Background: Fractured bone healing requires three to nine months, which prolongs the patients’ morbidity. Long bone fracture is considered to be difficult due to the dependence of bodily mobility and freedom. Bone tissue engineering materials includes hydroxyapatite (HAp), titanium, alumina, and polymers. HAp is found to be heavily abundant in cuttlefish. This study is conducted to prove that the cuttlebone has an effect of accelerating the fractured long bone healing process. Methods: This is an experimental study using a total of 32 samples of Rattus norwegicus. The Treatment Group received the cuttlebone extract + 0.9% NaCl while the Control Group received only NaCL 0.9%. Both groups were fractured beforehand. On the 14^th day the fractured area was harvested and assigned for histopathology and radiographic exam. Results: The Treatment Group was found to have thicker callus formation and more osteoblasts. Conclusions: The cuttlebone extract application caused thicker callus and higher osteoblast production, proving an accelerated fractured bone healing process.

Background: Diabetes is clinically known to cause prolongation to bone fracture healing. This research aims to find the effect of cinnamon in the process of bone remodeling, and changes in the activity of osteoblast cells in diabetic bone after giving cinnamon as a supplement in diabetic rats. Method: The design employed was experimental with randomized post-test group design research. A total of 24 Wistar Rats was randomly divided into four groups, which consist of normal without treatment, normal with treatment, diabetic without treatment and diabetic with treatment. Treatment of 300 mg/kg cinnamon extract was given per-orally. Upon euthanizing the samples, femur samples were taken and processed to histopathological slides. All slides were analyzed under light microscopes to find the osteoblast cells. The Kruskal-Wallis method was used to test the results; due to the population of sample was not normally distributed. Results: The osteoblast cells found were scored in mean ranks. The normal group mean rank 12.25, normal with treatment group 12.17, diabetic without treatment group 8.58, and diabetic with treatment group 17.00. Asymptotic significance was 0.195. Conclusion: This research concludes that there is no significant increase in osteoblast activity in diabetic Wistar rats after the administration of 300 mg/kg cinnamon extract.

Background: Breast cancer was, in general, a heterogeneous disease with diverse biological characteristics, types, subtypes and clinical behavior. Its treatment and management need to be personalized and individualized. Breast cancer in young ages, although rare, is usually a unique and more aggressive cancer associated with poorer prognosis. The combination of young age and advanced stages of breast cancer would make this particular breast cancer harder to treat and cure. Unfortunately, majority of Breast Cancer Patients in Bali were in younger ages, and at advanced stages, that the mainstay of treatment was neo-adjuvant chemotherapy followed by other treatment modalities. Improve prognosis only, those patients who had had a complete pathological response involving primary tumor and regional lymph nodes in the axilla. Several factors had been studied and contributed to breast cancer response to combined neo-adjuvant chemotherapy. Usually, younger patients, was associated with high proliferation rate represented by Ki-67 and early distant metastasis represented by VEGF, which also had role as prognostic markers. The purpose of this study was to determine whether high Ki-67 and VEGF expression correlate with response to NAC and hence, they would be important predictive factors for response to NAC. Method: This study was a cross-sectional and a nested case-control study of stage III breast cancers affecting patients 40 years of age or less, at Sanglah General Hospital and Prima Medika Hospital, conducted from September 1^st, 2012 until March 31^st, 2014. Clinical and pathology reports were traced and recorded from both hospitals; routine Immunohistochemistry (IHC) examinations were performed by both pathology labs. Statistical analysis was performed using Chi-Square test, Odds Ratio (OR), and logistic regression analysis with p<0.05. Results: There were 66 Stage III young breast cancer patients, where 35 (53%) showed no or negative response and 31 (47%) showed a positive response. Cross-sectional analysis showed that there was a significant correlation between positive Ki-67 protein expression and response to NAC (p<0.05; OR 5.538; 1.856 – 16.524; 95% C.I.) and between positive VEGF protein expression and response to NAC (p<0.05; OR. 3.455; 1.251-9.539; 95% C.I.). In Case-Control study, bivariate analysis from 62 samples had shown that higher Ki-67 expression in the study group compared to control group (p=0.004; OR. 4.747; 1.575-14.312; 95% C.I.). Bivariate analysis also showed that VEGF expression was also higher in the study group compared to control group (p=0.042; OR.2.879; 1.026-8.074; 95% CI.). Multivariate analysis had shown that an adjusted OR. 4.747 (1.575-14.312; 95% C.I.; p=0.006) for Ki-67, and an adjusted OR. 2.553 (0.860-7.582; 95% C.I.; p=0.091) for VEGF. Conclusion: We concluded that high Ki-67 and VEGF protein expression was associated with less response to combined neo-adjuvant chemotherapy/NAC and that high Ki-67 protein expression was an independent risk factor for poorer response to NAC in Stage III young age breast cancer. The possible role of high VEGF expression as a risk factor for less responsive breast cancer in younger patients had to be considered.

