AMINO PCC AMSC 2021: United Kingdom Volume 2 by AMSA-Indonesia

AMINO AMSA-Indonesia Competition Archive

Pre-Conference Competition AMSC: United Kingdom 2021

All the works publicized here are the works of AMSA-Indonesia’s member who participated in Pre-Conference Competition AMSC: United Kingdom 2021

AMINO | PCC AMSC: United Kingdom 2021

FOREWORD

Steven Millenio Widjaja

Secretary of Academic AMSA-Indonesia 2020/2021

The AMSA-Indonesia Competition Archive or AMINO for short is a program by AMSA-Indonesia to facilitate all members to get inspiration on how to make a scientific masterpiece. AMINO acts as an archive where all the works submitted by participants in competitions in AMSA, including Pre-Conference Competition East Asian Medical Students’ Conference (PCC EAMSC), Indonesia Medical Students’ Training and Competition (IMSTC), Pre-Conference Competition Asian Medical Students’ Conference (PCC AMSC) and from AMSA International Competitions, are published. In this series of AMINO, all the scientific masterpieces of AMSA-Indonesia in Pre-Conference Competition Asian Medical Students’ Conference have been compiled, which consists of the following categories: Scientific Paper, Scientific Poster, and White paper & Video. We hope that through this volume of AMINO, we are able to further motivate and inspire our members to construct more scientific masterpieces. On behalf of AMSA-Indonesia, I would like to extend my deepest gratitude to personal to all the participants of the PCC AMSC, the Academic Team of AMSA-Indonesia, the Executive Board of AMSA-Indonesia 2020/2021, and other parties that have contributed to the creation of AMINO. Without each and every single contribution, AMINO would not have been possible. May the release of AMINO increase the academic enthusiasm and ignite the potentials of AMSA-Indonesia members. “Igniting Potentials, Unleashing Possibilities” Viva AMSA!

AMINO | PCC AMSC: United Kingdom 2021 PCC AMSC: United Kingdom 2021 Scientific Poster • First Winner Performance of Glial Fibrillary Acidic Protein as A Biomarker for Mild Traumatic Brain Injury Among Children: A Systematic Review and Meta-Analysis of Cohort Studies

• Second Winner Impact of COVID-19 in Operating Room Management and Timing of Traumatology Patients: A Systematic Review

• Third Winner Efﬁcacy of Novel Extracorporeal Membrane Oxygenation Utilization in Trauma Patients: A Systematic Review

• PCC District Winner ■ Effectiveness of Telerehabilitation as Potential Remote Restoration After Hip and Knee Fracture or Arthroplasty During Pandemic Situation: A Systematic Review and Meta-Analysis of Randomised Controlled Trials ■ The Efﬁcacy of Preoperative Interventions Measures on Reducing the Risk of Postoperative Delirium (POD) in Elderly Patient after Hip Fracture Surgery: A Systematic Review of Randomized Controlled Trials ■ Thoracic Endovascular Aortic Repair (TEVAR) Reduces Mortality Rate in Blunt Thoracic Aortic Injury (BTAI) Patients: A Systematic Review • Entries ■ Collection of Retrospective Studies on The Effect of Nonpenetrating Wounds Trauma affecting the Maternal and Fetal mortality in Pregnant Women: A Systematic Review ■ Virtual Reality Exposure Therapy for Post-Traumatic Syndrome Disorder Diagnosed Patients: A Systematic Review ■ Mannitol Versus Hypertonic Saline Effect on ΔICP and Duration of ICU Stay in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis ■ Shoulder Dislocation Incidence and Society’s Health Seeking Behavior in Indonesia: Driving Factors to the Mindset About Treatment

20 22 24

AMINO | PCC AMSC: United Kingdom 2021 ■ A Systematic Review of Comparative Experiments Between Robot Assisted Gait Training Versus Overground Gait Training as A Potential Of Rehabilitation In Spinal Cord Injured Patient ■ Comparing Trauma and Injury Severity Score, New Injury Severity Score, and Revised Trauma Score for Trauma Mortality Prediction: A Meta-Analysis ■ The Potential of Biodegradable Magnesium Screw as an Alternative Implant for Internal Fixation in Orthopaedic Trauma: A Systematic Review ■ Emergency Box as A Solution to Reduce Early Death Caused by Trauma from Trafﬁc Accidents on Highways ■ Serum Biomarkers as Diagnostic and Prognostic Tools in Patients with Traumatic Spinal Cord Injury: a Systematic Review ■ Effect Of Mandatory Motorcycle Helmet Laws for All-Ages Vs Underages In The Prevention Of Traumatic Brain Injury: A Systematic Review ■ A Review of Quality of Life in Elderly Patient with Hip Fracture Following Post-Operative Treatment and Rehabilitation ■ Comparing The Effect Of Erythropoietin And Atorvastatin For Traumatic Brain Injury: A Systematic Review ■ Role of Mobile Application for First Aid in Indonesia ■ Efﬁcacy of Therapeutic Hypothermia on Intracranial Pressure or Cerebral Perfusion Pressure in Pediatric Patients with Severe Traumatic Brain Injury: A Systematic Review ■ The Use of Tissue Plasminogen Activator as Frostbite Treatment

28 30 32 34 36 39 44 47 49 52

AMINO | PCC AMSC: United Kingdom 2021 White Paper and Videography • First Winner Improving Emergency Medical System using Machine Learning (ML) through E-mergency to Overcome Trauma Care Problems in Indonesia

• Second Winner An Innovation Dealing with The Lack of First Aid Readiness Among Nonmedical Citizens To Improve Emergency Medical Services

• Third Winner M-PUTEE: A Mental Health-Based Application as A Promising Solution to Boost Psychological Resilience of Post Limb Amputation Patients In Indonesia

• PCC District Winner EFAST “Emergency Fracture Automated System and Tools” As A Solution For Accurate Prehospital Treatment Of Road Trafﬁc Injuries

• Entries ■ The Use of Wii Video Game to Enhance Rehabilitation Outcome of Pediatric Burn Injury Patients in Indonesia ■ First Aid Management With G-Alert for Online Taxibike Drivers As First Responders To Road Trafﬁc Injuries

101 111

SCIENTIFI

IC POSTER

TESTIMONY

AMINO | PCC AMSC: United Kingdom 2021

Muhammad Kevin Ardian AMSA-Universitas Indonesia 1st Winner of Scientific Poster Category PCC AMSC is a wonderful competition to join. This is a prestigious competition held annually by AMSA-Indonesia to find the best submission to represent Indonesia in the Asian Medical Students’ Conference. Moreover, PCC AMSC is well-known among AMSA-Indonesia members. By joining the competition, we will represent our home university so it will give a pride moment for those who participate. Like every competition in AMSA, I recommend you to observe the announcement carefully at the start of a new tenure about PCC AMSC because this event’s submission deadline will change according to the situation of COVID-19 pandemic. In that way, you can prepare yourself better. AMSA-Indonesia also gives a great opportunity to the members by publishing AMINO. Make sure you see and read it to know the details about the structure of some works made by AMSA-Indonesia members. Making a scientific poster, scientific paper, and other branches needs team work. This competition also needs you to make a good timeline with your team such as making decisions about your topic, the reference, and your work. The more you try in a competition the more you get used to it. If you are afraid to start, place in your mind the regret you will get in the end. So, start now and don’t regret it later!

AMINO | PCC AMSC: United Kingdom 2021

Anita Dominique Subali AMSA-Universitas Brawijaya 2nd Winner of Scientific Poster Category PCC challenges medical students to produce scientific works regularly. It is an opportunity for us to keep learning and become a young researcher. Always coming up with different yet fresh topics, this competition demands us to think out of the box. We need to catch up with the latest update, understand the current problems and needs, and explore potential solutions. Besides equipped with sufficient prior knowledge, gaining awareness and curiosity, taking advice from lecturers and seniors are essential to find our topic. Don’t limit ourselves as there is no too stupid idea (but remember to check the guidelines too!). Also, previous masterpieces from the AMINO can help us to find additional insights. Although deadline is the best pressure to accelerate the process, last minute attempt is not recommended to submit our masterpiece. Keeping up with tight academic schedules while working on our paper can be challenging. We managed our best and thank God, we made it. Joining PCC AMSC will definitely boost your scientific skill. Don’t be afraid, just do it. I believe you can. Make this event as your chance to learn, improve yourself, and give your best shot. It may not be easy at first but it’s gonna be worth it.

AMINO | PCC AMSC: United Kingdom 2021

Derren David C. H. Rampengan AMSA-Universitas Sam Ratulangi 3rd Winner of Scientific Poster Category Being a first-year medical student, I believe it is important for me to gain as much experience as I can. That's why I decided to join AMSA. I want to excel not only in academics but also in organizational and social fields as well. I took part in this competition because I want to challenge myself and gain more experience. I’m grateful for the opportunity given to me and also for my seniors and team partner who helped me. Without them none of this would've been possible. To be honest this is my first competition and I didn't expect to win. However, I'm very humbled by this achievement and I hope that in the future I'll be able to represent Indonesia internationally. I think hard work and teamwork are the key because without a good communication with your teammate you'd lose, no one can work alone. You have to be able to rely on your team and your team to rely on you. I've learned a lot during this competition and I hope that i'd be able to keep learning moving forward to be an impactful person. VIVA AMSA

MASTERPIECE

Performance of Glial Fibrillary Acidic Protein as A Biomarker for Mild Traumatic Brain Injury Among Children: A Systematic Review and Meta-Analysis of Cohort Studies Ade Gautama, Gideon Hot Partogi Sinaga, Muhammad Kevin Ardian AMSA-Universitas Indonesia Abstract

