonetheless, PCR amplifications are frequently impaired by high GC content of the target sequence, leading to low yield and specificity of products, with no product at all in the worst cases. Locally high-temperature melting regions within the template can act as permanent termination sites.

Method: Here we designed and tested an effective and low-cost PCR enhancer, a combination of dimethyl sulfoxide (DMSO) 10% (v/v) and magnesium chloride (MgCl2) 1,5 mM that broadly enhanced the qualitative output of PCRs. We used Mycobacterium tuberculosis strain H37vR as a PCR template.

Result: It was found that PCR enhancer containing 10% (v/v) of DMSO and 1,5 mM of MgCl2 improved the amplification of GC-rich template of M. tuberculosis gene other than without the PCR enhancer.

Conclusion: Therefore, this PCR enhancer could be widely useful to improve the amplification of GC rich construct from another genome.

Desperately needed in Indonesia: Basic Epilepsy Surgery Centers with Simple but Reliable pre-surgical investigations, based on Semarang’s Experience

Background: Even with optimized anti-epileptic medications, 30% of epilepsy patients will be refractory and this condition leads to cognitive and psychosocial decline, resulting in worse quality of life and higher mortality. With 0,75% prevalence, there are more than 2.0 million epileptic in Indonesia, about 360.000 will be refractory, and half of them are potential candidates for epilepsy surgery (ES). After 17 years since the first ES on July 1999, number of ES increases every year reaching around 50 cases per year. By the end of 2017,  the total number reached 615 and most was temporal lobe epilepsy (TLE) cases. Pre-surgical investigations were compared in relation to the seizure free results between the first five-year and the recent twelve-year. Despite the excellent result shown, all of these ES were still performed in Semarang (Diponegoro University), and demographic analysis showed that 80% patients came from Java-Bali area. So that new basic centers capable of performing ES for simple TLE cases are desperately needed to improve treatment for refractory epilepsy cases elsewhere.

Material and methods: Until the end of 2017, there were 615 ES cases, including 514 Temporal Lobe Epilepsies (TLEs). Pre-surgical investigations were grouped as Simple (MRI with specific protocol and routine EEG), Difficult (needs long-term ictal EEG, and /or PET CT), and Complex (needs invasive or intracranial/ subdural grid EEG, and or Electrocorticography/ ECoG during the surgery). For the first five year-period, besides seizure semiology, decision to operate were based on MRI and routine EEG (Simple) in 54 out of 56  (96,4%) TLE cases. One patient had long-term ictal EEG and another had subdural grid EEG implanted, both patients showed visually normal MRI. But for the recent twelve-year, Simple TLEs occupy only 234 out of 458 (51%) TLE cases. Long-term ictal EEG were performed in 161 patients (35,2%), PET study in 39 patients (8,5%), subdural grid EEG in 30 patients (6,5%), and ECoG in 61 patients  (13,3%).

Results: As a new ES center performing only simple TLE cases, our surgical results were Class I: 82%, Class II: 11%, and Class III: 7% (9). As a semi advance ES center (after more than 5 years, and only half were simple ES cases), the Class I or seizure free results were 78,7% for simple TLEs, 73,4% for Difficult TLEs, and 65,2% for Complex TLEs.            

Demographic distribution showed that almost 80% of ES patients came from Java-Bali area, and half of them were from Central Java Province with Semarang as its capital. Patients from other parts of the country were scarce, especially from remotely located islands of East Indonesia.

The hypercoagulation state among major β-thalassemia patients at H. Adam Malik Hospital, Medan, Indonesia

Background: Thalassemia is the most common hereditary blood disorder in the world and Indonesia. Major β-thalassemia is classified as Transfusion-Dependent Thalassemia (TDT). Specific changes in the composition of red cell membrane lipids and hemosiderosis may lead to hypercoagulation. This study aimed to determine the difference in Protein C, Protein S, Antithrombin III (AT-III), and D-dimer between major β-thalassemia patients and normal people.

Methods: This was an observational analytical study with a cross-sectional design, including 18 major β-thalassemia patients in H. Adam Malik Hospital Medan who met the study criteria and 18 normal controls. Subjects were examined for Protein C, Protein S, AT-III and D-dimer. The assessment was also carried out among patients based on their transfusion frequency and serum ferritin.

Results: There were significant differences in Protein C, Protein S, and D-dimer levels between major β-thalassemia patients and normal controls (p < 0.05). AT-III level in major β-thalassemia patients was lower than healthy controls, however the difference was not significant. The level of Protein C in patients who infrequently and frequently underwent blood transfusions were 34.88 ± 8.6 and 45.19 ± 7.8 respectively, which was significantly different (p < 0.05). A significant differences in Protein C, Protein S and D-dimer were also found between patients with serum ferritin level < 2,500 ng/ml and  ≥ 2500 ng/ml.

