Khazanah Riset

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CHAPTER IV ONCOLOGY & DIAGNOSTIC 123

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Asian Pacific Association for The Study of The Liver Consensus Recommendations on Hepatocellular Carcinoma Masao Omata, Laurentius A. Lesmana, Ryosuke Tateishi, Pei-Jer Chen, Shi-Ming Lin, Haruhiko Yoshida, Masatoshi Kudo, Jeong Min Lee, Byung Ihn Choi, Ronnie T. P. Poon, Shuichiro Shiina, Ann Lii Cheng, Ji-Dong Jia, Shuntaro Obi,Kwang Hyub Han, Wasim Jafri, Pierce Chow, Seng Gee Lim, Yogesh K. Chawla, Unggul Budihusodo, Rino A. Gani, C. Rinaldi Lesmana, Terawan Agus Putranto, Yun Fan Liaw, and Shiv Kumar Sarin Abstract The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations. Methods The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian- Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements. Results Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference. Keywords: Hepatocellular carcinoma Consensus statements Recommendations Epidemiology Diagnosis Treatment algorithm 125

Office Hysteroscopy and Outpatient Transvaginal Endoscopy in Low Resource Minimal Setting Ardianto Pramono , Ristaniah Soetikno, Achmad Hussein Sundawa Kartamihardja, Tinni Trihartini Maskoen , Terawan Agus Putranto, Erwin Setiawan Abstract Background: The limited number of case reports about Cerebral Venous Sinus Thrombosis (CVST), especially in the pediatric population who also present with Autism Spectrum Disorders (ASD) symptoms, prompted the authors to be the pioneer in reporting of pediatric CVST with ASD symptoms case in Indonesia. In this study, we would like to report a case of an 8-year-old patient with ASD who was diagnosed with CVST after undergoing Magnetic Resonance Imaging (MRI) examination. After the diagnosis was established, the patient underwent a modified Digital Subtraction Angiography (DSA) method, which was later termed as Intra Arterial Heparin Flushing (IAHF) as its treatment option. Case presentation: An 8-year-old-boy was brought by his parents to Gatot Soebroto Hospital with speech and communication problems, and also cognitive and behavioral problems such as the inability to count, read words, follow orders and maintain emotional stability. After a thorough standard examination by the attending physician, further examination using Magnetic Resonance Imaging with MR perfusion was suggested to establish a diagnosis. The imaging results showed a decrease in blood flow in the transverse sinus and straight sinus, and also in the internal jugular vein. The patient was diagnosed with CVST. The patient underwent anticoagulation therapy, which was administered through a modified DSA method, which was later termed as IAHF procedure, to increase the cerebral blood flow. Conclusion: After the patient underwent the IAHF procedure, good clinical outcomes were immediately seen, even at six months follow up. The parents reported that there were improvements in the patient‟s cognitive and behavioral status. Keywords: autism spectrum disorder, cerebral venous sinus thrombosis, digital subtraction angiography, intra arterial heparin flushing 126

Overview of Chromogranin A screening in IBS Patients and Suspected Patients GEP-NET Endra Tri Prabowo, Murdani Abdullah, Ina S Timan, Arini Setiawati, Terawan Agus Putranto, Taruna Ikrar Abstract Aim: To get an overview of Chromogranin A (CgA) levels in patients with Irritable Bowel Syndrome (IBS) and patients suspected Gastro Entero Pancreatic Neuro Endocrine Tumor (GEP-NET). Methods: A cross-sectional descriptive analytic study on IBS patients and patients suspected GEP-NET in the Department of Internal Medicine, Cipto Mangunkusumo Hospital, Jakarta. The levels of CgA were compared in three groups (normal control, groups of IBS, suspected GEP-NET) with Enzyme Linked Immunosorbent Assay (ELISA) and the results will be analyzed by Kruskal Wallis analysis. Results: Mean, median, and interval of CgA value in normal control; 50.70 g/L, 48.89 mg/L, and 42.66-80.62 g/L. Mean, median, and interval of CgA value in IBS group; 76.67 g/L, 64.82 mg/L, and 45.52-243.18 g/L. Mean, median, and interval of CgA value in GEP-NET premises; 126.82 g/L, 66.23 mg/L, and 49.89-656.41 g/L. According to calculations results with ROC analysis, the AUC results is 0.85 with 95% confidence interval (CI): 0.79- 0.92. The cut-off value is 51.4 g/L between the normal control group by group (IBS+GEP-NET) on sensitivity 80%, specificity 73%, positive predictive value 54%, negative predictive value 90%. Rated positive likelihood ratio 2.96; the value of the negative likelihood ratio 0.27. Conclusion: There are no significant differences found between CgA level of IBS patiens group and suspected group of GEP-NET, therefore both groups are at risk of suffering from GEP-NET in the future. CgA markers can be used for screening examinations in subjects who were clinically diagnosed with IBS and possibility of GEP-NET. Keywords: chromogranin A, IBS, GEP-NET, flushing 127

The Features of Multi-Drug Resistant Organisms in Tertiary Hospital in Indonesia : A One-Year Hospital Based Study Febria Asterina, Martina L Yana, Febria Asterina, Endra T Prabowo, Joko Widayanto, Soroy Lardo Abstract Background: Antimicrobial resistance has become national concern in Indonesia, that the goverment has published the regulation of Minister of Health no 8 year 2015 regarding the Antimicrobial Stewardship Program. As a first step effort to carry out the program, the hospital conducted mapping epidemiological data of the Multi Drug Resistant Organism (MDRO). Methods: A retrospective review of MDRO records had conducted throughout the period from july 2016 until June 2017. The MDRO Organism were identified and tested by an automated identification and susceptibility tests using Vitek 2 compact system for aerobic gram negative rods, aerobic gram positive coccus and yeasts. Antibiotics susceptibility testing was confirmed by disk diffusion method. Results: There were 307,819 patient admissions during July 2016 –June 2017. Out of total 307,819 admissions, there were 956 patients with MDRO, excluding data tuberculosis resistant. Giving an overall prevalence rate 3.11 per 1000 admissions (3.11 ‰ ). Other than that, there were 22,880 inpatients admissions, and the MDRO among the inpatients were 933, giving an inpatient admissions prevalence rates 40.8 per 1000 admissions (40.8 ‰). In additions, the Laboratory Identification rates (lab ID rates) of MDRO were 956 per 2,212 total isolates (43.2 %), when described by type of isolates are as follows: Carbapenem Resistant Enterobacteriaceae (CRE) 255 of 1208 isolates (21.1%), Extended Spectrum Beta Lactamase (ESBL) 241 of 1028 isolates (23.4 %), Methycillin Resistant Staphylococcus aureus (MRSA) 18 of 122 Staphylococcus aureus isolates ( 14.8 %), Resistant Enterococcus were 14 of 144 isolates (9.7%), consist of 10 Vancomycin Resistant Enterococcus (VRE) ( 6.9 %) and 4 Pandrug resistant Enterococcus (2.8 %). There were 123 Resistant organism of 274 Pseudomonas aeruginosa isolates (44.9 %), consist of 66 Multidrug Resistant Pseudomonas aeruginosa (24.1%) and 57 Pandrug Resistant Pseudomonas aeruginosa (20.8 %). The most prevalence MDRO isolates were resistant Acinetobacter baumannii, 308 of 464 isolates (66.4 %), consist of Multidrug Resistant Acinetobacter 128

baumannii 203 of 464 (43.8 %) and possibility of Pandrug Resistant (PDR) were also found in 105 of 464 Acinobacter baumannii isolates ( 22.6 % ). There were no MDRO in 500 yeast isolates. Conclusion: The overall prevalences 3.11 cases per 1000 admissions were lower compared to prevalence rate in a teaching hospital in Oman, 10.8 cases per 1000 admissions (Abdullah Balkhair et all, 2014). Although the overall prevalence were low, the inpatient admission prevalence rates 40.8 cases per 1000 admissions and total laboratory identification rates (Lab ID rates) of MDRO (43.2 %) are an emerging challenge. Continuious monitoring of hospital antibiogram and data of MDRO, and strict adherences to infection prevention guidelines are essential to overcome the antimicrobial resistance problems in hospital. Along such quest, restrictions of antibiotics prescriptions are needed. Keywords: MDRO mapping, admission rates, lab ID rates. 129