Introduction: Around the world, 69 million people suffer from traumatic brain injury. TBI is one of the most common head injuries in children, occurring in over 837,000 children. TBI is caused by a bump, blow, or jolt to the head that disrupts the normal function of the brain. CT scan was the gold standard diagnostic tool for detecting TBI. Unfortunately, this modality has a negative impact on children, especially the radiation exposure. Therefore, we would like to analyse the alternative diagnostic tool, glial fibrillary acidic protein (GFAP), as a new biomarker for mTBI diagnosis. Objectives: To explore the utility of GFAP in mTBI detection by analyzing the serum level of the biomarker post-injury and evaluating the sensitivity and specificity when used as a diagnostic tool Materials and Methods: We searched literature from PubMed, Scopus, ScienceDirect, EBSCOHost, and ProQuest then found 3145 literatures. We found four full-text articles that match with our inclusion and exclusion criteria. Those journals are included for quantitative analysis. Further, we assess the quality of studies with the STROBE checklist for cohorts. Results and Discussion: We analysed from several journals and found that GFAP serum level significantly higher in children with mild traumatic brain injury (mTBI) compared with control (p<0.0001). Nevertheless, those journals are considerable heterogeneity studies. Moreover, we also discover that GFAP has high sensitivity but low specificity in detecting mTBI among children. Conclusion: From our systematic review and meta-analysis, we conclude that there is a significant difference of GFAP serum level in children with mild traumatic brain injury versus control. However, further research across the world with large samples are needed to be conducted to discover this novel biomarker for diagnosis of mTBI among children. Key Findings: mild traumatic brain injury, concussion, children, glial fibrillary acidic protein

Impact of COVID-19 in Operating Room Management and Timing of Traumatology Patients: A Systematic Review Anita Dominique Subali, Bernadine Tiara, Triana Amelia L., Revina Maharani ABSTRACT Introduction: The current worldwide COVID-19 pandemic threatens to overwhelm the healthcare system and thus impact the ability to care for critically trauma injured patients and other surgical emergencies. With the massive reduction in operational capacities and the reallocation of personnel also the duration of the operation itself, elective and non-urgent surgeries are postponed or canceled. A large number of Covid-19 patients increase infection of health care providers in performing orthopedic surgery on trauma patients. Therefore, adjustment on theatre setting and timing is important to perform a safe surgery both for the surgeons and the patient. This review aims to assess the current methods to perform safe trauma surgeries during the Covid-19 pandemic as well as evaluating the impact of Covid19 in surgery duration. Method: A systematic review was conducted based on PRISMA guidelines and performed through databases, such as Pubmed, Science Direct, Cochrane, Proquest, SpringerLink, and Wiley. Original research articles which assessed the operating room requirements or surgery timing in orthopedic trauma patients in the Covid-19 setting are considered to be eligible. Result & Discussion: 6 cohort and pilot studies are included and divided into surgery setting and timing analysis. Compared to 2019, total trauma surgical procedures are declining during the Covid-19 outbreak. The study summarized several important recommendations, such as patient prior screening, OR separation of Covid positive and suspected patients, patient preparation, use of negative pressure OR with adequate air exchange, avoidance of general anesthesia and aerosol producing procedure, PPE enhancement, and reduction of staff numbers in surgery. The pandemic has affected the surgical timing of OR orthopaedic and trauma surgeries. Compared to the prior pandemic in 2019, anesthetic time, in general, has decreased and surgical time, in general, has increased mainly due to help lower aerosol productions by reducing time in giving anesthetics and develop more carefulness in commencing surgery procedures. Conclusion: Transformation of trauma surgical practices, such as surgery theatre setting and timing, are essential to perform a safe procedure in the current pandemic. Re-evaluation on surgical indications, patient screening, PPE enhancement, modification of both operating rooms, and duration can provide optimal patient care with personal safety.

Key Findings: orthopaedic surgery, orthopaedic trauma, operating room, time, COVID-19

Efficacy of Novel Extracorporeal Membrane Oxygenation Utilization in Trauma Patients: A Systematic Review Derren David C. H. Rampengan, Natalie Gabriela Edravenia Tombokan, Yorghi Liesapali, Nikita Pratama Toding Labi AMSA-Universitas Sam Ratulangi

Introduction: The development of extracorporeal membrane oxygenation (ECMO) has advanced significantly and has been used in critical trauma cases. However, the utilization of ECMO within the presence of severe acute trauma still remains an unclear indication and the clinical results vary. Therefore, we conducted a systematic review to describe the reported evidence use of ECMO in trauma patients. Objective: To investigate the efficacy of ECMO utilization in trauma patients. Methods: A systematic literature search was conducted in PubMed, PubMed Central, and ScienceDirect database based on PRISMA statement guideline to identify the efficacy of novel extracorporeal membrane oxygenation utilization in trauma patients in several retrospective studies. We found ten studies that matches our inclusion and exclusion criteria. Those studies are included in our qualitative synthesis. Results: From 10 retrospective studies with 419 participants, the age range was <1-86 years. 87% of participants that used ECMO were adults, the rest were pediatric patients. The injury severity score (ISS) ranged from 18 to 75, and the most common cause of trauma is traffic accident. Veno-venous (VV) ECMO with peripheral cannulation is the most prevalent ECMO mode. Initiation and duration of ECMO are varied among studies. Most of the studies found no correlation between the time to start ECMO and mortality. There are some variations of methods of anticoagulation in each study from full heparin systemic anticoagulation to heparin-free ECMO. The overall mortality rate ranged from 16.7% to 72.2%. Conclusion: The existing reports show that ECMO could be an option for the most critical patients who fail from conventional therapies. However, there are many issues related to ECMO utilization in trauma patients, further research into the safety and efficacy of ECMO in trauma patients is required. A large-scale trauma ECMO registry or clinical trial in the future will give much evidence of the ECMO utilization in trauma patients. Key Findings: Extracorporeal Membrane Oxygenation, ECMO, trauma

Table 2. Characteristics of studies

INTRODUCTION

YEAR OF AUTHOR, YEAR

STUDY TYPE

One of the most common causes of death among adults in the world is trauma. Hemorrhagic shock, cardiopulmonary dysfunction, and severe brain damage are the main causes of early death in trauma patients. There are multiple ways to

SAMPLE SIZE

GENDER(M/F)

PUBLICATION/STUDY

AGE IN YEARS (MEDIAN,RANGE)

Lang NW et al., 20191

Retrospective study

2019 (2002-2016)

11/7

29.5 (1-64)

Fenton SJ et al., 20192

Retrospective study

2019 (2009-2016)

4/2

4.8 (3-8)

Wu MY et al., 20183

Retrospective study

2018 (2006-2014)

31/5

28.5 (24-43)

Grant AA et al., 2018

Retrospective study

2018 (2014-2017)

22 (7 Pre-AEP, 15 Post-AEP)

Pre-AEP: (6/1); Post-AEP (13/2)

Pre-AEP: 30; Post-AEP: 36.5

Ahmad SB et al., 20175

Retrospective study

2017 (2006-2015)

29/10

28 (22-45)

Retrospective study

2017 (2012-2014)

68/12

26.5 (19-41)

Retrospective study

2017 (2008-2014)

44/5

50 (16-86)

Watson JA et al., 2016

Retrospective study

2017 (2007-2011)

144 (36 ECLS, 108 Non-ECLS)

29/7 (ECLS group)

12 (<1-18) (ECLS group)

Chen TH et al., 20169

Retrospective study

2016 (2009-2012)

6/1

31 (21-49)

Retrospective study

2013 (2008-2012)

12/6

46 (15-69)

reduce mortality in trauma patients and one of them is extracorporeal membrane oxygenation (ECMO). ECMO device has developed significantly in the past decades, and it can be a salvage therapy to aid recovery for trauma patients who are in advanced shock and respiratory failure. However, the utilization of ECMO within the presence of severe acute trauma still remains an unclear indication and the clinical results vary. Therefore, we conducted a systematic review to describe the reported evidence use of ECMO in trauma patients and its related outcomes.

Burke CR et al., 2016

OBJECTIVE

Ull C et al., 20167 8

To investigate the efficacy of ECMO utilization in trauma patients.

MATERIALS AND METHODS

Bonacchi M et al., 2013

Abbreviation: AEP: Advanced ECMO Program; ISS: Injury Severity Score; ECLS: Extracorporeal Life Support; GCS: Glasgow Coma Score

•

INCLUSION

EXCLUSION

CRITERIA

Retrospective studies (cohort/ case studies)

•

Reported age, gender, or cause of trauma and cause of death

Keywords: “Extracorporeal Membrane Oxygenation” OR “ECMO” AND “Trauma”

AUTHOR, YEAR

Systematic Review in line with PRISMA statement

•

Expert opinion, review paper

•

Non-trauma patients

•

Non-English literature and irretrievable

Table 3. Outcome of studies

Lang NW et al., 2019

CAUSES OF TRAUMA

GCS

HOSPITAL MORTALITY

Traffic accident 10, falling 4, stab 2, other 2

34.5 (16–50)

6.6 ± 4.8(3–15)

12 (66.6%)

MOF, sepsis, hypoxic cerebral edema

Traffic accident 5, crush injury 1

36 (27–40)

1 (16.7%)

Large right-sided ischemic cerebrovascular

Wu MY et al., 20183

Traffic accident 24, falling 5, burn 3, stab 1, electrocu-

29 (19–45)

15 (41.7%)

Pre-AEP: 30

22 (56%)

Cardiorespiratory arrest 10, brain death 1 died

Collecting studies from PubMed, PubMed Central, ScienceDirect

CAUSE OF DEATH

Fenton SJ et al., 20192

accident

tion 1, near-drowning 1, compressing injury 1

Inclusion and exclusion criteria screening Grant AA et al., 20184

full text

Gunshot wound 4, assault 1, traffic accident 7, burn 3, falling 3, stab wound 1

Post-AEP: 34

Quality assessment using Newcastle-Ottawa Scale Ahmad SB et al., 20175 Figure 1. Conceptual Framework

IDENTIFICATION

ISS

Burke CR et al., 2016

Records identified through database searching (n= 1375)

Traffic accident 26, falling 3, gunshot 6, stab 1,

Survivors 25 (18–32)

impalement 1, near-drowning 1, crush injury 1

Non-survivors 41 (26–50)

Penetrating trauma 9, blunt trauma 66, other

25 (16.5–33)

3 (3–14)

29 (36%)

after withdrawal of care 11

mechanism 5

PubMed (n= 14) PubMed Central (n= 798)

Ull C et al., 20167

32 (4–66)

17 (34.7%)

Watson JA et al., 20168

Motor vehicle collision 16, gunshot wound 6, burn 6,

≥25

15 (41.7%)

Irreversible brain damage with vasodilatory shock;

drowning 4, suffocation 1, poisoning 2, other 1

ScienceDirect (n= 923) Chen TH et al., 20169

Traffic Accident 5, falling 2

36 (27–57)

3 (43.8%)

Bonacchi M et al., 201310

Traffic accident 15, falling 2, crash 1

53 ± 17 (18–75)