Conclusion: Significant changes were found in anticoagulation proteins of major β-thalassemia patients. Frequent blood transfusions and chelation therapy should be emphasized for major thalassemia patients because they affect anticoagulation protein levels.

Hemostasis changes and its relationship with SOFA score in sepsis patients

Introduction: Sepsis is a major health problem, and the incidence is still increasing. Generally, sepsis occurs in about 2% of all inpatients in developed countries. The immunologic response that causes sepsis is a systemic inflammatory response that causes activation of the inflammatory and coagulation pathways. If sepsis untreated, it can lead to organ failure then death. Organ dysfunction is expressed as an acute change of Sequential Organ Failure Assesment (SOFA) score >2 points as a consequence of infection.

Methods: This is a cohort prospective’s study. Prothrombin time (PT), activated partial thromboplastin time (aPTT), Thrombin time (TT), Fibrinogen, D-dimer were examined 3 times (first, second, third day), and then assessed to see its relation with the corresponding SOFA score. Twenty-four subjects of the study were ICU patients in H. Adam Malik Hospital who matched the inclusion and exclusion criteria.

Results: There were significant differences of PT on the first, second and third day (p =0.03). There were no significant differences in aPTT, TT, Fibrinogen, D-dimer on the first, second, third day. There were no significant correlations of PT, aPTT, TT, Fibrinogen with the corresponding SOFA score on the first, second, third day. There was a moderate positive correlation between D-dimer and SOFA score in the first, second and third day of examinations (p <0.05).

Conclusion: PT changes occurred significantly on the first, second, third day of sepsis and D-dimers can be used to asses the risk of organ failure in septic patients.

Hyperferritinemia and oxidative stress in the kidney of beta thalassemia major

Background: Thalassemia is a genetic disorder which until now has become a global health problem. Regular blood transfusions in managemen of BTM result in iron overload. Free iron in the form of intracellular ferrous (Fe²⁺), in the presence of oxygen, will initiate the formation of reactive oxygen species (ROS), produce another free radical superoxide that will oxidize the lipid and protein compounds of the cell membrane. F₂-IsoPs is the best, most stable and more accurate marker of lipid peroxidation in vivo, found urine. This study aimed to determine the association between hyperferritinemia and lipid peroxidation in kidney reflected as elevated u-F₂IsoPs as controlling several factors affecting oxidative stress in the kidney.

Methods: This cross sectional study was conducted between May and June 2016. Thirty subjects of BTM admitted to pediatrics unit of Dr. Moewardi Hospital Surakarta who met the inclusion and exclusion criteria were enrolled. The data were analyzed to calculate prevalence ratio and 95%CI for each variable, followed by multivariate analysis with logistic regression.

Results: The prevalence of lipid peroxidation in kidney, characterized with elevated u-F₂IsoPs of > 2 ng/mg urine creatinine, was 67%. Age, hyperferritinemia status and duration of illness did not associate with lipid peroxidation in the kidney. Transfusion volume of ≥25 unit/year showed statistically significant association with lipid peroxidation (PR 24.10; 95%CI 2.16-268.42; p=0.010).

Conclusion: Transfusion volume, rather than hyperferritinemia, independently associated to oxidative stress and lipid peroxidation of the kidney in BTM.

Geriatric fractures in single Orthopedic Hospital: The role of domestic fall and comprehensive geriatric assessment

Background: The geriatric population has continued to grow globally. The incidence of geriatric fractures increases along with the population. The geriatric assessment could be useful to build a warning sign for the fall risk.

Aim: The authors aimed to describe the geriatric fractures; the factors affecting; to further give recommendation regarding its prevention and management.

Methods: This is a cross-sectional study involving 741 patients with geriatric fractures admitted to Surabaya Orthopedics and Traumatology Hospital from 2012-2017. All data acquired from medical records.

Results: The number of female patients in our study are three times the male patients. The distribution of the cases across ethnicity, gender, and different age group were quite similar. The case of vertebral and hip fracture was significantly higher. Domestic accident was the mechanism of injury in 80% of all cases, and this MOI is significant across all fracture types. Only 32% patients do not have confounding disease. However 25% has diabetes mellitus, and 42% has hypertension.  Although patients with diabetes mellitus, hypertension, moderate to severe anemia, and hyponatremia were more frequent but not significant to be the risk factor for certain fracture type.

Relationship of Plasma Cystatin C level and renal dysfunction in patients with preeclampsia

Background: Renal dysfunction is an important aspect of the pathophysiology of preeclampsia besides vascular endothelial dysfunction and placental hypoperfusion. Cystatin C is one of the most important inhibitors of extracellular protease enzymes and can be reliable marker for the calculation of Glomerular Filtration Rates (GFR). This study aimed to determine the relationship between plasma levels of cystatin C and renal dysfunction in patients with preeclampsia.