Adenocarcinoma Esophagus in Asymptomatic Barret Esophagus Trian Satrio, Deka Larasati, Diany N. Taher, El Nissi Abstract Introduction: Esophageal complications caused by GERD include reflux esophagitis and Barrett‟s esophagus (BE), and the latter predisposes patients to esophageal adenocarcinoma (EAC). BE is a premalignant condition in which the normal stratified squamous epithelium of the distal esophagus is replaced by columnar mucosa with intestinal specialized metaplasia. Esophageal cancer is considered a serious malignancy with respect to prognosis and mortality rate, accounting for more than 400000 deaths worldwide in 2005. It is possible that many cases of BE occur in asymptomatic adults who do not experience symptoms of GERD or do not seek medical attention for GERD symptoms because the increase in esophageal adenocarcinoma case does not appear to be solely attributable to a rise in the prevalence of GERD Case Illustration: 57 year old man came to Gatot Soebroto Army Hospital with a swallowing discomfort. the symptoms was worsen in 3 days before the admissions. The patient admit there was a progression of the symptoms since 1 month before and usually it came with vomitting. There was a history of weight loss (7 kgs) since 1 month ago and he was heavy smoker. There was no history of heartburn, dyspepsia and reflux symptom or any AH2/PPI treatment in this patient. Esofagogastroduodenoscopy was done in this patient and there was friable and easy to bleed tumour at Z line. The biopsy was adenocarcinoma of esophagus in barrett‟s esophagus. Discussion: We understand that Barrett‟s esophagus occurs in GERD cases without inadequate treatment and with a risk of helicobacter infection. In this case we found Barrett‟s esophagus could occur asymptomatic and found became esophageal adenocarcinoma. Reflux symptoms with or without an alarm sign would bring the patient into treatment. When the symptoms are not shown, the prevention and early therapy cannot be done and prognostic became worsen. Keywords: Barrett’s esophagus, asymptomatic, esophageal adenocarcinoma 130

The Progress of The Implementation of Hospital Transfusion Reaction Reporting and Investigation System Febria A Said Abstract Background: One of the hospital blood bank duties is to report and investigate adverse event related to transfusion, as stated in the Indonesian Goverments Regulations No. 7 year 2011 concerning blood transfusion services. However, there is no established national guidelines to conduct it, such as how to assess, classify the symptoms, and standardize the reporting forms. Although there is a monthly report to the Indonesian Red Cross Society, but until now there is no institusion appointed by the local authorities to perform an audit on the transfusion reactions reports. Nevertheless, since January 2012, the hospital blood bank has developed an acute transfusion reaction reporting and investigation system to meet the function of haemovigilance. Here we reported the 2012-2015 experience of implementation. Aim: To review the reporting and investigation system of the acute blood transfusion adverse reactions in the Indonesia Army Central Hospital- Gatot Soebroto for better health services and patient safety. Methods: Since January 2012 we have implemented the blood transfusion related adverse effect reporting and investigating system using a paper- based reporting form with check-box format containing 11 signs and symptoms of transfusion reactions. Because of the requirement of the Joint Commission on International accreditation (JCI) to maintain the quality of patient safety by strict monitoring and evaluation during blood administration, in October 2013, the reporting form was revised and redesigned to be a blood transfusion monitoring and evaluation check-box form. Attached to it is a notification form to be completed when adverse reactions are found. Based on the above, the blood bank carried out an investigation and examination into the complete immunohematology tests. Result: All of the transfusion reaction data from 2012-2015 were collected and analyzed. In 2012, there were 12 cases of transfusion reaction out of 17806 blood bags (0.067%). In 2013 , the reported cases showed an increase to 33 cases out of 19290 blood bags (0.171 %). In 2014, transfusion monitoring and evaluation form was fully implemented in the hospital, and the reported cases rose to 48 cases out of 16791 blood bags 131

(0.286%). The last in 2015 showed a decreased to 24 cases out of 14096 bags (0.172 %). Atotal there were 117 cases out of 67983 blood bags, and based on the signs and symptomps, classified accordingly as showed in table and diagrams below. All of the cases were investigated with immunohematology confirmation examinations, It was found that there was 2 minor incompatibility and 1 mayor incompatibility, the rest was all compatible. It was discovered that there was 1 near-miss case and 1 error case because of wrong blood grouping due to blood discrepancies. There was no fatal incident in these cases. Conclusion: The transfusion adverse reaction reporting rates vary, and may be under reported. With the better designed monitoring and evaluation form, there has been a significant increase in the reporting of suspected transfusion reaction cases. Although in this 3 years span no fatal incidents have been reported, the transfusion reaction rates especially error incidents should be minimize by practising haemovigilance program to achieve patient safety. Keywords: Haemovigilance, Reporting System, Transfusion Acute Adverse 132

Molecular Detection of N Gene Measles Virus with Conventional PCR and Reverse Transcriptase Real-Time PCR for Diagnosis of Measles Disease Muhamad Tolib, Vivi Setiyawati, Daniel Djoko W Abstract Measles is one of the acute infectious disease caused by measles virus infection. Transmission of measles can occur through the air which is contaminated by droplets. Measles ranks 5th of 10 deadly diseases that affects children. So far, clinical diagnosis for measles is based only on physical symptoms. It causes a lot of mis-diagnosis in patients with measles, especially in the early stages of infection. Therefore, we need a method of diagnosis that has high accuracy through the PCR method. Two PCR methods that can be used in the detection of measles virus infection are conventional method of PCR and real time PCR. Detection of measles virus infection can be done by detecting the presence of N gene that encode nucleoprotein. The purpose of this study was to determine the ability of conventional method of PCR and real time PCR in the detection of N gene measles virus and also to compare the detection results using both methods. The research design used analysis observational analytic research in cross-sectional. Data were analyzed using descriptive and comparative detection results of both methods were analyzed using non- parametric statistical tests with kappa test (к). The level of positive N gene detection results using RT-PCR in the urine sample of 25,64% and using RT-qPCR is 35,89%. Based on conformance test Kappa (к) both methods have a low level. Keywords: measles, N Gene, PCR 133