13 (72.2%)

septic shock with MOF

SCREENING

Document excluded on the basis of duplication (n= 243)

Records screened based on title and abstract (n= 1132)

ECMO failure 4, septic MOF 2, cerebral death 7

Abbreviation: AEP: Advanced ECMO Program (ECMO program by multidisciplinary team); ISS: Injury Severity Score; ECLS: Extracorporeal Life Support; GCS: Glasgow Coma Score; MOF:

ECMO Strategies in Trauma Patients (Mode, Initiation, Duration, Anticoagulation, Team) Document excluded on the basis of inclusion and exclusion (n= 1078)

ELIGIBILITY

Full text articles assessed for eligibility (n= 54)

INCLUDED

The most prevalent ECMO mode in trauma is veno-venous (VV) ECMO with peripheral cannulation. Only a few studies have looked at the impact of

Studies included in qualitative synthesis (n=10)

veno-arterial (VA) ECMO in trauma patients. VA ECMO was used in the study by Lang et al. 1, 11 patients died from 15 cases. A recent study 3 that used ECMO to treat patients with refractory shock found that VV and VA ECMO had different mortality rates (27.3% for VV, 64.3% for VA). Patients who needed VA ECMO probably had a lower survival rate because of the shock severity. More research into the safety and efficacy of VA ECMO in critical Document excluded on the basis of lack essential data (n= 44)

trauma population is still required. Initiation and duration of ECMO are varied among studies. Most of the studies found no correlation between the time to start ECMO and mortality.5,6,9 Due to systemic anticoagulation, ECMO initiation, particularly in patients with intracranial or active systemic bleeding, can increase bleeding risk in the early stages of trauma. However, early ECMO initiation can provide benefits such as reducing ventilator time to avoid iatrogenic lung damage from

Figure 2. Search Method

high-pressure and high FiO2 ventilation, providing lung and heart rest, also providing sufficient tissue oxygenation and perfusion. The studies are underpowered to conclude the correlation between ECMO duration and mortality.

RESULTS AND DISCUSSIONS

For anticoagulation, there are some variations of methods in each study, including full heparin systemic anticoagulation, heparin minimized, and heparin-free technique. The use of anticoagulation is found significantly correlated with mortality in a study by Ahmad et al. 5 Nonetheless, in a study

Table 1. Risk of Bias Assessment (Newcastle-Ottawa Scale)

AUTHOR, YEAR

by Chen et al.9, patients can be successfully treated on heparin-free ECMO without increasing bleeding frequency. Advances in ECMO technology can

SELECTION

COMPARABILITY

EXPOSURE

TOTAL SCORE

Lang NW et al., 2019 1

***

7/9

Fenton SJ et al., 2019 2

6/9

Wu MY et al., 2018

***

7/9

Grant AA et al., 20184

***

7/9

Ahmad SB et al., 2017 5

***

7/9

Burke CR et al., 2016 6

***

7/9

Ull C et al., 2016

***

6/9

Watson JA et al.,20168

6/9

Chen TH et al., 20169

***

6/9

Bonacchi M et al., 201310

***

6/9

support these patients, using more effective centrifugal pumps, membrane oxygenators, and heparin-bonded circuitry, for example. The severity of the trauma, active bleeding, and the timing of ECMO should be addressed when administering anticoagulation. Finally, the multidisciplinary team conducting ECMO program was proven to correlate with excellent outcomes (shorter hospital/ICU length of stay, shorter ventilator, and ECMO days).4 Since the majority of the population in this study was young and had a good cardiopulmonary function at baseline, the cause should consider both the overall injury and ECMO-related injuries.

Complication Common complication is bleeding from different sites, the most common is surgical and cannula site bleeding, the other were diffused bleeding, intracranial, intrabdominal, and intrathoracic bleeding. Deep venous thrombosis, pulmonary embolism, and circuit clotting were among thrombotic

Lower total score means higher risk of bias.

References

complications. Ischemia of the lower extremity, acute lung edema, abdominal compartment syndrome, brain swelling, and pseudoaneurysm formed

on the site of cannula were among the other ECMO-related complications. Limitation and Recommendation Overall, low negligible heterogeneity has been shown. Including the publications that are retrospective studies or case series with minimal data, lack of evidence, and unclear risk of bias. Large-scale trauma ECMO registry or clinical trial may be conducted to determine the safety and efficacy of ECMO utilization in trauma patients.

1. Lang NW, Schwihla I, Weihs V, Kasparek M, Joestl J, Hadju S, et al. Survival rate and Outcome of extracorporeal life support (ECLS) for treatment of acute cardiorespiratory failure in trauma patients. Scientific Reports. 2019;9:12902. doi: 10.1038/s41598-019-49346-z

2. Fenton SJ, Hunt MM, Ropski PS, Scaife ER, Russell KW. Use of ECMO support in pediatric patients with severe thoracic trauma. Journal of Pediatric Surgery. 2019;54(11):2358-2362. doi: 10.1016/j.jpedsurg.2019.02.018

3. Wu MY, Chou PL, Wu TI, Lin PJ. Predictors of hospital mortality in adult trauma patients receiving extracorporeal membrane oxygenation for advanced life support: a retrospective cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2018;26(14):1-12. doi: 10.1186/s13049-018-0481-6

CONCLUSION

4. Grant AA, Hart VJ, Lineen EB, Lai C, Ginzburg E, Houghton D, et al. The Impact of an Advanced ECMO Program on Traumaticall y Injured Patients. Journal of Artificial Organs. 2018;42(11):1043-1051. doi: 10.1111/aor.13152

5. Ahmad SB, Menaker J, Kufera J, O’Connor J, Scalea TM, Stein DM. Extracorporeal membrane oxygenation after traumatic injury. Journal of Trauma and Acute Care Surgery. 2017;82(3):587-591. doi: 10.1097/ta.0000000000001352

6. Burke CR, Crown A, Chan T, McMullan DM. Extracorporeal life support is safe in trauma patients. International Journal of t he Care of the Injured. 2016;48(1):121-126. doi: 10.1016/j.injury.2016.11.008

7. Ull C, Schildhauer TA, Strauch JT, Swol J. Outcome measures of extracorporeal life support (ECLS) in trauma patients versus patients without trauma: a 7-year single-center retrospective cohort study. Journal of Artificial Organs. 2016;20:117-124. doi: 10.1007/s10047-016-0938-1

Despite the lack of evidence on ECMO in trauma patients, the existing reports show that ECMO could be an option for the most critical patients who fail from conventional therapies. The benefits and efficacy of ECMO used in trauma patients are becoming generally recognized. Consideration ought to be developed for the growth of ECMO utilization in trauma patients at trauma centers with ECMO capabilities. However, there are many issues

8. Watson JA, Englum BR, Kim J, Adibe OO, Rice HE, Shapiro ML, et al. Extracorporeal life support use in pediatric trauma: a review of the National Trauma Data Bank. Journal of Pediatric Surgery. 2016;52(1):136-139. doi: 10.1016/j.jpedsurg.2016.10.042

9. Chen TH, Shih JYM, Shih JJM. Early Percutaneous Heparin-Free Veno-Venous Extra Corporeal Life Support (ECLS) is a Safe and Effective Means of Salvaging Hypoxemic Patients with Complicated Chest Trauma. Acta Cardiological Sinica. 2016;32:96-102. doi: 10.6515/acs20150302b

10. Bonacchi M, Spina R, Torracchi L, Harmelin G, Sani G, Peris A. Extracorporeal life support in patients with severe trauma : An advanced treatment strategy for refractory clinical settings. The Journal of Thoracic and Cardiovascular Surgery. 2013;145(6):1617-1626. doi: 10.1016/j.jtcvs.2012.08.046

related to ECMO utilization in trauma patients, further research into the safety and efficacy of ECMO in trauma patients is required. Large-scale trauma

ECMO registry or clinical trial in the future will give much evidence of the ECMO utilization in trauma patients.

Effectiveness of Telerehabilitation as Potential Remote Restoration After Hip and Knee Fracture or Arthroplasty During Pandemic Situation: A Systematic Review and Meta-Analysis of Randomised Controlled Trials Muhammad Mikail Athif Zhafir Asyura1, Valerie Josephine Diryayanto1, Naufalia Brillianti Sambowo1, Fahrayhansyah Muhammad Faqih1 1

Undergraduate Program Faculty of Medicine, AMSA University of Indonesia *muhammad.mikail91@ui.ac.id

ABSTRACT Introduction: Geriatric populations are particularly vulnerable to knee and hip injuries which cause significant increase fracture prevalence. After surgical treatment, rehabilitation is compulsory in order to gain strength and function, which greatly influences quality of life. In recent years, studies regarding other possible rehabilitation methods that require less effort and time for mobilisation have been done and become distinctively needed especially restrictive conditions within the pandemic. Objective: This systematic review aims to evaluate the effectiveness of telerehabilitation compared to traditional physical rehabilitation on handling hip and knee fracture during COVID-19. Method: A comprehensive research was performed to select Randomized Clinical Trials (RCTs) found through PubMed, Cochrane Central, Science Direct, and EbscoHost. Studies included discussed about patients undergoing telerehabilitation after hip or knee fracture replacement with outcome in physical functionality, muscle strength, and quality of life. Data shown have been arranged based on the PRISMA guideline and assessed using Cochrane ROB 2. Results: Our systematic review and meta-analysis included 6 studies with a total of 517 subjects and intervention ranging from 6 to 12 weeks. We found that telerehabilitation proved to help improve physical functionality and physical strength, decrease pain on the lower extremities, and have better secondary outcome which all correlates to better Quality of Life. Quantitative synthesis showed equal outcomes for telerehabilitation and non-telerehabilitation (I2=95%, p=0.3). Although, this only solidify telerehabilitation as an equally potent alternative to standard face-to-face procedures. Conclusion: In conclusion, telerehabilitation has been sought upon as a potential alternative for palliative care, and has been proven to be an effective intervention by this review. Despite the meta-analysis being insignificant to both groups, this only further supports the possibility of telerehabilitation as an equal alternative to traditional care especially in restrictive conditions such as a pandemic. Keyword: hip fracture, knee fracture, telerehabilitation,