Background: This research aims to find a cure for anti-inflammation, based on the utilization of red piper crocatum. The research was started with descriptive study to explore active components of red piper crocatum leaf and followed by experimental study to investigate red piper crocatum activity of the leaf extract in anti-inflammation induced Wistar rat. In this research observed three dominant components: caryophyllene bicyclo [5.2.0] none,2 methylene-4,8,8-trimethyl-4-vinyl; phytol; 5,9-propano-5H-benzocycloheptene,6,7,8,9-tetrahydro-7,11-bis(methylene); 4,4-ethynedioxy-2-hexadecen-15-15 olide 1,4,9-trioxaspiro [4,15] eic os-6-en-8-one, 10 methyl; 1H-1,2,4-triazole-5(H)-thione,4-allyl-3-(3-furyl); Benzofuran,2,3-dihydro-2-methyl-7-phenyl which are possibly active to inhibit anti-inflammation to atherosclerosis. Bad eating habits also can cause various health problems, such as obesity, dyslipidemia, inflammation to atherosclerosis. This study was conducted to investigate of red piper crocatum leaves extract as an anti-inflammation through decrease of biochemistry markers TNF-α and IL-6 levels. Method: This is a true experimental with randomized pre-test and post-test control group design, using 50 Wistar rats that are divided into 5 groups: control group using 0 mg/kg BW red piper crocatum leaves extract, treatment group 1 using 50 mg/kg BW red piper crocatum leaves extract, treatment group 2 using 100 mg/kg BW red piper crocatum leaves extract, treatment group 3 using 150 mg/kg BW red piper crocatum leaves extract, and treatment group 4 200mg/kg BW red piper crocatum leaves extract. Results: It was observed that intake of 150 mg/BW red piper crocatum leaves extract results in the highest significance decrease of 45.63% of TNF-α levels from (28.62 ± 1.25 to 15.56 ± 7.20 рg/mL) and a significance decrease of 15.42% of IL-6 level from (134.64 ± 1.98 to 113.87 ± 4.30 рg/mL). Conclusion: It can be concluded that intake of red piper crocatum leaves extract acts as anti-inflammation for Wistar rats with atherosclerosis through decrease of TNF-α and IL-6 levels. Further research is required to determine whether the application of red piper crocatum leaves extract on human will result in similar effects of anti-inflammation. 

Background: A cell injury from surgical stress in a trauma or a non-trauma case will induce a hyper metabolic response in which the protein degradation increases, the somatic protein synthesis decreases and the amino acid catabolism increases. Thus, the pyper metabolic response contributes to nitrogen loss in urine. This response, without an adequate nutrition, will lead an iatrogenic malnutrition and deterioration. A balance nitrogen formula through urinary urea nitrogen is one of many nutrition evaluation methods. This method aids in evaluating the daily nutrition status and it can be the baseline data for daily intake. Objective: To find a correlation between the protein intake and the nitrogen balance of the surgical patients in anesthesiology and intensive care installation, Sanglah General Hospital, Denpasar, Bali. Methods: Fifty-one surgical patients with trauma and non-trauma cases were observed for their protein intake for 2-3 days continuously. Moreover, they were evaluated for their nitrogen balance based on the urinary urea nitrogen per 24 hours for 2-3 days. For statistical analysis, we utilized Shapiro-Francia, Shapiro-Wilk, Spearman Frank correlation, two-sample t test, and multivariate regression analysis in Strata SE 12.1. Results: The correlation between the protein intake and the nitrogen balance on the first day was r^a=0.50 (p<0.05), on the second day r^a=0.70 (p<0,05), and on the third day r^a=0.740 (p<0,05). Conclusions: There is a correlation between the protein intake and the nitrogen balance of surgical patients in Anesthesiology and Intensive Care Installation Sanglah General Hospital Denpasar.