High Dose 50 mCi or 100 mCi Nal-131 for Preventive Thyroablation of Thyroid Remnant in Patients with Differentiated Thyroid Cancer Djoko Nariman, Eko Purnomo Abstract Differentiated thyroid cancer was indolent cancer and it can be aggressively especially for old patients upon 50 years.diagnosis and management of differentiated thyroid cancer was reviewed and the guidelines were proposed. Primary treatment was surgical exisions, total thyroidectomy was recommended and additional therapy was preventive thyroablation with Nal-131, then hormone thyroid. Total thyroidectomy was done but generally thyroid remnant still available through thyroid scanning.thyroid remnant can be destroyed with thyroablation therapy. Destroy thyroid monitoring thyroglobulin as tumor marker for further evaluation. The aim of this study was compare the efficacy of single high dose 50 mCi and 100 mCi Nal-131 for preventive thyroablation, post total thyroidectomy without regional node metastasis or distant metastasis. Methods: in retrospective study (new patients in 2010) 34 subjects with DTC without metastases, post total thyroidectomy, and thyroid scintigraphy. 20 subjects were given 50 mCi Nal-131 ( 4 men, 16 women) age from 23 to 71 years, mean; 48 years and then all subjects were given thyroid hormone with suppressive doses. Three month later, all were to examine for evaluation with thyroid scintigraphy, TSHs, thyroglobulin and anti thyroglobulin. Stop hormone thyroid for three weeks before examination. Results: before theraphy Nal-131 50 mCi” thyroid scanning; it was thyroid remnant, upatake thyroid from 0.03 to 1.86%, mean ; 0.64%. after therapy: Thyroid Scanning: no residual thyroid tissue, uptake 0%, mean TSHS; 42,95 uIU/ml, mean thyroglobulin; 2.08 ng/ml and anti thyroglobulin was negative. Before therapy Nal- 131 100 mCi: Thyroid Scanning: no residual thyroid tissue, upatake 0%, mean TSHs; 36,95 uIU/ml, mean thyroglobulin; 2,1 ng/ml and anti thyroglobulin was negative. Therapy using Nal 50 mCi or 100 mCi was gave the same result that there is no residual thyroid tissue; uptake thyroid 0%, high TSHs, low thyroglobulin and negative antiglobulin. We found no significant difference in two groups with high dose preventive thyroablation. Conclusion: we did not find any difference between preventive thyroablation with 50 mCi and 100 mCi Nal-131 for destroyed thyroid remnant.The preventive 134

thyroablation with 50mCi dose enough for destroyed thyroid remnant without regional node metastasis or distant metastasis. 135

Importance of Dental and Facial Records in Forensic Dental Identification Indonesia Army Iwan Dermawan Abstract Indonesia Army Dental to form The Dental forensics specialization as we known as a DVI. Disaster victim identification (DVI) is an intensive and demanding task involving specialists from various disciplines. The forensic dentist is one of the key persons who plays an important role in the DVI human identification process. In recent years, many disaster incidents have occurred that challenged the DVI team with various kinds of difficulties related to disaster management and unique situations in each disaster. New technologies have been developed to make the working process faster and more effective and the different DVI protocols have been evaluated and improved. The aim of this article is to collate all information regarding diagnostic tools and methodologies pertaining to forensic odontological DVI, both current and future. It can be concluded that lessons learned from previous disaster incidents have helped to optimize working protocols and to develop new tools that can be applied in future DVI operation. The working procedures have been greatly improved by newly developed technologies. Keywords: forensic odontology, Disaster Victim Identification (DVI), human identification, mass casualty 136

Our Experience in The Application of P-32 for Palliative Treatment of Painful Disseminated Bone Metastases Eko Purnomo, Ratna D., Yusuf, Firdaus S. Sohar, Wahid Ibrahim D. Abstract Aim: To evaluate and share an experience with application and efficiency of P-32 in Palliative painful bone metastases therapy. Material and methods: From February to May 2005, we selected 11 patients (3 male, 8 female). The average age 34-57 years with metastatic bone pain, breast cancer, 2 nasopharynx cancer, 1 prostate cancer, 5 lung cancer were treated with P-32, two of them received second dose. They had painful bone metastases with osteoblastic activity, confirmed on a Tc99m-MDP bone scan; all showed an extensive metastatic disease. All of the patients have been administered 12 mCi P-32 oral solution, after hydration and vasting 10 hours. We established for pain, haematological parameters, scintigraphic, Karnovsky index below 50. Clinical assessment was performed 1 month later. Responses were classified in completed (good), partial and absent regard to symptoms and drugs reduction. Four weeks after the treatment a whole blood count was determined to assess the possible myelotoxicity of P-32. The discontinuation or the reduction of the opiate dosage was also considered as a successful palliative result of treatment. Result: Pain relief was obtained in 10/11 patients, P-32 treatment wasw effective in patients with reduced drug assumption. The response to P-32 was good in 611 (54.6%) of the patients and partial in 4/11 (36.3%); there was no response in the remaining 1/11 (9%). The application of a P-32 in patients with painful disseminated bone metastases has a satisfactory pain alleviating effect. The easy application and low cost are important factors in this group of patients. Conclusion : A better of the P-32 application can be expected be expected because of the favorable palliation effect and the low cost of P-32 it could be a choice, especially in patients with limited budget. 137

Automated Bone Scan Index as Predictors of Survival in Prostate Cancer Joko Wiyanto, Djoko Nariman, Eko Purnomo, Budi Darmawan, Basuki Hidayat and A. Hussein S. Kartamihardja Abstract Prostate cancer is the second most diagnosed cancer in men. Among patients who die from prostate cancer the incidence of skeletal involvement appears to be >85%. Bone scan (BS) is the most common method for monitoring bone metastases in patients with prostate cancer. The extent of bone metastasis was also associated with patient survival, a bone scan index (BSI) has shown clinical significance as a prognostic imaging biomarker. The aim of this study was to investigate automated BSI measurements as predictors survival in prostate cancer. Methods: Retrospectively cohort studied 50 patients with prostate cancer who had undergone BS between January 2010 and December 2011 at our institution. All data collected was updated up to August 2016. CAD system analyzing bone scan images to automatically compute BSI measurements. Patients were stratified in three BSI categories BSI value 0, BSI value ≤1 and BSI value >1. Kaplan-Meier estimates of the survival function accordance with the BSI values. Results: Subjects with low automated BSI value had longer overall survival (OS) in comparison with the other subjects (P = 0.004). Conclusion: Automated BSI measurements was shown to be a strong prognostic survival indicator in prostate cancer. Keywords: Prostate Cancer, Bone Scan, Bone Scan Index, Bone Metastases 138

The Effect of Mechanical Bowel Preparation with NaP and MgSO4 to The Colonic Mucosa in Vivo Experimental Study in Rabbit Ahmad Zumaro, Ignatius Riwanto, Andy Maleachi Abstract Background: Although the mechanical bowel preparation (MBP) before colorectal surgery was still debate able. The MBP prepare for colonoscopy and radiology procedure has been standard. Many studies have revealed the sodium phosphate effect on colonic mucosal abnormalities, but there were have no evidence about magnesium sulfate effect compared with NaP on the colonic mucosal damage. Method: Randomized control trial-double blind in vivo experimental study in rabbit. Samples were 18 New Zealand rabbits, with systematic random sampling the subjects were divided into 3 groups: control (only given by mineral water), MgSO4 and NaP group. We evaluated these samples and macroscopically review at The Comprehensive Laboratory of Animal Research and Examination on Yogyakarta. The histological review by one blinded observer (an experienced pathologist) at the Pathology Anatomy Department of Semarang Kariadi Hospital. Results: MgSO4 better than NaP at the effect of colonic mucosa. In this histological study the colonic mucosal damage consist of; loss of superficial mucus (p=0,027), Goblet cell loss (p=0,014), submucosal congestion (p=0,043), pre-ulcer lesion (p=0,027), mucosal denudation (p=0,195), edema of lamina propia (p=0,195), Lymphocytes infiltration (p=0,135), and PMN infiltration (p=0,105). MgSO4 have protective effect to the colonic mucosa. Conclusions: MgSO4 was better than NaP for MBP at the effect of colonic mucosa histologycally. Need for futher study to reveal the protective effect of MgSO4 to the colonic mucosa. Keyword: Mechanical bowel preparation, magnesium sulfate, sodium phosphate. 139