The Efficacy of Preoperative Interventions Measures on Reducing the Risk of Postoperative Delirium (POD) in Elderly Patient after Hip Fracture Surgery: A Systematic Review of Randomized Controlled Trials Khansa Iffa Puti Alya, Salsabila Farradisya, Nanda Ayu Sabrina, Adrian Desmar P R AMSA-Universitas Brawijaya ABSTRACT Introduction : Postoperative management in elderly patients has many risks, and the most common complication is Postoperative Delirium (POD). POD causes psychiatric symptoms, abnormal behaviors and the risk increases with age. POD also increased mortality and morbidity, so it is important to reduce the rate of delirium after hip fracture surgery with non-pharmacological or pharmacological measures. Objectives : To analyze the efficacy and feasibility of preoperative interventions to reduce the risk of POD in elderly patients undergoing hip fracture surgery Methods : A search was applied to PubMed, Cochrane, Science Direct, and Springerlink central database (from 2018 to 2021). All studies showing the reduced incidence of POD after pharmacological interventions, especially pharmacological and anesthesia. The delirium scoring used are MMSE, CCI, Confusion Assessment Method Delirium Score (CAM), ALD, and Neecham. Data were pooled to analyze the efficacy and feasibility of preoperative preventions to reduce the risk of POD. Results : A total of 6 studies were selected, which included 1036 elderly patients (aged 65 and above) with hip fracture and an approach in pharmacology and anesthesia that performed a variation to delirium incidence with another control and have variety in a result of delirium incidence by calculation by various delirium scoring tools. All studies that included have a lower incidence than the totality of incidence which indicates the efficacy of preventive measures of POD after hip fracture surgery in the elderly especially preemptive analgesia with continuous FICB and antiinflammatory drug methylprednisolone.

Conclusion : All the studies indicate the use of pharmacological interventions appears to be essential for achieving further reduction in the incidence and severity of POD in hip fracture surgery in elderly patients. Key Findings : Postoperative Delirium; Hip Fracture Surgery in Elderly

Thoracic Endovascular Aortic Repair (TEVAR) Reduces Mortality Rate in Blunt Thoracic Aortic Injury (BTAI) Patients: A Systematic Review Stevens Wijaya; Ennia Yuniarti Br Bancin; Andi Hanna Shelinda Silva; Yason Nikolaus Liyadi Hasanuddin University, Makassar, South Sulawesi ABSTRACT Introduction: Blunt thoracic aortic injury (BTAI) is a tear in the aorta as a result of a combination of shear and stretch forces, rapid deceleration, increased intravascular pressure and compression of the aorta between the anterior chest wall and vertebrae. Although the incidence of BTAI is less than 1%, this injury is the second leading cause of death in blunt trauma. The most common mechanism of BTAI involves motor vehicle collisions (MVCs). About 81% cases of BTAI are caused by Motor vehicle accidents. Up to 80% of patients presenting with BTAI die before hospitalization, and those who survive often present with multiple associated injuries, including cardiac lesions, rib fractures, hemothoraces, and intra-abdominal injuries(1). In 2014, it was reported that approximately 28,000 fatalities due to accidents on the streets and roadways in Indonesia and the fatality rate from traffic accidents was about 12 per 100,000 population. It is estimated that in 2020, traffic fatality in Indonesia will reach 40,000 per year. This is very high compared to the neighboring countries like Singapore (4.8) and Australia (5.2). These numbers show that traffic accidents in Indonesia are extremely high. Over 60% of blunt aortic injuries occur at the aortic isthmus, where the relatively fixed descending aorta meets the more mobile aortic arc. Therefore, this junction bears considerable strain on sudden deceleration. Other segments of the aorta, however, may also be involved. These include the ascending aorta (8–27%), aortic arch (8–18%), distal descending aorta (11– 21%), and abdominal aorta (2). Nowadays, the most commonly performed managemen of BTAI is endovascular aortic repair (TEVAR) . The American Association for the Surgery of Trauma (AAST) has classified thoracic vascular injuries based on the type of artery and the extent of arterial circumference involved. TEVAR has emerged as the dominant therapy for BTAI. Although the SVS clinical practice guidelines recommend urgent (<24 h) repair, some studies suggest that delayed therapy is well

tolerated and may lead to improved outcomes. In this review we aim to evaluate the hospital managements of BTAI in reducing the mortality rate in BTAI patients (1). Objective: To evaluate hospital managements

of Blunt Traumatic Aortic Injury cases in

reducing the mortality rate in patients diagnosed with BTAI. Methods: The methods used in this study are systematic review and meta-analysis, conducted in “PubMed”, “ScienceDirect”, and “ProQuest” using the keywords “Blunt Trauma” and “Aortic Injury”, and written in English. Results: The diagnosis of BTAI starts with a thorough history and physical examination. The initial evaluation conforms to the Advanced Trauma Life Support guidelines. Patients may present in shock or with normal hemodynamics. Similarly, patients may report chest pain radiating to the back or remain asymptomatic. Important physical examination findings include distended neck veins, absent or muffled heart sounds, tracheal deviation, subcutaneous emphysema, chest wall instability or ecchymoses, abnormal breath sounds, and diminished peripheral pulses (1). Imaging plays a central role in the diagnosis of BTAI. The initial imaging modality is a chest radiograph. Suggestive radiographic findings include a widened/abnormal mediastinum left pleural effusion, first and second rib fractures, tracheal deviation, a depressed left bronchus, an indistinct aortic knob, or apical capping. If there is clinical suspicion for BTAI, a computed tomographic angiogram (CTA) of the chest is necessary. Although for nearly four decades aortography/angiography was considered the gold standard for diagnosis of blunt aortic injury, CTA is considered the diagnostic test of choice in the modern era. If CTA findings are equivocal, intravascular ultrasound (IVUS) can be a helpful adjunct. Finally, angiography is a potential diagnostic modality but, with the advent of CTA, has been relegated from a screening to a mainly therapeutic role. In addition to faster and more accurate diagnosis, advances in modern imaging also provided a more detailed analysis of aortic lesions and thus paved the way for improved staging and treatment (3). The current standard of care for grading BTAI was proposed in 2009 and has been adopted by the Society for Vascular Surgery clinical practice guidelines for the management of BTAI. Injuries are assigned one of 4 grades based on CTA imaging: (4)

Grade 1: Intimale tear

Grade 2: Intramural hematoma

Grade 3: Pseudoaneurysm

Grade 4: Rupture

The treatment of BTAI starts with adequate blood pressure control. Depending on the grade of the injury, this intervention serves as either a definitive or a temporizing measure. On the basis of the Society for Vascular Surgery (SVS) clinical practice guidelines, expectant management with effective blood pressure control is sufficient for grade I lesions, as the majority of these lesions heal spontaneously. Medical management with anti-impulse therapy is the initial and, for some patients, definitive intervention. For grade II–IV lesions, however, the SVS clinical practice guidelines recommend urgent TEVAR (1). We acquired clinical case reports on TEVAR and open repair management of Aortic aneurysm caused by Blunt Thoracic Aortic Injury, based on the study data performed by (5): a. Mortality risk Eighteen studies including 22,702 patients reported 30-day mortality. TEVAR reduced the risk of 30-day mortality (OR, 0.56; 95% CI, 0.4-0.74). Subgroup analysis was done to compare 30-day mortality risk between intact (19,985 patients) and ruptured (2282 patients) aneurysms. In each subgroup, TEVAR reduced the risk of 30-day mortality in intact aneurysms (nine studies; OR, 0.6; 95% CI, 0.36-0.99; I 2 ¼ 77%) and in ruptured aneurysms (five studies; OR, 0.58; 95% CI, 0.38-0.88; I 2 ¼ 65%). Only one study compared 30-day mortality20 for patients with supradiaphragmatic TAAAs. The difference between the TEVAR and open repair groups was not statistically significant (OR, 0.55; 95% CI, 0.181.66). b. Paraplegia risk Six studies including 771 patients reported 30-day paraplegia or spinal cord ischemia. TEVAR reduced paraplegia or spinal cord ischemia (OR, 0.35; 95% CI, 0.2-0.61). c. Stroke risk Eight studies including 41,401 patients reported 30-day stroke rates. The reduction in risk with TEVAR was not statistically significant (OR, 0.89; 95% CI, 0.76-1.03). d. Pulmonary complication risk

Four studies including 18,996 patients reported 30-day pulmonary complications. TEVAR was associated with a reduction in risk (OR, 0.41; 95% CI, 0.37-0.46) e. Length of Hospital and ICU stay Four studies including 346 patients reported ICU length of stay. TEVAR was associated with shorter stay (pooled mean difference, -5.89 days; 95% CI, -9.65 to -2.12). Six studies including 1331 patients reported hospital length of stay. TEVAR was associated with shorter stay (pooled mean difference, -5.17 days; 95% CI, -7.77 to -2.57). Alternatively, full cardiopulmonary bypass via femoral cannulation can be used. Although contemporary outcomes of surgical repair have improved, the overall and aortic-related mortalities remain relatively high (19.7%). Citing lower risks of death and spinal cord ischemia, the SVS clinical practice guidelines recommend TEVAR over open repair for all age groups with suitable anatomy. TEVAR was used in 76.4% of the 382 BTAI patients. The majority (50.3%) of injuries were grade III lesions, followed by grade I (24.6%), grade II (17.8%), and grade IV (7.3%) lesions. The overall in-hospital mortality was 18.8%, and the aortic-related mortality was 6.5%. TEVAR also reduce Mortality in patients admitted with traumatic thoracic aortic injuries declined from 24.5% to 13.3% (1). Conclusion: Patients of aortic aneurysm complication in Blunt Thoracic Aortic Injury who undergo TEVAR have reduced risk of mortality, paraplegia, and pulmonary complications within 30 days of intervention compared with patients who undergo open repair. Patients undergoing TEVAR also had a shorter hospital and ICU length of stay. Therefore, the procedure of TEVAR for the treatment of Blunt thoracic aortic injury (BTAI) patients is has been recommended for most cases. TEVAR was the only protective variable against aortic-related mortality. Advances in imaging, development of a contemporary classification system, and the advent of TEVAR have all decreased the risk of mortality in Blunt thoracic aortic injury (BTAI) Keyword: Blunt Thoracic Aortic Injury, blunt Aortic injury, blunt trauma, management, Thoracic Endovascular Aortic Repair (Tevar) , bypass for repair of Aortic injury.

BIBLIOGRAPHY 1.