Background: Leptin is a metabolic signal that plays a role in reproduction through the hypothalamic-pituitary - ovary axis. The aim of this study is to determine the effect of leptin on the levels of FSH and development of ovarian follicles of post-partum anestrus in Bali cattle. Postpartum anestrus in Bali cattle were divided into three groups of nine; group 1 (control) was injected with physiological saline, group 2 (treatment I) and group 3 (treatment II) were injected with recombinant o-leptin 100 µg and 200 µg/head respectively. Injection was done twice with an interval of 12 hours. Blood sample was collected via the jugular vein at intervals of 12 hours before the start of treatment until the appearance signs of estrus. Follicle diameter performance was measured using ultrasonography before treatment and during the appearance of estrus. The results showed the average levels of FSH before treatment for group 1, group 2, and group 3 were 11.3 + 0.36 mIU/ml, 11.6 + 0.40 mIU/ml, and 11.4 + 0.28 mIU/ml respectively. While at the end of the research, the levels of FSH were 11:02 + 0.39 mIU/ml, 13.0 + 0.48 mIU/ml, and 13.47 + 1.05 mIU/ml respectively. Ovarian follicle diameter for group 1, group 2, and group 3 before treatment were 5.10 + 0.41 mm, 5.21 + 0.36 mm, and 5.00 + 0.37 mm respectively. Whereas at the end of the research, the ovarian follicle diameters were 4.92 + 0.40 mm, 8.37 + 0.43 mm, and 8.45 + 0.38 mm respectively. In conclusion, administration of o-leptin in postpartum anestrus of Bali cattle increases the level of FSH and ovarian follicle development.

Background: Appendicitis is the most occurred acute abdominal case found in children.¹ In United States of America alone, there were 250,000 cases annually. The ratio between boys and girls are 3:2, with most cases caused by late diagnosis and the morbidity factor. Previous studies found that there’s a relation between eating patterns, fiber diet and food hygiene as risk factors for appendicitis.^{1, 2} At the time this paper is written, there hasn’t been any study that explains the relation between appendicitis and the diet pattern of children from various places in Indonesia. Another condition that further motivates this study is a common conception that children hate to consume vegetables and fruits, which contain the much-needed fiber. Obstruction of the appendix lumen is the main cause of inflammation in the appendix. Fecalith makes up one third of appendicitis cases, which is consists of fats (coprosterols), inorganic salts (calcium phosphate), and organic residual (fibers).³ Other causes including obstruction process by hypertrophy of mural lymphoid follicle as a response from the inflammation of the appendix lumen.³ Obstruction of appendix lumen can be caused by low fiber diet, which causes fecalith to build up in appendix lumen.⁴ The mechanism of lumen appendix inflammation can be caused by lymphoid hyperplasia, fecalith buildup, foreign object or parasite.⁴ Therefore, a study needs to be done to determine the mortality prediction easier, more efficient, and not static, in which it’s harder to measure the therapeutic response. In this case, lactate clearance is hoped to have the capability to determine the mortality rate in patients with severe sepsis. Method: This research is an analytic with cross-sectional design. The subjects were 35 child patients with appendicitis in RSHAM which fulfilled the criteria of severe sepsis diagnosis, and were receiving treatment in the period of January-December 2014. Results: Male children are the majority of the patients (62.9%) with average age of 11.89 ± 4.16. Laparotomy is the most administered treatment (54.3%), and most of the subjects have low-fiber diet (54.3%). 19 of the subjects have perforated appendicitis (54.3%). Conclusion: There’s a significant correlation between low-fiber diet with appendicitis incidence (p=0.0001). From the 19 patients with low-fiber diet, 14 of them (73.7%) have acute appendicitis. Meanwhile only 2 of the patients (12.5%) with high-fiber diet have acute appendicitis.