Condom Added for Overtube The Experiences and Innovative Idea for Endoscopic Foreign Body Extraction Ahmad Zumaro, Kunsemedi Setyadi, Andy Maleachi Abstact Introduction: More than 10% cases of foreign body in gastrointestinal tract cannot spontaneously pass out and need for intervention with endoscope. An overtube is recommended when removing sharp or pointed objects to avoid damage to the esophagus and pharynx. Case report: Between January 2012 – December 2013: 11 cases with foreign body in gastrointestinal tract. Nine cases (82%) was spontaneously pass out, 2 cases (18%) need for endoscopic intervention. A girl 17 year old and a child 12 year old, both of them had pin cushion were pricked at the prepyloric area. We applied flexible endoscopy with tip of the scope added a condom as overtube which fixed with rubber band. The condom is opened and retracted back along the scope. Polypectomy snare used for pin cushion retrieval. Condom will protrusion and covered the pin cushion when scope pull out through esophagus and pharynx. Discussion: Foreign bodies that remain in stomach for more than 72 hours should undergo early endoscopic extraction since their spontaneous passage was unlikely. An overtube used by attaching a plastic parachute cover (piece of latex or silicon glove) to the tip of the endoscope. We have been used condom as overtube. This technique is cheap and very easy, employed through the gastroscope for grasping the pin cushions, manipulating them and removing them while protecting the esophagus and pharynx. Conclusion: Condom added for overtube is recommended when removing sharp or pointed objects to avoid damage to the esophagus and pharynx. Keywords: Therapeutic endoscopy, overtube, foreign body, gastrointestinal tract 140

The Difference of The Incidence of Surgical Site Infection Between Lichtenstein Repair With Macroporous Monofilament Mesh and Shouldice Repair in Incarcerated Hernia Ahmad Zumaro, Ignatius Riwanto, Andy Maleachi, Edy Dharmana, Tjahyono Abstract Background: Lichtenstein technique is the gold standard for adult open hernia repair. However, it is still in doubt whether mesh use in the clean contaminated operation such as incarcerated inguinal hernia is safe. Objective: To exam the difference of surgical site infection (SSI) incidence between Lichtenstein with monofilament macro porous mesh and Shouldice repair, in the incarcerated inguinal hernia without any gut resection. Method: This study was approved by the human research ethics committees of Kariadi Hospital and Medical Faculty of Diponegoro University. A randomized control trial was conducted in 58 subjects with incarcerated hernia patients. Subjects were divided into two groups, Lichtenstein and Shouldice. Herniorrhaphies were performed in ER. Clinically SSI were diagnosed on the first day until 4thday, 7th, 10th, 14th, and 28th day after operation. Bacterial culture were performed if there was any sign clinically SSI of the second grade or higher of procedures (Hulton‟s criteria). Result: On the first day until fourth day after operation all of cases were in the first grade clinically SSI. On the 14th day and 28th day all of cases had no sign of clinically SSI, all of these wounds were on primary healing. On the 7th day there were 16 subjects with first grade clinically SSI (9 Lichtenstein, 7 Shouldice). There was no difference in the prevalence of SSI (X2=0,345 p=0,557). On the 10th day there were 13 cases first grade clinically SSI (8 Lichtenstein, 5 Shouldice), there was also no significance (X2=0,892 p=0,345). Conclusion: There was no difference on the prevalence of clinically SSI between Lichtenstein and Shouldice in incarcerated hernia repair. Substantially, there was no infection in the both technique. Keyword: Surgical site infection, polypropylene mesh, incarcerated hernia. 141

Surgical Embolectomy for Submassive Pulmonary Embolism in Young Adult Patient : A Case Report Themes: Adult Cardiac Surgery Arya Utama, Wijoyo Hadi Mursito, Andreas Andri lensoen, Arief Widya Taufiq Abstract Introduction: We present case of a 26 years old man,who had submassive pulmonary embolism one month after surgery of laminectomy for herniated nucleus pulposus, failed with thrombolysis therapy and remain survived after pulmonary embolectomy with no complication. Interesting Point for Discussion: Surgical embolectomy is often indicated for central pulmonary embolism with hemodynamic instability but remains controversial for hemodynamic stable patient with sign of right ventricular dysfunction. Timing to use pulmonary embolectomy as the first or alternative treatment is important for treating pulmonary embolism. Solution and Rationale : A team approach including a cardiovascular surgeon may be effective to determine timing for pulmonary embolectomy. Final Outcome: Patient survive and discharge from the hospital with no complication. 142

Compatibility Between Chest Ultrasound with Chest X-Ray, Chest Ultrasound with Clinical Diagnosis, and Chest X-Ray with Clinical Diagnosis in Cases of Pediatric Pneumonia Sophia Utami, Eddy Sudijanto, Hesti Gunarti Abstract Background And Objectives: Pneumonia is one of the leading causes of death in children. Chest X-ray still is a routine examination to diagnose pneumonia. Chest Ultrasound (US) is a technique that does not use radiation, portable and easy to learn, which it has become a new diagnostic tool in diagnosing pneumonia. This research aims to determine the compatibility of chest US with chest X-ray in diagnosing pneumonia in children, the compatibility of chest US results with clinical diagnosis of pneumonia in children and the compatibility of chest X-ray results with clinical diagnosis of pneumonia in children, as well as knowing the features of chest US that can be found in children with a suspicion of pneumonia. Methodology: This study uses a prospective monocentric study conducted on children with a suspicion of pneumonia at Gatot Soebroto Army Central Hospital from November 2019 to February 2020. The research design was cross-sectional analytic by testing the compatibility between chest US results with chest X-ray results, chest US results with clinical diagnosis and chest X-ray results with clinical diagnosis and also describes the features of chest US in children with a suspicion of pneumonia. Results: A total of 27 samples have been studied by examining the chest X-ray, chest US, and recording the clinical diagnosis from the medical record. In the compatibility test between chest US results with chest X-ray results, obtained p = 0.054; because p > 0.05 there is a compatibility between chest US results with chest X-ray results in diagnosing pneumonia in children. In the compatibility test between chest US results with clinical diagnosis, obtained p = 0,000; because p < 0.05 there is no compatibility between chest US results with clinical diagnosis. In the compatibility test between chest X-ray results with clinical diagnosis, obtained p = 0,015; because p < 0.05 there is no compatibility between chest X results with clinical diagnosis. The most common feature of chest US in children with a suspicion of pneumonia was multiple B-lines accompanied by pleural irregularity (66.7%); followed by multiple B-lines accompanied by pleural irregularity and consolidation (14.8%) and normal appearance (18.5%). 143