Akhmerov A, DuBose J, Azizzadeh A. Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges. Ann Vasc Dis [Internet]. 2019 Mar 25 [cited 2021 Apr 3];12(1):1–5. Available from: /pmc/articles/PMC6434345/

Teixeira PGR, Inaba K, Barmparas G, Georgiou C, Toms C, Noguchi TT, et al. Blunt thoracic aortic injuries: An autopsy study. J Trauma - Inj Infect Crit Care [Internet]. 2011 Jan [cited 2021 Apr 3];70(1):197–202. Available from: https://pubmed.ncbi.nlm.nih.gov/21217494/

Azizzadeh A, Valdes J, Miller CC, Nguyen LL, Estrera AL, Charlton-Ouw K, et al. The utility of intravascular ultrasound compared to angiography in the diagnosis of blunt traumatic aortic injury. J Vasc Surg [Internet]. 2011 Mar [cited 2021 Apr 3];53(3):608–14. Available from: https://pubmed.ncbi.nlm.nih.gov/21129901/

Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury Concepts and management [Internet]. Vol. 15, Journal of Cardiothoracic Surgery. BioMed Central Ltd.; 2020 [cited 2021 Apr 3]. p. 62. Available from: https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-020-01101-6

Alsawas M, Zaiem F, Larrea-Mantilla L, Almasri J, Erwin PJ, Upchurch GR, et al. Effectiveness of surgical interventions for thoracic aortic aneurysms: A systematic review and meta-analysis. J Vasc Surg [Internet]. 2017;66(4):1258-1268.e8. Available from: http://dx.doi.org/10.1016/j.jvs.2017.05.082

THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) REDUCES MORTALITY RATE IN BLUNT THORACIC AORTIC INJURY (BTAI) PATIENTS: A SYSTEMATIC REVIEW STEVENS WIJAYA; ENNIA YUNIARTI BR BANCIN; ANDI HANNA SHELINDA SILVA; YASON NIKOLAUS LIYADI

Introduction

Discussion and Limitations

Blunt thoracic aortic injury (BTAI) is a tear in the aorta as a result of a combination of shear and stretch forces, rapid deceleration, increased intravascular pressure and compression of the aorta between the anterior chest wall and vertebrae. Although the incidence of BTAI is less than 1%, this injury is the second leading cause of death in blunt trauma. The most common mechanism of BTAI involves motor vehicle collisions (MVCs). About 81% cases of BTAI are caused by Motor vehicle accidents. Up to 80% of patients presenting with BTAI die before hospitalization, and those who survive often present with multiple associated injuries, including cardiac lesions, rib fractures, hemothoraces, and intra-abdominal injuries (1).

The diagnosis of BTAI starts with a thorough history and physical examination. The initial evaluation conforms to the Advanced Trauma Life Support guidelines. Patients may present in shock or with normal hemodynamics. Similarly, patients may report chest pain radiating to the back or remain asymptomatic. Important physical examination findings include distended neck veins, absent or muffled heart sounds, tracheal deviation, subcutaneous emphysema, chest wall instability or ecchymoses, abnormal breath sounds, and diminished peripheral pulses (1).

In 2014, it was reported that approximately 28,000 fatalities due to accidents on the streets and roadways in Indonesia and the fatality rate from traffic accidents was about 12 per 100,000 population. It is estimated that in 2020, traffic fatality in Indonesia will reach 40,000 per year. This is very high compared to the neighboring countries like Singapore (4.8) and Australia (5.2). These numbers show that traffic accidents in Indonesia are extremely high.

The current standard of care for grading BTAI was proposed in 2009 and has been adopted by the Society for Vascular Surgery clinical practice guidelines for the management of BTAI. Injuries are assigned one of 4 grades based on CTA imaging: (4) - Grade 1: Intimale tear - Grade 2: Intramural hematoma - Grade 3: Pseudoaneurysm - Grade 4: Rupture The treatment of BTAI starts with adequate blood pressure control. Depending on the grade of the injury, this intervention serves as either a definitive or a temporizing measure. On the basis of the Society for Vascular Surgery (SVS) clinical practice guidelines, expectant management with effective blood pressure control is sufficient for grade I lesions, as the majority of these lesions heal spontaneously. Medical management with anti-impulse therapy is the initial and, for some patients, definitive intervention. For grade II–IV lesions, however, the SVS clinical practice guidelines recommend urgent TEVAR (1). We acquired clinical case reports on TEVAR and open repair management of Aortic aneurysm caused by Blunt Thoracic Aortic Injury, based on the study data performed by (5): 40

Mortality Rate (%)

Nowadays, the most commonly performed management of BTAI is endovascular aortic repair (TEVAR) TheAmerican Association for the Surgery of Trauma (AAST) has classified thoracic vascular injuries based on the type of artery and the extent of arterial circumference involved. TEVAR has emerged as the dominant therapy for BTAI. Although the SVS clinical practice guidelines recommend urgent (<24 h) repair, some studies suggest that delayed therapy is well tolerated and may lead to improved outcomes. In this review we aim to evaluate the hospital managements of BTAI in reducing the mortality rate in BTAI patients (1).

30 20 10

The methods used in this study are systematic review and meta-analysis, conducted in “PubMed”, “ScienceDirect”, and “ProQuest” using the keywords “Blunt Trauma” and “Aortic Injury”, and written in English.

Conclusions

Patients of aortic aneurysm complication in Blunt Thoracic Aortic Injury who undergo TEVAR have reduced risk of mortality, paraplegia, and pulmonary complications within 30 days of intervention compared with patients who undergo open repair. Patients undergoing TEVAR also had a shorter hospital and ICU length of stay. Therefore, the procedure of TEVAR for the treatment of Blunt thoracic aortic injury (BTAI) patients) has been recommended for most cases. TEVAR was the only protective variable against aortic-related mortality. Advances in imaging, development of a contemporary classification system, and the advent of TEVAR have all decreased the risk of mortality in Blunt thoracic aortic injury (BTAI).

Acknowledgement The authors would like to acknowledge AMSA-UNAIR and AMSA-UNHAS for facilitating the supervisor in this research.

Conflict of Interest The authors declare no conflict of interest.

Study Background The low incidence yet high mortality of Blunt Thoracic Aortic Injury (BTAI) had gained our interest to perform this research. Up to 80% of patients presenting with BTAI worldwide die before hospitalization, and the rest survive with poor prognosis. This brought us to evaluate whether the current recommended hospital management, Thoracic Endovascular Repair (TEVAR), could effectively reduce the mortality rate in patients presenting with BTAI.

R TE VA

An t

th er

ct io

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Methods

0 By

Over 60% of blunt aortic injuries occur at the aortic isthmus, where the relatively fixed descending aorta meets the more mobile aortic arc. Therefore, this junction bears considerable strain on sudden deceleration. Other segments of the aorta, however, may also be involved. These include the ascending aorta (8–27%), aortic arch (8– 18%), distal descending aorta (11–21%), and abdominal aorta (2).

Imaging plays a central role in the diagnosis of BTAI. The initial imaging modality is a chest radiograph. Suggestive radiographic findings include a widened/abnormal mediastinum, left pleural effusion, first and second rib fractures, tracheal deviation, a depressed left bronchus, an indistinct aortic knob, or apical capping. If there is clinical suspicion for BTAI, a computed tomographic angiogram (CTA) of the chest is necessary. Although for nearly four decades aortography/angiography was considered the gold standard for diagnosis of blunt aortic injury, CTA is considered the diagnostic test of choice in the modern era. If CTA findings are equivocal, intravascular ultrasound (IVUS) can be a helpful adjunct. Finally, angiography is a potential diagnostic modality but, with the advent of CTA, has been relegated from a screening to a mainly therapeutic role. In addition to faster and more accurate diagnosis, advances in modern imaging also provided a more detailed analysis of aortic lesions and thus paved the way for improved staging and treatment (3).

Managements of BTAI a. Mortality risk Eighteen studies including 22,702 patients reported 30-day mortality. TEVAR reduced the risk of 30-day mortality (OR, 0.56; 95% CI, 0.40.74). Subgroup analysis was done to compare 30-day mortality risk between intact (19,985 patients) and ruptured (2282 patients) aneurysms. In each subgroup, TEVAR reduced the risk of 30-day mortality in intact aneurysms (nine studies; OR, 0.6; 95% CI, 0.36-0.99; I 2 ¼ 77%) and in ruptured aneurysms (five studies; OR, 0.58; 95% CI, 0.38-0.88; I 2 ¼ 65%). Only one study compared 30-day mortality20 for patients with supradiaphragmatic TAAAs. The difference between the TEVAR and open repair groups was not statistically significant (OR, 0.55; 95% CI, 0.18-1.66). b. Paraplegia risk Six studies including 771 patients reported 30-day paraplegia or spinal cord ischemia. TEVAR reduced paraplegia or spinal cord ischemia (OR, 0.35; 95% CI, 0.2-0.61). c. Stroke risk Eight studies including 41,401 patients reported 30-day stroke rates. The reduction in risk with TEVAR was not statistically significant (OR, 0.89; 95% CI, 0.76-1.03). d. Pulmonary complication risk Four studies including 18,996 patients reported 30-day pulmonary complications. TEVAR was associated with a reduction in risk (OR, 0.41; 95% CI, 0.37-0.46) e. Length of Hospital and ICU stay Four studies including 346 patients reported ICU length of stay. TEVAR was associated with shorter stay (pooled mean difference, -5.89 days; 95% CI, -9.65 to -2.12). Six studies including 1331 patients reported hospital length of stay. TEVAR was associated with shorter stay (pooled mean difference, -5.17 days; 95% CI, -7.77 to -2.57). Alternatively, full cardiopulmonary bypass via femoral cannulation can be used. Although contemporary outcomes of surgical repair have improved, the overall and aortic-related mortalities remain relatively high (19.7%). Citing lower risks of death and spinal cord ischemia, the SVS clinical practice guidelines recommend TEVAR over open repair for all age groups with suitable anatomy. TEVAR was used in 76.4% of the 382 BTAI patients. The majority (50.3%) of injuries were grade III lesions, followed by grade I (24.6%), grade II (17.8%), and grade IV (7.3%) lesions. The overall in-hospital mortality was 18.8%, and the aortic-related mortality was 6.5%. TEVAR also reduce Mortality in patients admitted with traumatic thoracic aortic injuries declined from 24.5% to 13.3% (1).