Method: This was an analytical cross sectional study conducted at Haji Adam Malik General Hospital Medan, Dr. Pirngadi Hospital Medan, several affiliated hospitals of the Faculty of Medicine University of North Sumatra and Prodia Clinical Laboratory Medan. A total of 26 preeclamptic patients were included in this study. Samples were divided into renal dysfunction and without renal dysfunction group.

Results: Eleven subjects with renal dysfunctions were mostly aged 20 – 35 years (73.3%), and the other eight subjects without renal dysfunctions were at the age of 20 – 35 years (72.7%). Most of the subjects had multigravida pregnancies, five subjects (33.3%) with renal dysfunctions, and six subjects (54.5%) without renal dysfunctions. The mean level of cystatin C in renal dysfunction (1.52 ± 0.37 mg/L) was significantly higher than without renal dysfunction (1.17 ± 0.12 mg/L) (p < 0.05).

Hospital Deductions, Types and Causes

Objective: The current study aims to provide valid information about the causes and types of hospital deduction records via a systematic review.

Method: This systematic review was performed by searching the databases including PubMed, Scopus, Science Direct, Ovid, Medline, Cochrane, ProQuest, and IranMedex, Magiran, Sid, and Medlib databases for studies without time limitation. Updates were added to the searches during the study. Search strategies included the combination of keywords including “Billing error” OR “Deductive” OR “Error payment” OR “Insurance claim” OR “Medical claim” OR “Improper payment” OR “Insurance reimbursement” OR “Medical payment” OR “payment error” with “Hospital” and “medical records”. The reference lists of each article were manually searched to find additional relevant articles. All records without time limitation, those written in Persian and English, and the ones investigating the types and causes of deductions in hospital inpatient bills records were included. To determine the eligible records, two authors extracted the data independently; and discrepancies were resolved through discussion or, if required, through consultation with a third author. The quality of the articles was analyzed using STROBE checklist.

Results: The search strategy yielded 1,264 records from electronic databases, and 15 records were identified by the manual search. After removing the duplicates and screening the database by titles and abstracts, 39 of these records remained. The full text of these 39 records was checked and, finally, 22 of them met inclusion criteria. The major causes of deductions in the documentation included human errors, incomplete document registration, documentation errors, added prices, added request, and calculation errors.

Conclusions: Education and cooperation of staff and collaboration of all stakeholders such as hospitals, insurance organizations, and related staff in this field are necessary for conducting a substantial action to reduce hospital deduction.

The role of brain-derived neurotrophic factor (BDNF) in cognitive functions

Nerve growth factor (NGF) was uncovered in near beginning the 1950s which had a growth effect on sympathetic and sensory neurons. In the dorsal root neuron ganglion, the second member of a group of neurotrophic factors widely known as the brain-derived neurotrophic factor (BDNF) appeared. Like other members of the neurotrophin group, such as neurotrophin 3 (NT-3) and NT-4/5, it is explained to have trophic effects on peripheral and central neurons. Since BDNF purification in 1982 evidence of its involvement in development, physiology, and brain pathology demonstrated. BNDF is significant within the molecular mechanism of synapse plasticity regarding neuronal growth and cell survival. The initial step associated with the central nervous system depends on its adaption of synapse transmission, especially in the hippocampus and neocortex. Pathological intensities of the BDNF relationship and synapse plasticity affect sort of situations such as epilepsy and chronic pain sensitization, where BDNF applications can affect therapy in neurodegenerative diseases and neuropsychiatric diseases. BDNF plays a pivotal role in cognitive processes, affecting the advancement and brain structures’ motion. Predominantly in the hippocampus and prefrontal cortex, by modulating synaptic neurotransmission, it changes the plasticity and proliferation of neurons through regulation of neuronal migration processes such as differentiation, perseveration, neuronal modification and replacement of synaptic structures. BDNF also affects the development of dopaminergic, serotonergic, cholinergic and GABAergic. BDNF further causes rapid postsynaptic reactions in ion channels and N-Methyl D-Aspartate (NMDA) receptors. BDNF as a vital component in the normal functioning of the brain is one of the neurotrophins that contributes to the development, maintenance of function and healthy neuron cells and cynical plasticity.

Spontaneous recovery of Medial Prefrontal Syndrome following Giant Olfactory Groove Meningioma resection: A case report

Introduction: Anterior skull base meningiomas are frequently associated with changes in personality and behavior. Olfactory groove meningiomas take their origin from the cribriform plate and frontoethmoidal suture in the floor of the anterior cranial base. The cardinal clinical features usually observed are mental changes, visual deterioration, and headaches as a result of olfactory or optic nerve and frontal lobe compression. However, several authors have reported minimal changes in cognition or behavior following surgical resection, and many patients do not return to their premorbid level of function.