Conclusion: Chest US is an effective and safe examination modality in diagnosing pneumonia in children. Ultrasound is not to replace the chest X- ray but can be used to complete the examination so that X-rays can be used more rationally. It is recommended that chest X-ray and chest US be performed as a preliminary examination, and subsequent chest US can be used for routine daily imaging in the patient's follow-up, especially in clinically stable patients. There is a compatibility between chest US with chest X-ray in the diagnosis of pneumonia in children. There is no compatibility between chest US results and clinical diagnosis of pneumonia in children. There is no compatibility between chest X-ray results with clinical diagnosis of pneumonia in children. Features of chest US that can be found in children with a suspicion of pneumonia are multiple B-lines accompanied by pleural irregularity, followed by multiple B-lines accompanied by pleural irregularity and consolidation and normal appearance Keywords: Chest Ultrasound, Pneumonia, B-lines. 144

Conventional and Conformal Technique of External Beam Radiotherapy in Locally Advanced Cervical Cancer: Dose Distribution, Tumor Response, and Side Effects N Mutrikah, H Winarno, T Amalia and M Djakaria Abstract The objective of this study was to compare conventional and conformal techniques of external beam radiotherapy (EBRT) in terms of the dose distribution, tumor response, and side effects in the treatment of locally advanced cervical cancer patients. A retrospective cohort study was conducted on cervical cancer patients who underwent EBRT before brachytherapy in the Radiotherapy Department of Cipto Mangunkusumo Hospital. The prescribed dose distribution, tumor response, and acute side effects of EBRT using conventional and conformal techniques were investigated. In total, 51 patients who underwent EBRT using conventional techniques (25 cases using Cobalt-60 and 26 cases using a linear accelerator (LINAC)) and 29 patients who underwent EBRT using conformal techniques were included in the study. The distribution of the prescribed dose in the target had an impact on the patient‟s final response to EBRT. The complete response rate of patients to conformal techniques was significantly greater (58%) than that of patients to conventional techniques (42%). No severe acute local side effects were seen in any of the patients (Radiation Therapy Oncology Group (RTOG) grades 3–4). The distribution of the dose and volume to the gastrointestinal tract affected the proportion of mild acute side effects (RTOG grades1–2). The urinary bladder was significantly greater using conventional techniques (Cobalt- 60/LINAC) than using conformal techniques at 72% and 78% compared to 28% and 22%, respectively. The use of conformal techniques in pelvic radiation therapy is suggested in radiotherapy centers with CT simulators and 3D Radiotherapy Treatment Planning Systems (RTPSs) to decrease some uncertainties in radiotherapy planning. The use of AP/PA pelvic radiation techniques with Cobalt-60 should be limited in body thicknesses equal to or less than 18 cm. When using conformal techniques, delineation should be applied in the small bowel, as it is considered a critical organ according to RTOG consensus guidelines. Keywords : Cervical cancer, External Beam Radiotheraphy, Conformal Radiotheraphy 145

Progesterone Receptor Relationship with The Formation of Kalvaria Hyperostosis on Meningioma Handrianto Setiajaya Abstract Background : meningioma is the most commonly found benign tumor of the brain tumors and is often accompanied by calvaria abdormality in the form of hyperostosis whose cause is yet to be known Purpose : this study was aimed to analyze the relation of progresteron receptor in meningioma tumor with hyperostosis in calvaria Method : the research design was analytic observational with cross sectional patients were collected by purposive sampling, which was performed from 2013 to 2015, involving 37 patients. Selected samples were given head CT Scan to group them into 2 groups, hyperostosis, following by blood sample collection to check progresterone, estrogen, cholesterol and Ca levels in the laboratory of RSPAD. Selected patients were given craniotomy. During surgery tumor sample and calavaria were collected. Meningioma samples were examined using immunohistochemical performed on progresterone receptors and estrogen receptors and Ki67. Bone were measured for Thickness and osteoid measurement using micrometer. Data analysis used bivariated and multivariate analyses Result : the study was performed on 37 meningioma patients, 81,1% patients were female anf 18,9& were male with average age 48 years old. Bivariate analysis was performed to see inter variable relation. Female patients have hyperostosis more often 94,7%. The correlation between intensity of progresteron receptors and hyperostosis was moderately negative (r= -0,34 ; P=0,09). Multivariate analysis found ages factor has moderate negative correlation (adjusted r= -0,52 ; p=0,002) with thickness of the osteoid as independent factor on hyperostosis group. Weak negative correlation was found between progresterone receptors with thickness of osteoid (r adjusted -0,15, p 0,55) on hyperosteoid group. Conclusion : the intensity of progresterone receptor has negative correlation with the thickness of osteoid and hyperostosis in menigioma. Keywords : Meningioma, Progresterone receptor, Osteoid, Hyperostosis 146

Hürthle Cell Carcinoma: A Rare Case with Unique Morphological Features Familia Bella Rahadiati, Agnes Stephanie Harahap and Maria Fransiska Ham Abstract Hürthle cell carcinoma (HCC) of the thyroid is an unusual and relatively rare type ofthyroid cancer. Small series of HCC patients have been reported in the literature, butbecause of its relative rarity, its pathological and clinical significance have not been welldocumented. A 55-year-old woman presented with rapid neck mass enlargement and hoarseness. Thorax X-ray imaging suggested intrathoracic struma. Ultrasonographicexamination showed struma nodosa in the right lobe. Fine-needle aspiration biopsy results suggested a follicular neoplasm of Hürthle cell type. Grossly, the right thyroid size was 6 × 5 × 4 cm and was brown, firm, and encapsulated. The cut surfaces were brown and lobulated, with no papillary growth or calcification. A histological examination showed large tumor cells in a trabecular arrangement, rounded nuclei, coarse chromatin, some vesicular with prominent nucleoli, and abundant granular eosinophilic cytoplasm. Another section revealed capsular invasion, and a solid area containing scattered bizarre giant cells with irregular nuclei. The histopatological features and imunohistochemical staining results supported a diagnosis of encapsulated angioinvasive HCC with bizarre nuclei. HCC is a rare type of carcinoma that remains controversial and difficult to diagnose. Careful assessment should be performed to look for bizarre nuclei to prevent overdiagnosis. Keywords: carcinoma, Hürthle cell, morphology, thyroid, unique 147

Proton Therapy for Defence and Resilience of The Indonesia Health Sector Muhamad Tolib Abstract Cancer is a malignant tumor that has progressive, infiltratif, and metastatic properties. GLOBACON, the International Association of Cancer Registries (IACR) reported on 2012, there were 14,067,894 new cases registered globally for cancer and 8,201,575 deaths unavoidable. Proton therapy is a benefit of radionuclear from the hydrogen proton. Proton is able to make the energy peak (Bragg peak) where it can be used to transfer strong radiation to a range of tumor cells in the body by reducing the disturbance in the normal part. Proton utilization provides minimal damage to cells passed by light radiation because energy distribution can be stored better and accurately according to the volume of tissues to be treated. Research at Loma Linda Hospital showed an increase in the free survival of 97% (n = 100). At this time Indonesia does not have proton therapy services facilities. Adequate human resources and infrastructure facilities are required to provide this therapeutic services facility. Besides physicians who specialize in Radionuclear, technical staff with medical physics qualifications are also required. The presence of proton therapy will have a significant effect on health. The existence of proton therapy services in Indonesia will make Indonesia's first country in southeast Asia that has proton therapy services. The existence of proton therapy will increase the resilience and defence of the nation's health sector. Keywords: proton, proton therapy,Bragg Peak, Radionuclear, cancer 148