References

1. Akhmerov A, DuBose J, Azizzadeh A. Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges. Ann Vasc Dis [Internet]. 2019 Mar 25 [cited 2021 Apr 3];12(1):1–5. Available from: /pmc/articles/PMC6434345/ 2. Teixeira PGR, Inaba K, Barmparas G, Georgiou C, Toms C, Noguchi TT, et al. Blunt thoracic aortic injuries: An autopsy study. J Trauma - Inj Infect Crit Care [Internet]. 2011 Jan [cited 2021 Apr 3];70(1):197–202. Available from: https://pubmed.ncbi.nlm.nih.gov/21217494/ 3. Azizzadeh A, Valdes J, Miller CC, Nguyen LL, Estrera AL, Charlton-Ouw K, et al. The utility of intravascular ultrasound compared to angiography in the diagnosis of blunt traumatic aortic injury. J Vasc Surg [Internet]. 2011 Mar [cited 2021 Apr 3];53(3):608–14. Available from: https://pubmed.ncbi.nlm.nih.gov/21129901/ 4. Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury - Concepts and management [Internet]. Vol. 15, Journal of Cardiothoracic Surgery. BioMed Central Ltd.; 2020 [cited 2021 Apr 3]. p. 62. Available from: https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-020-01101-6 17 5. Alsawas M, Zaiem F, Larrea-Mantilla L, Almasri J, Erwin PJ, Upchurch GR, et al. Effectiveness of surgical interventions for thoracic aortic aneurysms: A systematic review and meta-analysis. J Vasc Surg [Internet]. 2017

Collection of Retrospective Studies on The Effect of Nonpenetrating Wounds Trauma affecting the Maternal and Fetal mortality in Pregnant Women : A Systematic Review Ester Elita¹, Michele Indrawan¹, Jonathan Juniard Anurantha¹ ¹ AMSA-UPH ABSTRACT Introduction : In pregnancy, there are many risks that threaten maternal mortality and fetal mortality, one of them is maternal trauma injury. Nonpenetrating trauma is the common thing that might happen during pregnancy. Such as traffic crashes, falling, or partner violence¹. During pregnancy, there are a lot of important physiologic and anatomic adjustments in multiple organs, thus it is important to maintain appropriate watch to both mother and the fetus. In this study, we would like to evaluate the correlation between non-penetrating trauma and complication during pregnancy, maternal and fetal mortality Objective : The objective of our study is to assess the correlation between blunt trauma or nonpenetrating wounds and the effect on pregnancy complications such as maternal and fetal mortality in pregnancy. Material and Methods : In our systematic review, we collected our data from an online journal which includes Pubmed and Google Scholar. Systematic Analysis approaches were used in this study, for example, MESH Terminology. For the MESH Terminology, the terminology we used were ((((((("Abdominal Injuries"[Mesh]) AND "Wounds, Nonpenetrating"[Mesh]) AND "Pregnancy"[Mesh]) AND "Pregnancy Complications"[Mesh]) AND "Fetal Mortality"[Mesh]) OR "Fetal Death"[Mesh]) AND "Maternal Mortality"[Mesh]) AND "Retrospective Studies"[Mesh] Result and Discussion : By using the inclusion and exclusion criteria, we have found 4 studies that were relevant. According to Petrone et al², Blunt trauma accounts for 2% of maternal mortality and 10% of fetal mortality. Study conducted by Esposito et al³ shows that blunt trauma accounts for 47% of neonatal deaths for known cases and 15% of maternal deaths. According to Al Thani et al⁴ and Shah et al⁵, blunt trauma caused more fetal mortality than maternal mortality, but only in small numbers. Conclusion : Out of these 4 retrospective studies, we concluded that blunt trauma has significant correlation with pregnancy complications such as maternal and fetal deaths. Other complications were also noted such as severe abdominal injury, respiratory distress, hemorrhagic shock and also premature birth in the fetus. And that proper management when the maternal injury happens is necessary. Keywords : Pregnancy, Pregnancy Complications, Non-Penetrating Wounds, Retrospective Study

Collection of Retrospective Studies on The Effect of Nonpenetrating Wounds Trauma affecting the Maternal and Fetal mortality in Pregnant Women : A Systematic Review ¹

Ester Elita , Michele Indrawan , Jonathan Juniard Anurantha

¹ AMSA-UPH

INTRODUCTION

In pregnancy, there are many risks that threaten maternal mortality and fetal mortality, one of them is maternal trauma injury. Nonpenetrating trauma is the common thing that might happen during pregnancy. Such as traffic crashes, falling, or partner violence¹. During pregnancy, there are a lot of important physiologic and anatomic adjustments in multiple organs, thus it is important to maintain appropriate watch to both mother and the fetus. In this study, we would like to evaluate the correlation between nonpenetrating trauma and complication during pregnancy, maternal mortality, and fetal mortality

DESIGN

METHODS

RESULT

In our systematic review, we collected our data from an online journal which includes Pubmed and Google Scholar. Systematic Analysis approaches were used in this study, for example, MESH Terminology. "((((((("Abdominal Injuries"[Mesh]) AND "Wounds, Nonpenetrating"[Mesh]) AND "Pregnancy"[Mesh]) AND "Pregnancy Complications"[Mesh]) AND "Fetal Mortality" [Mesh]) OR "Fetal Death"[Mesh]) AND "Maternal Mortality"[Mesh]) AND "Retrospective Studies"[Mesh]

DISCUSSION

By using the inclusion and exclusion criteria, we have found 4 studies that were relevant. According to Petrone et al², Blunt trauma accounts for 2% of maternal mortality and 10% of fetal mortality. Study conducted by Esposito et al³ shows that blunt trauma accounts for 47% of neonatal deaths for known cases and 15% of maternal deaths. According to Al Thani et al⁴ and Shah et al⁵, blunt trauma caused more fetal mortality than maternal mortality, but only in small numbers.

"Abdominal Injuries" AND "Blunt Trauma" AND "Pregnancy" AND "Fetal Mortality" OR "Maternal Mortality" AND "Retrospective Studies"

PubMED (101)

Google Sch (8)

1 9 Filtering Double Literature

8 Relevant Study

Inclusion Criteria Retrospective Study Abdominal Blunt Trauma Trauma during pregnancy Fetal/Maternal Mortality outcome Exclusion Criteria Meta-analysis Literature review Systematic review Prepregnancy/ Postpartum trauma(iatrogenic) Animal study

CONCLUSION Out of these 4 retrospective studies, we concluded that blunt trauma has significant correlation with pregnancy complications such as maternal and fetal deaths. Other complications were also noted such as severe abdominal injury, respiratory distress, hemorrhagic shock and also premature birth in the fetus. And that proper management when the maternal injury happens is necessary.

REFERENCE 1. Greco P, Day L, Pearlman M. Guidance for Evaluation and Management of Blunt Abdominal Tra 2. uma in Pregnancy. Obstetrics & Gynecology. 2019;134(6):1343-1357. 3. Petrone P, Talving P, Browder T, Teixeira P, Fisher O, Lozornio A et al. Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers. Injury. 2011;42(1):47-49. 4. ESPOSITO T, GENS D, SMITH L, SCORPIO R. Evaluation of Blunt Abdominal Trauma Occurring during Pregnancy. The Journal of Trauma: Injury, Infection, and Critical Care. 1989;29(12):1628-1632. 5. Al-Thani H, El-Menyar A, Sathian B, Mekkodathil A, Thomas S, Mollazehi M et al. Blunt traumatic injury during pregnancy: a descriptive analysis from a level 1 trauma center. European Journal of Trauma and Emergency Surgery. 2018;45(3):393-401. 19

Virtual Reality Exposure Therapy for Post-Traumatic Syndrome Disorder Diagnosed Patients: A Systematic Review Jovanicha Putri Setiawan, Kelvin Liemanto, Michael Jevon Jessu, Michael Manuel Faculty of Medicine, University of Pelita Harapan, Tangerang, Banten, Indonesia

ABSTRACT Introduction: Post-Traumatic Stress Disorder (PTSD) is a disabling psychiatric disorder that results from being exposed to real or threatened upsetting event such as injury, death, and sexual assault. It is associated with functional and cognitive impairment. Studies have shown that psychotherapy and pharmacotherapy are effective towards the PTSD patients. With the rapid technological progress in this modern world, virtual reality is slowly invading our day to day life. Researchers have questioned whether virtual reality therapy can be as effective as usual exposure therapy for patients with PTSD.

Aim: Our aim in this study is to evaluate the effect of Virtual Reality Exposure Therapy as a consideration for post-traumatic stress disorder treatment.

Methods: In this systematic review, the data is collected from scientific journal such as Pubmed and Google Scholar using keyword “Post Traumatic Stress Disorder” OR “PTSD” AND “Virtual Reality” OR “VR” AND “Clinical Trial” OR “CT”. Result and Discussion: By using the inclusion and exclusion criteria, we have found 8 relevant studies conducted by Albert “Skip” Rizzo et al, Deborah C Beidel et al, Robert N. McLay et al, Robert N. McLay et al, Barbara O. Rothbaum et al, David J. Ready et al, Melissa Peskin et al, dan Aaron M Norr et al. Conclusion: In conclusion for our study, we found that all of the papers that was found supports the hypothesis which is Virtual Reality Exposure Therapy can reduce Post Traumatic Syndrome Disorder’s symptoms and severity. But there was no significant difference found if compared to control exposure therapy.