Background: Men and women have the same rights and obligations in family planning program. Practically, participation in family planning program is still predominated by women while participation of men is still low. Low participation of men in family planning program is due to very limited choices in male contraceptive method. In recent years, studies have been refocused on investigating traditional plants as antifertility herbal medicine for men. Studies on antifertility effects of unripe papaya seeds have been done. However, similar studies on hexane fraction extract have not yet been done. In this study, unripe seeds were collected from local Balinese papaya (Carica papaya) fruits. Objective: This study was aimed to assess the effect of unripe papaya seeds hexane fraction extract on spermatogenesis and the testosterone level of male mice. Hexane fraction extract of unripe papaya seeds contains glycosides and triterpenoids, which is assumed to have an antifertility property, so it can be used as a male contraceptive, although the mechanism of action remains to be elucidated. Method: This study used pre-test and post-test control group design, using 30 male mice of balb C strain, 12 weeks of age, weighing 20-22 gram, which were randomly grouped into 3 groups, each consisting of 10 male mice. One control group (P0 = control group) was given double-distilled water, and two treatment groups were given hexane fraction extract of unripe Carica papaya seeds 20 mg/20gram/day, and methanolic extract of unripe Carica papaya seeds 20 mg/20 gram/day (P1 and P2, respectively). After 36 days of treatment, evaluation of the testes and blood of the male mice was conducted. Results: Data were analysed by normality test of Kolmogorov-Smirnov Goodness of Fit, homogeneity test, and Anova test. This study showed that spermatogonia A, primary pachytene spermatocytes, spermatid and Sertoli cells were decreased significantly (p < 0,05) but Leydig cells and testosterone levels were not decreased significantly (p > 0,05). Conclusion: It can be concluded that hexane fraction extract of unripe Carica papaya seeds can decrease the mean number of spermatogonia A cells, spermatocyte of primary pachytene spermatocytes, spermatid and Sertoli cells better than methanolic extract of unripe Carica papaya seeds.

Backgroud: Head and neck squamous cell carcinoma (HNSCC) is the most common type of head and neck cancer. Most patients came with advanced disease which results in suboptimal treatment. EGFR is one of prognostic factors that play important role in HNSCC pathogenesis and progression. Unraveling the expression profile of EGFR in anterior and posterior HNSCC and its comparison would provide physician with better information regarding EGFR based treatment or its prognostic value. Methods: An observational cross sectional analytic study was conducted to compare EGFR expression between anterior and posterior HNSCC. The association between EGFR expressions with clinicopathological aspects (tumor stadium and histological grade) of HNSCC which analyzed separately. Baseline characteristic and each variables was first analyzed descriptively. Comparative analysis was conducted using Chi-Square and Fisher exact test with p value less than 0.05 was considered significant. Result: 48 samples were used in this study. Most of the subjects were elderly (b3.2%), men (72.9%) and came with advanced disease (Clinical Stadium III-IV) (83.3%). Most of the subjects were EGFR (+) (93%). In anterior region group, low expression of EGFR was found in 6 patients (25%) and high expression in 18 patients (75%). Meanwhile in posterior region group we found low expression in 10 patients (41.7%) and 14 patients with high expression of EGFR (58.3%). We found no association between EFGR and HNSCC location (anterior or posterior) (p=0.221). Insignificant association also reported between EGFR expression with clinical stage of anterior (p=0.625) and posterior (p=0.283) HNSCC as well as histopathological grade of both location (p=0.33 for anterior group and p=0.371 for posterior group). Conclusion: We concluded that EGFR was diffusely expressed in HNSCC but there was no association between EGFR expression and clinicopathological characteristics and location of HNSCC.

Background: program evaluation is an integral and expected component in the development of any healthcare program. It helps decision-makers to base their decisions on facts. Objective: This paper analyzes the effect of accreditation on three indicators related to patient safety and hospital care quality in ICU wards of an Iranian teaching hospital. Methods: This interventional study was accomplished based on executive management and scientific methods such as plan-do-check-act (PDCA) cycle and audit to improve quality and safety. We used data reported from ICU wards of the hospital to analyze the effect of accreditation on the three selected indicators. (SPSS) version 22.00 was used for the statistical analysis. Results: In total, 6997 patients were analyzed. The accreditation interventions appeared to be effective at reducing pressure ulcer incidence average (from an average of 6.8 percent to 4.1 percent) (p=0.045). The accreditation also. The average stay of the patients during the study also positively changed from an average of 1.58 days to 10.13 days (1.45 improvements)(p=0.0303). In relation to hospital acquired infection but, unexpectedly, its effect on hospital was negative, then it considerably increased and rose from 1.5 percent to 8.1 percent (p=0.001). However this increasing was due to enhanced infection incident report system. Conclusion: hospital accreditation has presented ample opportunity a significant positive effect on hospitals. 