Modified Rapid Urease Test for The Detection of Helicobacter pylori from Gastric Biopsies in Patients with Dyspepsia Angky Budianti, Mardiastuti, Lisa Yuliantiningsih, Ardiana Kusumaningrum and Ari Fahrial Syam Abstract Up to now, rapid detection of Helicobacter pylori is still a problem due to its difficulty in culturing and having accurate histopathology result. In clinical setting, internists usually perform urea breath test. In laboratory setting, urease test, MIU test, culture, PCR and histopathology examination are utilized for detecting Helicobacter pylori. The objective of this study is to detect H. pylori in gastric biopsies using a modified rapid urease test. This is a cross sectional study. We obtained gastric tissue biops specimens (antrum and corpus) from untreated dyspepsia patients who come to Gastroenterohepatology Division, Department of Internal Medicine, dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia. One set of specimen was fixated in 10% formalin and was sent to Anatomy Pathology Laboratory. The other was sent directly to Microbiology Laboratory without fixation Rapid Urease Test medium was prepared by modifying Christensen Urea and Motility Indole Urease Test. Urea concentration, pH indicator concentration (phenol red) and incubation temperature were optimized. The optimum concentration of urea was 40%, while the optimum concentration of phenol red was 0.5%. Of 34 samples, 12 (35.3%) were positive by rapid urease test (RUT) (either antrum and/or corpus). There were 2 (5.8%) samples which only positive by histopathology examination, 7 (20.6%) samples were only positive by RUT and 5 (14.7%) samples were positive by histopathology and RUT (14.7%). We assumed that Helicobacter pylori detection should not only based on histopathology examination, but also in combination with RUT. Keywords: Biopsi, Dyspepsia, Helicobacter pylori 149

Topical Nitroglycerin is Associated with A Reduced Mastectomy Skin Flap Necrosis-Systematic Review and Meta-Analysis Rachel Vania, Raymond Pranata, Denny Irwansyah, Budiman Abstract Introduction The flap necrosis rate remains high despite the advancement of technology in daily practices. Several randomized trials of topical Nitroglycerin (NTG) have shown promise in reducing flap necrosis. We aim to evaluate the efficacy and safety of topical NTG in preventing flap failure based on existing databases. Method We searched through PubMed, EuropePMC, EBSCOhost, Cochrane CENTRAL database, Clinicaltrials.gov, and hand sampling for “flap survival”, “topical nitroglycerin”, and “flap perfusion”. Results With a total of 6947 patients from 3 RCT and 2 retrospective cohorts, NTG was shown to prevent flap failure in mastectomy flaps by NTG with an OR 0.23 [0.10, 0.53]; p < 0.001), I2 73%. Upon sensitivity analysis to reduce heterogeneity, the OR was 0.17 [0.07, 0.40]; p < 0.001, I2 52%. Upon subgroup analysis of RCT, the OR was 0.17 [0.10, 0.30]; p < 0.001, I2 50%. Newer studies subgroup had OR 0.48 [0.33, 0.70]; p<0.001; I2 46. Upon subgroup analysis of single application only, the OR for flap necrosis was 0.36 [0.18, 0.73]; p = 0.005, I2 67% and subgroup analysis repeated application had an OR of 0.05 [0.01, 0.21]; p < 0.001, I2 14%. Conclusion Nitroglycerin seemed to be an ideal agent to increase the chance of flap survival in mastectomy flaps. It has an excellent safety profile, hence, is suitable for empiric use. More randomized controlled trials comparing different regiments and other preparations are needed to conclude whether repeated application at a low dose is most effective, and whether the success is reproducible on other types of flaps. Keywords : Flap, Necrosis, Nitroglycerin 150

Viability of Cartilage Grafts with Perichondrium Attachment: Experimental Study Maria Valentine, Prasetyanugraheni Kreshanti Abstract Background: The present study was conducted to evaluate the viability of implanted both side perichondrium attachment autologous cartilage grafts in rabbits and to study the effect of the scoring on cartilage survival and resorption. Methods: 7 adult male New Zealand white rabbits were operated upon. Three equal sized auricular cartilage grafts were harvested from each rabbit and implanted on the both scapulae of the same rabbits. The viability of graft was examined by implanting three types of both side perichondrium cartilage grafts; the first block cartilage, the second with parallel scored, while in the third, diced pattern. Ten weeks after their implantation, all cartilage grafts were retrieved, examined macroscopically and subjected to histological examination. Post-implanted cartilage grafts were stained by: Haematoxylin & Eosin, Mason Thricrhome, Toluidine blue, and Safranin O stains to evaluate cell growth, apoptotic cells, astbest degeneration, and infalmation. The results were compared among three groups. Result: Gross examination revealed no obvious deviation from the preimplanted auricular cartilage graft regarding color, texture and consistency with capsular tissue covering the graft. All groups show the same viability regardless the scoring manipulation on histological examination. There is an evident of chondrotic proliferation on three groups, with indifferent amount in the scored side on parallel scored and diced scored group. Conslusion: Manipulation with scoring on the surface side makes no difference of viability of the cartilage, but there is evident of proliferating cells on the scored site, which macroscopically no marking different of contour is noticeable. Keywords: perichondrium, conchal cartilage, scoring, parallel scoring, diced cartilage 151

Bunionplasty in Plastic Surgery Point of View Maria Valentine, Budiman Abstract Background: Bunionplasty can be considered as an aesthetic procedure for foot surgery on behalf of treating bunion. It is a common condition, particularly in women with inappropriate footwear, such as shoes that overly tight in toes and high heels. Indication for surgery is common, with more than 150 different surgical procedures to correct the condition have been described, with most of surgery intervention were done by orthopedics and podiatry Case Report: We presented one case of female, 28 years old, with chief complain deformity and pain on her first toe of both feet since 2 years ago. The use of pointed toe and high heels shoes was undeniable. From the clinical appearance, we can see deformity of first toe in both feet, which can be classified to grade 3 Manchester scale. We performed proximal phalangeal osteotomy and plating with 2.0 plating system and also buniectomy. Early mobilization was achieved; no complication found post surgery, and patient was satisfied with the result. Discussion: Concomitant foot deformity may have interfered in process of bunion, other than the use of tight and pointed shoes. Most procedures offered in the literature for correction of hallux valgus do work if properly performed in the right indications. Osteotomy and plating may offer the fastest mobilization post procedure with comparable result with other procedure, it also reduces risk of infection and twisting of the osteotomy part compare to the use of K-wire for fixation. Summary: Correcting pain and deformity, avoiding recurrence, establishing normal foot function, and early mobilization are the ultimate goals of bunion surgery, which can be met with this procedure. Although many fields have been done invention in bunion surgery, bunionplasty is one of many procedures that plastic surgery should be conquered at. Keywords: bunion, hallux valgus, hallux abducto valgus, varus deformity 152

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CHAPTER V NURSING 154

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Nursing Managemet of Chronic Wound Siti Anisah Abstract Introduction.The challenge of managing chronic wounds when quality of life is a significant issue, especially for an elderly patient. Development of chronic wound is common as is a healing with scarring, depressed, and long of stay at the hospital. Sometimes, treatment is a symptomatic and wound management forming a large of part of care to achieved palliative care. Methodology: Case report series. Results: When the response to wounding does not conform to the described cycle of wound recovery after period 2–4 weeks, the wound may have become “stuck” and unable to progress through the phases of healing without intervention. Examples of chronic wounds included diabetic foot ulcers, malignancy wound, pressure ulcers, and arterial/venous ulcer. Wounds managed in a moist environment covered by an occlusive dressing do not form a scab, so epidermal cells are able to move rapidly over the surface of the dermis through the exudate that collects at the wound dressing interface. Key consideration in clinical practice in concepts such as the TIME guidelines of wound bed preparation. Moisture is a key component for keeping every cell in the body alive and functioning. Conclusion: Management and optimizing wound conditions at local and systemic level, wound bed preparation is necessary for all chronic wounds to achieve rapid, efficient, cost effectively wound closure and can increased quality of life patient. Keywords : Chronic wound; Q o L; Nursing 156