Keyword: Post-traumatic stress disorder, virtual reality exposure therapy, Treatment, Systematic Review

Mannitol Versus Hypertonic Saline Effect on ∆ICP and Duration of ICU Stay in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis 1

Ali Habibi , Yehuda Tri Nugroho Supranoto , Naufal Ahmad Syafiiqi Attabriizi , Siti Zahra Arfiani 1

Faculty of Medicine, Universitas Jember, Jember, Indonesia

Abstract Introduction: Traumatic Brain Injury (TBI) is a major cause of death and disability, causing significant personal suffering to victims and their families, as well as enormous direct and indirect societal issues. The use of hyperosmolar drugs plays an important role in the treatment of the increased intracranial pressure (ICP) caused by TBI. Mannitol is the standard hyperosmolar drug for reducing ICP. Hypertonic saline (HTS), used in various concentrations (1.8-30%) is useful for the alternative treatment of increased ICP. HTS is now used as the second-line hyperosmolar drug due to the lack of conclusive evidence. Intensive Care Unit (ICU) also plays a comprehensive role in the TBI treatment. The shorter duration of ICU stay means the patient's condition has been improving faster and also has other benefits, such as reducing costs and ICU bed occupancy rate. Objective: This systematic review and meta-analysis aimed to compare the effect especially on ∆ICP and duration of ICU stay in patients with TBI. Materials and Methods: A literature search was conducted with multiple electronic databases, such as PubMed, Scopus, ScienceDirect, and Google Scholar based on PRISMA. Results and Discussion: The current review identified 4566 studies from all databases. We found 7 full-text articles that match our inclusion and exclusion criteria for qualitative synthesis and 5 for quantitative synthesis (meta-analysis). This current meta-analysis indicated that HTS 57% more effective in reducing ICP compared with mannitol for TBI treatment. (MD=-0.57, 95% CI (-1.48 – 0.33), p=0.22, I2=55%). The meta-analysis also indicated that HTS more effective in reducing the duration of ICU stay by 0.84 day comparing to mannitol for the patient with TBI treatment. (MD=0.84, 95% CI (-0.10 – 1.77), p=0.08, I2=0%). Conclusion: This review article provides strong valuable evidence showing that HTS is significantly effective in reducing ICP and the duration of ICU stay for patients with TBI comparing to mannitol.

Keywords: Traumatic brain injury (TBI), mannitol, hypertonic saline (HTS), Intracranial pressure (ICP), intensive care unit (ICU)

Mannitol Versus Hypertonic Saline Effect on ∆ICP and Duration of ICU Stay in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis Ali Habibi, Yehuda Tri Nugroho Supranoto, Naufal Ahmad Syafiiqi Attabriizi, Siti Zahra Arfiani Faculty of Medicine, Universitas Jember

2. 1.Methods Intoduction

1. Introduction

3. Results

Table 1. Characteristic of studies and assessment outcome for ΔICP and the duration of ICU stay between mannitol and hypertonic saline treatment group.

Figure 2. Forest plot of ΔICP (ICP Pre-treatment – ICP Post-treatment) between Mannitol and Hypertonic Saline treatment group.

Figure 1. PRISMA ﬂow chart of literature search

4. Discussion

Figure 3. Forest plot of the duration of ICU stay between Mannitol and Hypertonic Saline treatment group.

5. Conclusion

References 23

Shoulder Dislocation Incidence and Society’s Health Seeking Behavior in Indonesia : Driving Factors to the Mindset About Treatment Amalia Dewindra Candra Puspita 1a, Ni Komang Ayu Septia Primayanti1, Widya Widati1, Febrianto Adi Husodo1 Undergraduate Program, Faculty of Medicine, Universitas Hang Tuah1 a

amaliadewindra@gmail.com

ABSTRACT

Introduction: Shoulder dislocation is the most common traumatic dislocation. Although traumatic dislocations rarely cause death, it could lead to bone, fibrous, and ligamentous damage and vascular and neural structure damage. Despite the modern technology advancedly used in the medical field, some people still prefer to use traditional treatment as a therapeutic choice as it is less expensive and relatively short-term treatment. This could be a serious problem especially when it leaves complications due to mismanagement by traditional treatment.

Objective: This study aims to seek for factors of community's preference in traditional treatment in shoulder dislocation.

Methods: This observational analytic study with cross-sectional design used both quantitative and qualitative methods. We administered an online questionnaire consisting of open- and close-ended 24 questions related to healthcare seeking behavior towards shoulder dislocation. We distributed questionnaires via social media that targeted respondents all over Indonesia.

Results: There was a significant difference between gender and experience in shoulder dislocation. There was some insignificant data such as education level, BPJS health insurance ownership, and island where they live which influence the community’s decision in treating shoulder dislocation.

Conclusion: Shoulder dislocation tends to occur more often in men rather than in women.

Key Findings: Health Seeking Behavior; Shoulder Dislocation; Gender

Shoulder Dislocation Incidence and Society's Health Seeking Behavior in Indonesia : Driving Factors to the Mindset About Treatment Amalia Dewindra Candra Puspita, Ni Komang Ayu Septia Primayanti, Widya Widati, Febrianto Adi Husodo

Undergraduate Program, Faculty of Medicine, Universitas Hang Tuah Asian Medical Students' Association - Indonesia

INTRODUCTION

RESULTS

Shoulder dislocation is the most common traumatic dislocation (50.6%), especially in developing countries, including Indonesia, where a large number of people work physically.(1) Although traumatic dislocations rarely cause death, it is not an easy journey since it could result in bone, fibrous, and ligamentous damage and vascular and neural structure damage.(2) Despite the modern technology advancedly used in the medical field, especially in treating joint dislocation, some people still prefer to use traditional treatment as a therapeutic choice due to economic problem and the instant final result.(3) This could be a serious problem, especially when it leaves complications due to mismanagement by traditional treatment. It could lead to disability, if not treated immediately.(4) Therefore, this study aims to seek for factors of community's preference in traditional treatment in shoulder dislocation.

METHODS

21.7% had experienced shoulder dislocation

Table 1.1 Gender *Seeking Help

78.3% had never experienced shoulder dislocation Figure 2. Pie Chart of Study Paticipants

Table 1.2 BPJS Health Insurance *Seeking Help Table 1.5 Gender

Table 1.6 BPJS Health Insurance Table 1.3 Education *Seeking Help

This observational analytic study with cross-sectional design used both quantitative

Table 1.7 Education

and qualitative methods. We administered an online questionnaire consisted of open- and close-ended 24 questions related to healthcare seeking behavior towards shoulder dislocation. We distributed questionnaire via social media that targeted respondents in all over Indonesia. The inclusion criteria for our study participants were: - Male and female residents - Agreed to participate in the study

Table 1.8 Island

- Not illiterate The inclusion criteria for our references were: - Observational studies - Published in 2017-2021 - Related to shoulder dislocation and its treatment

Personal Attributes Age, Gender, Education, Health Insurance

Table 1.4 Island *Seeking Help

DISCUSSION Health Beliefs and Activity or Job of The Participants

Access to Services Costs, Physical, and Social Distance

Location Islands

Perceived Needs Health and Spiritual Needs

Health Seeking Behaviors Traditional or Medical Treatment

Table 1.9 Other Health Insurance

Society Recognition of Providers and Social Referrals

Figure 1. Conceptual Framework

According to this study, there were 360 participants, 78 (21.7%) of them had experienced shoulder dislocation, and 282 (78.3%) had never experienced shoulder dislocation. The average age of those who had ever experienced shoulder dislocation was 21.82 years, the youngest was 14 years and the oldest was 67 years. A. Medical Approach vs Traditional Approach In Indonesia, there is a famous traditional treatment called ‘Sangkal Putung’. Sangkal Putung is a traditional medicine which treats musculoskeletal problems, such as bone fracture, bone and joint dislocation, and sprains, by rubbing, pressing, stretching, and massaging the site of the problem. It is known as knowledge of local wisdom in health care which has been passed down from generations to generations, especially in rural places in Indonesia, where the traditions and cultures are still strong.(5) According to the data we analyzed, we found that the results were dominated with people’s preference in medical treatment, as it is safer and has been covered by insurance, BPJS. However, we still found quite large people prefered to go to traditional treatment rather than medical treatment (35.1%). Based on our indirect interview, economy and social culture play a big role in influencing people’s decisions. Beside the traditional treatment is less expensive, there are other reasons which influence people’s decision in treating shoulder dislocation : Family trust. Some of our study participants stated that going to traditional treatment is a habit passed down by their family. Also, they believed that it is safe since their family members had already been there before. Cultural belief. It is stated by one of our study participants that they believe traditional treatment can bring new energy to the body, and that they get healed in relatively short time. Accessible in their area. One of our study participants mentioned that traditional treatment is closer to their house than a medical facility. B. The Gender where Study Participants Resided and Their Healthcare Seeking Behaviors Based on the chi-square test, we discovered a significant difference (p = < 0.001) between gender and experience in shoulder dislocation. Majority of participants who had ever experienced shoulder dislocation was men (35.7%). However, women who had ever experienced shoulder dislocation were 15.3 %. This might be related with activity 25 and habit among male people which escalated the incident of shoulder dislocation among them.

A study showed that the severity of activity highly contributed in increasing the rate of shoulder dislocation. In developing countries, a large number of people work physically. In Indonesia, most people work as a laborer (40.83%), which require high stamina.(6) Athletes have a better chance at suffering in shoulder dislocation. According to a study, traumatic shoulder dislocation most commonly happens in contact sports, such as football, basketball, and wrestling, which gives worse effect to men rather than women athletes, since men participate more in these sports than women. Therefore, men contribute more in increasing the number of shoulder dislocation cases.(7) C. Insignificant Data We Found Through This Study Education level, which we found no significant difference (p= 0.382) between the education level in participants who had ever experienced shoulder dislocation and their health seeking behavior. This finding might be related to the escalation in utilization of the gadget, internet, and social media in which would help people to easily access a bunch of information related to shoulder dislocation regardless of their educational level. It is well-known that internet and social media platforms are effective to increase knowledge, awareness, and prevention behavior toward their health.(8) BPJS Health Insurance Ownership, which we found no significant difference (p= 0.093) between the ownership of BPJS in participants who had ever experienced shoulder dislocation and their health seeking behavior. This finding might be related to complicated administrative procedures and the accessibility to the medical facility. Despite the governmental programs held for Indonesian well-being, over 28.1% of Indonesia's population still have no JKN Card. One of the main reasons was that BPJS has complicated administrative procedures and a long administration process.(9) A 20-year-old man stated in our survey, “I prefer to go to a traditional facility because I don't have to wait for long. Also, it is closer to my home rather than to the hospital.” Island, which we found no significant difference (p= 0.235) between the island where participants who had ever experienced shoulder dislocation resided and their health seeking behavior. This finding might be related to health awareness built through social media platforms, regardless of where they live. Nowadays, most people in Indonesia are social media users. This could help people to easily access information related to traditional treatment, which help building a new mindset about healthcare, regardless of a baseless tradition.(10) D. Other Factors Related to Treatment Approach Based on Response of Participants There was no significant difference between education level, BPJS health insurance ownership, and island on seeking healthcare. Based on our study participants’ responses, these are their reasons regarding their decision : Those who chose traditional treatment : A 20-year-old woman from Central Kalimantan stated, “Fear of surgery.” A 22-year-old man from Maluku stated, “There are some explanations for this. The first is due to habit, the second one is the cost, and the last one is time efficiency which in this case for the people living on the islands have to travel long distances and take a long time to seek medical help.” A 46-year-old woman from Aceh stated, ”Avoiding chemical drugs.” Those who chose medical treatment : A 19-year-old man from Bali stated, “If performed medically, the complications can be prevented, and the mistake can be minimized.” A 20-year-old woman from East Java stated, “Since all medical professionals have been confirmed to be expert in their fields and have earned further education/related sciences than others.” A 21-year-old man from Yogyakarta stated, “They are more experts and therapy can be covered by the BPJS as well.” This study had some limitations. We were unable to control the study participants, they responded to the questionnaire according to their own understanding. The unequal distribution of the sample per region results in a bias in one area, and there are still other variables that affect the results that have not been studied in this study.