Background: Ageing process is related with multisystem disorders. One of them is immune response impairment. It is imperative to evaluate the association between age and related nutritional status with inflammatory response in elderly patient. Methods: A cross sectional study to evaluate inflammatory response among elderly patients (≥60 years) at Geriatric Out-patient Clinic, Sanglah Hospital was conducted. Seventy-two patients were enrolled in the study. Age, nutritional states (body mass index and mini nutritional assessment), and inflammatory markers (interleukin-2 [IL-2] and C-reactive protein [CRP]) and other anthropometric as well as laboratory parameters were measured in the study. Results: In the study it was revealed that age has a moderately negative correlation with both of plasma IL-2 and serum CRP levels (R= -0.305, p=0.009; and R= -0.413, p=0.005, respectively). Plasma IL-2 levels were positively correlated with several variables like body mass index (R=0.282, p=0.016), mini nutritional assessment (R=0.237, p=0.045), biceps skin fold (R=0.291, p=0.013), and triceps skin fold (R=0.258, p=0.028). While serum CRP levels has positive correlation with lying diastolic blood pressure (R=0.345, p=0.020) and negative correlation with calf circumference (R=-0.312, p=0.037). No significant associations were found between diabetes and hypertension with inflammatory markers. Conclusion: This study concluded that older age and worse nutritional state were related to worse inflammatory response in the elderly patients.

Background: Job burnout is an occupational hazard that reduces physical and mental energy of the staff. This study was aimed to investigate the relationship between the nurses' job burnout and their social responsibility considering the moderating role of control locus. Methods: In an analytical and cross-sectional study we used 3 valid questionnaires including Maslach burnout inventory, Dynson social responsibility and Rotter locus of control in 3 educational hospitals of Yazd, Iran. A total of 246 nurses contributed in the study. Data analysis was done through SPSS₁₉. We used Pearson and Kendall correlation coefficient in data analysis. Findings: The mean scores of job burnout and social responsibility of studied group were 60.75 +8.37 and 71.84+15.47, respectively. Job burnout is negatively correlated with social responsibility statistically (r= -0.250) while locus of control acts as the moderator of this correlation. Conclusion: Our results suggest that creating a supportive work environment for nurses enhances their social responsibility trough affecting their level of job burnout. Also, the approved moderating role of control locus in the relationship of job burnout and social responsibility indicates that the personality traits can be considered as the appropriate criteria for entry to nursing schools.

Background: Acute respiratory distress syndrome (ARDS) diagnosis requires an invasive arterial blood sampling to reveal the PaO₂and calculate the PaO₂/FiO₂ ratio. SpO₂/FiO₂ ratio has been proposed as a non-invasive alternative to identify oxygenation parameter in pediatric patients with ARDS. Objective: To evaluate sensitivity and specificity of SpO2/FiO2 as an oxygenation parameter to detect ARDS. Methods: We conducted a cross-sectional at the Pediatric Emergency and Intensive Care Department, Sanglah General Hospital, Denpasar, Bali. The inclusion criteria were 1 month to 12 years old patient admitted to our PICU and diagnosed with mild or moderate to severe ARDS based on blood gas analysis which fulfilled Berlin definition (ESICM 2012). The exlusion criteria were patient with a chronic lung disease and or a cyanotic heart disease. We collected SpO2/FiO2 ratio and calculated its sensitivity and specificity in detecting ARDS. Results: There were 124 patients enrolled. The most common diagnosis was diseases in respiratory system (62.1%). Based on ROC analysis to determine SpO₂/FiO₂ ratio needed to detect moderate to severe ARDS, the AUC was 0.76 (95%CI 0.677-0.843) and the cut-off point for SpO₂/FiO₂ ratio was <196. The sensitivity was 88.5% (95%CI 77.8-95.3) and specificity 44.4% (95%CI 31.9-57.5). Conclusion: SpO₂/FiO₂ ratio can be used as an oxygenation parameter in ARDS patients.

Background: Muscle strength impairment in stroke patient affect the patient daily life, especially when it occurs on the extremities muscles. Manual Muscle Testing (MMT) is an examination method to measure muscle strength using standardized scoring. Objectives: To find possible improvement of Manual Muscle Test (MMT) Score after administration of Intra Arterial Heparin Flushing in chronic ischemic stroke patient. Methods: This is an experimental study using pretest-posttest group design, with randomized controlled clinical trial, conducted among patients in Cerebrovascular Center Unit in Army Central Hospital Gatot Soebroto starting from February 2014. With 75 patients included in this study. The examination of muscle strength was done by trained physicians. The MMT score were taken before and after the IAHF procedure is conducted. Results: This study found higher score of MMT-MRC scoring system on chronic stroke patient with IAHF procedure (mean MMT-MRC Score = 6,05 point. With p<0,05). Indicating that IAHF procedure is associated with better muscle strength improvement shown with higher MMT-MRC score on stroke patient, which will have better prognostic outcome in their recovery. Conclusions: Intra Arterial Heparin Flushing have significant effect on chronic stroke patient with decreased muscle strength, which shows a significant increase of MMT-MRC score.