The Impacts of Kaizen Concepts Application in Management on Safety of Nurses from Injuries Caused by Needlestick in Hospital: Library Research Siti Anisah Abctract Introduction. A nurse manager conducts the prevention of pressure ulcers during the time when a patient is hospitalized as an effort to improve the quality indicators in clinical nursing, however this action has not been optimal. Any incidence of pressure ulcer demands high hospitalization cost, extends the patient's hospital stay, and causes pain and complications, which might lead to a decline in quality and patient safety. Aims. The purpose of this paper is to identify the optimization of the nursing manager's function in implementing the wound prevention strategy. The chief nurse and the head of the room play the role as a nursing manager should perform its function and then maintain its achievement with various strategies. Method. The pilot study method optimized the function of nursing manager with situation analysis strength weakness opportunity threat (SWOT), followed by fishbone diagram, plan of action (POA), implementation, evaluation and gap analysis with literature review. The result. The result of the implementation is the formation of a champion team; Draft guidance and consolidation; preparing the draft of clinical pathway flow of prevention activities; revising standard operating procedures (SPO); revising medical record (RM); brainstorming ideas for the pressure ulcer prevention, and initiation of research. The results of the consolidation of the champion team stated that the guidelines facilitated the prevention effort. Brainstorming increased 23.8% of nurse knowledge. Conclusison. It is recommended that managers perform managerial functions with new strategies, strong commitment and adhere to their implementation. Keywords: quality indicators, pressure ulcers, nurse managers, strategies 157

Workshop Methode Krabby Patty, Make Quality Implementation and Safety Patients are Beautiful in 2018 Susilowati, Didin Syaefudin, Desnita Fitri Abstract Objectives : The achievement of handover compliance and work culture based on patient safety principles through the implementation of a Krabby Patty workshop for nursing staff at the Gatot Soebroto Army Central Hospital Methods :This research is a type of action research that is an approach to improve the implementation of a program by making a change (intervention) and learning from experience in the changes made using quantitative methods. This type of research is a study that uses a quasi- experimental approach with a one-group pre-test-post test design (without a control group). This study sought answers to the extent to which the Krabby Patty-style workshop had an effect on knowledge, attitudes, motivation, leadership roles and monitoring to improve compliance with the implementation of nursing hand over at the Gatot Soebroto Army Central Hospital. The preparatory activities carried out for the Krabby Patty workshop and this research are like preparing to make a phenomenal Krabby Patty in the SpongeBob SquarePants series. Results : The material for this workshop is Patient Safety Goals using a krabby patty workshop method conducted in 2 waves, 5 and 6 July 2018. In the Auditorium, dr. Partomo Gatot Soebroto Gatot Soebroto Army Central Hospital. Starting at 7:30 a.m. 12.00 The varied workshop methods are lectures, discussions, simulations, video screenings, field practice and assessment / evaluation of hand over data as the implementation of patient safety targets using data for semester II of 2018. The population in this study is all nursing staff working at the Central Hospital The Gatot Soebroto Army as many as 1224 people. Because of limited time and energy, sampling is done by cluster random sampling. The number of samples taken for wave I and 143 people for wave II, using the formula from Joint Commission International (JCI). Krabby petty workshops significantly influence the increase of knowledge, attitudes, motivation, leadership roles and monitoring of hand over compliance in accordance with patient safety goals. The increase in hand over compliance before hand over and after the workshop was increased by 24.05% where before the workshop the compliance rate was 64% and after the workshop was 88.05%. Increased 158

knowledge, attitudes, motivation, leadership roles and monitoring of the hand over before and after the implementation of the workshop increased by 29%, where before the workshop the level of knowledge, etc. 70% and after the workshop became 89%. Conclusions : The krabby petty workshop significantly influences the increase of knowledge, attitudes, motivation, leadership roles and monitoring of hand over compliance in accordance with patient safety goals.The increase in hand over compliance before and after the workshop was increased by 24.05% where before the workshop the compliance rate was 64% and after the workshop was 88.05%.Increased knowledge, attitudes, motivation, leadership role and monitoring of hand over before and after the implementation of the workshop increased by 29%, where before the workshop the level of knowledge, etc. 70% and after the workshop became 89%. Keywords : Patient Safety, Hand Over, Workshop 159

Disorders Case Analysis of Neurology System Using Approach Roy Adaptation Theory in RSPAD Gatot Soebroto Jakarta Dyah Untari Abstract Nursing according to Mc Mahon states that nursing is a therapy that involves three (3) components of artnership, intimate and reciprocity in every action of nursing. So also must be done by a specialist nurse nurse or advanced nurse. Implementation of nursing residency practices a part of the process to achieve specialist nurse education. The role of nurse specialist in providing nursing care should have seven competencies that is to provide direct services, consultation, leadership, collaboration, education, research and decision makers that put ethics forward. This series of nursing specialist education is managing the main case, compiling 30 reported cases of patients with neurological disorders, performing an Evidence based Nursing (EBN) and innovating with patients with neurological disorders. innovation to make educational videos to increase self-awareness and family against the risk of recurrent stroke. Keywords: Meningitis Infections, Dysphagia Adaptation Models, Swallowing Exercises, Education Video 160

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CHAPTER VI MANAGEMENT & HEALTH LAW 162

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Legal Protection of Hospital Business Actors for Indications of Malpractices Iwan Dermawan Abstract The Law Protection of Hospital business Actors is based on Medical Malpractices, the purpose of the research are 1. To know and analyze legal protection of hospital business actors to the claims for compensation submit for indication of malpractice 2. To find out the legal reasons that lead to a doctor or health worker error in the case of malpractice as a consideration for the element of error . The research uses a juridical- sociological approach and it is a descriptive research describing clearly various things related to studied object, namely, various causes of dispute between hospital business actors, doctors and patient, legal protection of hospital business actors from perspective of balance of doctor and patient. Result of the research were: (1) In the context of vicarious liability, the accountability of hospital workers is diverted to hospital owners. The transfer of this responsibility considers the mistakes of each party for the violation of the individual rights of patients born from informed consent. (2) the medical dispute were cause especially is not primarily due to the passage of the rights and obligations between hospital business actors, doctors and patients in a legal relationship happens, and then it causes dissatisfaction in part of patient; (3) Dispute settlement between hospital business acto, doctor and patient was conducted through litigation and non litigation ways;(4) Legal protection for hospital business actors and doctor consists of therapeutic aspect and business contract. Keywords: Relationship between doctor and patient, dispute, legal protection, vicarious liability 164