Case presentation: A 42-year-old male with four months history of changes in behavior, apathy, and lack of motivation. Over the course of two months, his vision progressively worsened in both eyes, and he developed a diffuse, mild headache. On examination, he was fully alert and cooperative. He only had light perception and could see faint silhouettes of people. All other neurological examinations were normal. Head Computed Tomography (CT) demonstrated a large, extra-axial mass consistent with an anterior skull base mass extending to the sellar and suprasellar region, which suggests an olfactory groove meningioma. The patient underwent a bifrontal approach craniotomy tumor resection and subsequently recovered from medial prefrontal syndrome following tumor resection. Surgical tissue pathology confirmed the diagnosis as an olfactory groove meningioma.

Discussion: The anatomical location of the olfactory groove meningioma may cause prolonged psychiatric symptoms before the onset of more overt neurological deficits. Personality changes that occur may be subtle, so patients may avoid seeking treatment for their headaches and delay ophthalmic care until their complaints become severe. Anterior skull base meningiomas often involve the ventromedial prefrontal cortex (vmPFC) that is associated with elevated levels of apathy.

Conclusion: Olfactory groove meningiomas are treatable. Reversal of cognitive impairments and changes in behavior can be expected after surgical resection.

A rare case of Hb H disease caused by compound heterozygous for α thalasemia and Hb Quong Sze in Chinese Indonesian proband: a case report

Background: Hemoglobin H (HbH) disease is alpha thalassemia characterized by inactivation of three of four α-globin genes due to deletions with or without non-deletional α-thalassemia. Hb Quong Sze (Hb QS) is a very rare non-deletional α-thalassemia in Indonesia caused by a CTG^Leu>CCG^Pronucleotide substitution at codon 125 of α₂ globin gene generating highly unstable hemoglobin. Compound heterozygosity for Hb QS and Southeast Asian double α-globin gene deletion (--^SEA) result in accumulation of b-globin tetramers, causing hemolytic anemia.

Case Report: A 49 years old Chinese Indonesian female was assessed for thalassemia screening. The phenotype of the proband was normal and only mild anemia was noticeable. She experienced blood transfusion five years ago due to a sudden fall of hemoglobin level after malarial infection. Complete blood count found hemoglobin 8.3 g/dL, Mean Corpuscular Volume (MCV) 65.7 fl and Mean Corpuscular Hemoglobin (MCH) 17.1 pg. HbH disease suggested by abundant Hb H inclusion bodies in the red blood cells. Microcapillary hemoglobin electrophoresis result showed HbH 31.8 %, Hb Bart 0.4%, HbA 67.3% and HbA₂ 0.5%. Molecular studies were carried out using multiplex polymerase chain reaction (PCR) method, and the common a⁰-thalassemia(--^SEA) was detected in one allele. Direct sequencing analysis of the α₁ and α₂ globin genes revealed Hb QS in the other allele.

Conclusion: Non-deletional Hb H disease due to compound heterozygous of  Hb QS with Southeast Asian double α-globin gene deletion (--^SEA) has a very low incidence in Indonesia. An advanced molecular analysis should be performed to determine this rare mutation.

Testicular carcinoma in a female with 46-XY karyotype: a case report

Background: Testicular cancer is now the most common malignancy in young males. Markers available in the management of patients with testicular cancer are alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH). Female patients with androgen insensitivity syndrome (AIS) and pure gonadal dysgenesis have a pure XY karyotype and an increased risk of developing a gonadal malignancy.

Case Description: A 26-year-old female presented with a hardened stomach and primary amenorrhoea. Physical examination revealed Tanner Stage I for both the right and left breast and no pubic or axillary hair. On local examination, there was a large firm non-tender mass extending across the abdominopelvic region. Gynecological examinations revealed normal labia; however there was clitoromegaly, the vagina was blind (5 cm) with the absent cervix. Laboratory tests with increased abnormal results were as follows: LDH 3,448 U/L, AFP 1,842.6 ng/mL, Cortisol 22.41 ug/dL and Testosterone 128.7 ng/dL. An MSCT of the abdomen showed a solid mass with no signs of a vagina or uterus. Blood karyotyping results were 46 XY with the presence of the SRY gene. Due to an increase in LDH, AFP, Cortisol and Testosterone, with 46 XY karyotyping, Tanner stage 1 breasts, pubic and axillary hair, female genitalia phenotype and abdominal MSCT showing a solid mass with no signs of vagina and uterus, this patient was diagnosed with non seminoma testicular cancer with widespread disease and 46, XY karyotype (male).