The Factors That Affect Performance of Clinical Case Manager in The Implementation The Standard Assessment of Patients at The IRNA RSPAD Gatot Soebroto Desnita Fitri Abstract This research purpose is to know the influence and variable quantities of knowledge, attitude, motivation, and leadership roles in generating the performance of nursing case manager which is expected to be beneficial to strategize the development of case manager at RSPAD Gatot Soebroto Ditkesad. The research using the analytic correlative method. Research samples totaling 50 people using total sampling technique. The research was carried out in may 2015. The data were analyzed by regression linier analysis and logistic regression analysis using software statistical product and service solutions(SPSS), bivariate analysis on knowledge and leadership role become a factor that affects in clinic case manager performance (P = 0,000, CI 16,292, r= 0,638 and P = 0,025, CI 3,750, r = 0,416). Knowledge is the biggest factor that affects the performance of case manager (P = 0,000, OR 16,357). These factors needs attention from hospital management by remaining attentive to other factors so that the nursing case manager is able to improve its performance Keywords: Case Manager,Performance, knowledge, attitude, motivation, leadership roles 165

The Experience of Elderly Living in Elderly Residental House (PSTW) A Phenomenology Study Septirina Rahayu Abstract Elderly people are vulnerable to the decline in the functional ability. The need to adjust their current life and change of residence, well as the loss of relatives. This situation is very influenced by their prior life experiences. The aim of this study was to gain an overview of the experience of the elderly living in elderly residental home (Panti Sosial Tresna Werdha/PSTW). The study used qualitative method with descriptive phenomenology approach. Participants in this study consisted of six elderly people who live in the institutions. Data were collected through in deph interviews in accordance with the purpose of research, and analysis of data from interviews using the analysis stage by Collaizi. Three themes emerged from this study namely independent liiving needs and support systems as a reason for staying at PSTW, adaptive response of life in PSTW, and family support as a contributing factor to remain at PSTW. To improve the quality of life of elderly people who live in institutions , officials seek to provide good service in caring for the elderly. Keywords : Elderly, Elderly nursing, life of old age 166

Patients Safety Round, Extremely Bullets, General (A Study on The Analysis of The Influence of Patient Safety Culture, Leadership Style, Teamwork Through Patient Safety Rounds to Increase Reporting of Patient Safety Incidents at The Army Central Hospital In 2019) A.Budi Sulistya, Abraham Arimuko, Susilowati Abstract Objectives : The achievement of compliance with reporting of patient safety incidents through the implementation of patient safety rounds by Hospital Management in all Army Central Hospital service units so that a work culture based on patient safety principles can be realized. Methods : This research is a type of action research that is an approach to improve the implementation of a program by making a change (intervention) and learning from experience in the changes made. using quantitative methods. This type of research is a study that uses a quasi- experimental approach with a one-group pre-test-post test design (without a control group). The round has been held since January 4, 2019 until 31 July 2019. The time for evaluating / evaluating patient safety round data is the second trimester of 2019. With a total sample of 140 respondents, using the formula from Joint Commission International (JCI). Results : The results of the simultaneous study of these four variables namely transformational leadership style, feedback on events, non-punitive responses, commitment to goals and conflict handling significantly influence knowledge, attitudes, motivation, leadership roles and monitoring with a percentage increase of 29%, where personnel state they want reported patient safety incidents and proven patient safety incident incidents increased by 24.05%. Efforts to continue to improve and maintain a patient safety culture by implementing compliance with patient safety incident reporting, by providing and strengthening policies, guidelines, guidelines and Operational Procedure Standards on reporting patient safety incidents to support the formation of positive individual attitudes in reporting incidents so that the hospital knows the shortcomings on a running system to get improvement efforts Conclusions : The increase in compliance with reporting of patient safety incidents before and after the patient safety round was increased by 24.05% where before the round of compliance the rate of 64% and after the implementation of the round to 88.05%. Increased knowledge, attitudes, motivation, leadership roles and monitoring of reporting of patient safety 167

incidents before and after the implementation of the patient safety round increased by 29%, where before the round of knowledge levels, etc. 70% and after the round to 89%. Keywords : Patient Safety, Incident, Round 168

Small, Beautiful But Great Impact (A Study of The Effectiveness and Efficiency of Accreditation Exhibition Activities in The Implementation of International Accreditation Standards at The Central Army Hospital in 2016) Susilowati Abstract Objectives : The achievement of the implementation of JCI international accreditation standards in all service units of the Gatot Soebroto Army Central Hospital through the Accreditation Exhibition method Methods : This research is a non-experimental (observational) survey survey, using descriptive analytic methods to determine the effectiveness and efficiency of the JCI Accreditation Implementation Exhibition at the Gatot Soebroto Army Central Hospital in 2016. Results : The exhibition of JCI international accreditation implementation significantly increased employee knowledge, attitudes and motivations before and after the exhibition of JCI accreditation implementation with an average increase of 45% -65%. The description of the work behavior of personnel in accordance with the implementation of JCI accreditation increased between assessments before and after the exhibition of the implementation of JCI accreditation with an average increase of 13% to 69%. The exhibition of JCI accreditation implementation by analytical descriptive analysis has a significant influence in improving aspects of personnel work behavior, namely knowledge, attitudes, motivation, leadership roles and monitoring. Conclusions : Increasing the value of aspects of work behavior of personnel before and after the exhibition of JCI accreditation implementation can be assessed as successful, where the aspects of work behavior that support health service activities are supported from the driving factors namely knowledge, attitudes and motivations, enabling factors namely the role of leadership and the reinforcing factors namely monitoring. If the factors forming these aspects of good behavior, then the resulting work behavior will be good too. Therefore activities that can improve aspects of good work behavior should be recommended to be continued in order to improve the quality of human resources in particular and the quality of hospital services in general. Keywords : Accreditation, Exhibition, Work Behavior 169

Relationship Analysis of Patient Satisfaction on Quality of Health Services to Interest In Re-Use of Inpatient Services at The Gatot Soebroto Army Central Hospital In 2015 Ponco Agus Prasojo, Susilowati Abstract Objectives : This study aims to examine the analysis of the relationship of patient satisfaction about the quality of health services to the interest in re- use in the Inpatient Installation of Gatot Soebroto Hospital in 2015, which is expected to be useful for input for Gatot Soebroto Central Army Hospital about the description of the results of evaluation of patient satisfaction with the quality of inpatient services. Methods : This study uses a correlative analytic method. The research sample of 100 respondents, using a sampling method with the formula Taro Yamane. The study was conducted in May 2015. Data were analyzed by Chi Square test and logistic regression analysis using SPSS. Results : In the bivariate analysis, the variable of patient satisfaction with the quality of doctor's services and patient satisfaction with the quality of nursing services has a significant relationship as evidenced by the p value <0.05. In a multivariate analysis, the most influential sequentially on the interest in reusing health services was patient satisfaction with the quality of nursing services (0.301), patient satisfaction with the quality of doctor's services (0.054). Both of these factors need to get attention from the Hospital Management while continuing to pay attention to other factors so that Health Workers are able to improve their performance and quality into a work culture at the hospital. Conclusions : The results of the analysis of respondents' satisfaction about the quality of nurse services showed the number of respondents who stated the quality of nurse services as good as 75 people (75.0%) while respondents who stated the quality of nurse services as poor as 25 people (25.0%). The most influential variable on reuse interest is the independent variable patient satisfaction about the quality of nurse services can be seen from the value of Nagelkerke R2 (Imam, 2009), which shows a result of 0.301, which means the influence of patient satisfaction variables about the quality of nurse services on the interest in re-use of nursing services inpatient is 30.1% or in other words variable variability Interest in re-use of inpatient services that can be explained by the patient satisfaction variable 170

about the quality of nurse care is 30.1%, while 69.9% can be explained by other variables. Keywords: Patient Satisfaction, Health Service Quality, Reuse Interest 171