CONCLUSION Shoulder dislocation tends to occur more often in men rather than women. There were some insignificant data on education level, BPJS health insurance ownership, and island we found in this study. It might be caused by unequal distribution of the sample per region and online questionnaires distribution. It might also be that the variables used in this study have no impact on health seeking behavior. Thus, we recommend for future researchers to enlarge the scale on the survey and study about other variables such as fear of surgery, third-party encouragement, and others. As a medical student, we have an important role to spread awareness related to the importance of seeking medical treatment for shoulder dislocation due to possible complications on traditional treatment.

REFERENCES 1. Nabian MH, Zadegan SA, Zanjani LO, Mehrpour SR. Epidemiology of joint dislocations and ligamentous/tendinous injuries among 2,700 patients: Five-year trend of a tertiary center in Iran. Arch Bone Jt Surg. 2017;5(6):424–32. 2. Gutkowska O, Martynkiewicz J, Stȩpniewski M, Gosk J. Analysis of Patient-Dependent and Trauma-Dependent Risk Factors for Persistent Brachial Plexus Injury after Shoulder Dislocation. Biomed Res Int. 2018;2018. 3. Zakaria MM, Mahzuni D, Septiani A. Pengobatan Alternatif Penyakit Tulang Studi Kasus Kearifan Lokal Para Terapis Penyakit Tulang Di Wilayah Jawa Barat. Patanjala J Penelit Sej dan Budaya. 2019;11(3):431. 4. Flora JK. Volume X No. 2 Juli 2017. 2017;X(2):7–11. 5. Yuniar DP, Nasution Z. Perilaku Pemagang Pengobatan Sangkal Putung. J Pendidik Teor Penelitian, dan Pengemb. 2017;2(Sangkal Putung):1656–61. 6. Yosepha P. Distribusi Penduduk yang Bekerja Menurut Status Pekerjaan. 2020;1. Available from: https://nasional.tempo.co/read/1400653/ini-5-versi-hasil-survei-soal-kepuasan-kinerja-jokowi-maruf 7. Wagstrom E, Raynor B, Jani S, Carey J, Cox CL, Wolf BR, et al. Epidemiology of Glenohumeral Instability Related to Sporting Activities Using the FEDS (Frequency, Etiology, Direction, and Severity) Classification System: A Multicenter Analysis. Orthop J Sport Med. 2019;7(7):1–6. 8. Richards et al. HHS Public Access. Physiol Behav. 2018;176(5):139–48. 9. BPJS Kesehatan. Info BPJS Kesehatan: Pemanfaatan Data JKN untuk Perbaikan Sistem Kesehatan di Indonesia. Media Intern BPJS Kesehat [Internet]. 2019;23. Available from: https://bpjskesehatan.go.id/bpjs/dmdocuments/0775bd2f22814ddb26c71e02903c9226.pdf 10. Setiawan daryanto. Dampak Perkembangan Teknologi Informasi dan Komunikasi Terhadap Budaya Impact of Information Technology Development and Communication on. J Pendidik. 2017;X(2):195– 211.

乳⿏⼼肌提取

A SYSTEMATIC REVIEW OF COMPARATIVE EXPERIMENTS BETWEEN ROBOT ASSISTED GAIT TRAINING VERSUS OVERGROUND GAIT TRAINING AS A POTENTIAL OF REHABILITATION IN SPINAL CORD INJURED PATIENT Anisa Ulaya S1* ,Gladys Ariella1, Puspa Gracella Tambunan2 , Stephanie Amabella Prayogo3 1. 1st Year Medical Student, Anisa Ulaya S, Universitas Tarumanagara 2. Year Medical Student, Puspa Gracella Tambunan, Universitas Tarumanagara nd 3. 2 Year Medical Student, Stephanie Amabella Prayogo, Universitas Indonesia *anisawulaya@gmail.com 3rd

ABSTRACT Introduction : Spinal cord injury (SCI) is a traumatic condition caused by a lesion in the spine that can lead to severe morbidity and permanent disability. Several available trainings, such as Overground Gait Training (OGT) and Body-Weight-Supported (BWS) treadmill training, require therapist manual assistance. An electromechanical treatment, Robot Assisted Gait Training (RAGT), was developed later. However, there is no systematic review comparing both RAGT and OGT. Therefore, we conducted this systematic review to search for the best rehabilitation treatment for SCI patients. Objective: The aim of this study is precede a comparison of performances between RAGT and OGT which is being assessed with 4 major components 6MWT(6-Minutes Walking Test),10MWT(10-Meter Walking Test), LEMS (Lower Extremity Motor Score),and WISCI-II (Walking Index for Spinal Cord Injury II) in order to determine which of one of these factors of combinations has a better outcome for the purpose of rehabilitation for spinal cord injured patient. Method : A systematic review was conducted using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines for objective studies for a relevant analysis in both screening and research. A diverse accessible amount of databases was used consisting of PubMed, Google Scholar, Science Direct, and EBSCO. Duplicates title elimination were conducted by Google Spreadsheet using remove duplicates on the title of the journal. Result : Based on the 6 studies conducted, the RAGT results showed walking speed (6MWT) 0.11m / s, walking distance (10MWT) 48.99m / s, LEMS 4.48, WISCI-II 7.13, while OGT presented data with the value of the walking speed ( 6MWT) 0.05m / s, walking distance (10MWT) 21.7m / s, LEMS 5.4, WISCI-II 4.33. Reached from data extraction and final analysis obtained RAGT with 55.37 average mean change in all parameters showed better improvement than OGT with 17.39 average mean change. Conclusion: Based on the parameters that have become the prominent factors, RAGT has compelling evidence that in medical rehabilitation functioning as both improvement for locomotor abilities as well as increasing the level of dexterity that can be seen in daily physical activities for spinal cord injured patients. Keywords: Robot assisted gait training, Overground gait training, Spinal cord injury

Comparing Trauma and Injury Severity Score, New Injury Severity Score, and Revised Trauma Score for Trauma Mortality Prediction: A Meta-Analysis Bendix Samarta Witarto1a, Visuddho1, David Nugraha1 1

Undergraduate Program, Faculty of Medicine, Universitas Airlangga a

bendixsw@gmail.com

AMSA-Universitas Airlangga

ABSTRACT Introduction: Trauma has become one of the leading cause of mortality around the world. Early warning system plays a significant role in the patients’ triage and has a notable impact on mortality outcome of trauma patients. Trauma scores are usually used for patient’s prognostication. Several scoring systems have been developed, including the Trauma and Injury Severity Score (TRISS), New Injury Severity Score (NISS), and Revised Trauma Score (RTS). The good outcome predictive properties are crucial for a scoring system. Objective: To quantitatively compare the accuracy of TRISS, NISS, and RTS for predicting mortality in trauma patients. Method: A systematic search based on PRISMA statement was conducted in PubMed, Scopus, Proquest, ScienceDirect, and CINAHL Plus (through EBSCOhost), up to March 25, 2021. The articles were screened based on several eligibility criteria and further assessed for the risk of bias using QUADAS-2 Tool. Statistical analyses were performed using MetaDisc 1.4. Result: Five studies involving 3,117 trauma patients were included in this systematic review and meta-analysis. The pooled sensitivity and specificity of TRISS to predict mortality were 73% (95% CI = 69%-77%) and 67% (95% CI = 66%-69%), respectively. For NISS, the pooled results were 72% (95% CI = 68%-76%) for sensitivity and 80% (95% CI = 79%-81%) for specificity, whereas for RTS, the pooled sensitivity and specificity were 64% (95% CI = 60%-68%) and 83% (95% CI = 82%-84%), respectively. The pooled AUC of TRISS (AUSROC = 95.4%) was significantly higher compared to NISS (AUSROC = 87.3%; p = 0.01) and RTS (AUSROC = 86.1%; p = 0.005), whereas the pooled AUCs of NISS and RTS were not statistically different (p = 0.54). Conclusion: TRISS has the highest and better accuracy for predicting mortality in trauma patients compared to NISS and RTS. Further studies are warranted to confirm our findings.

Keywords: Trauma and Injury Severity Score, New Injury Severity Score, Revised Trauma Score, trauma, mortality

Comparing Trauma and Injury Severity Score, New Injury Severity Score, and Revised Trauma Score for Trauma Mortality Prediction: A Meta-Analysis Bendix Samarta Witarto1a, Visuddho1, David Nugraha1 1Undergraduate Program, Faculty of Medicine, Universitas Airlangga abendixsw@gmail.com Bendix Samarta Witarto - Visuddho - David Nugraha Table 1. Characteristics of the Included Studies.

INTRODUCTION Trauma is one of the world's public health problems affecting people of all ages. Trauma, with its varying degrees of severity, has become one of the leading cause of mortality all around the world, especially in the low and middle income countries.1 Early warning system of medical services plays a significant role in determining the appropriate intervention to reduce unnecessary complications and in order to ensure the right patients’ triage.2 These decisions have a notable impact on mortality outcome of trauma patients. In fact, trauma scores are usually used for the classification of trauma severity and prognostication.3 The proper consideration of the identified prognostic factors and good outcome predictive properties are crucial for a scoring system. There are several scoring systems have been developed and used worldwide, including the anatomicalbased (New Injury Severity Score - NISS), the physiological-based (Revised Trauma Score - RTS), and the combined anatomic-physiological-based scoring system (Trauma and Injury Severity Score - TRISS).4 Nevertheless, the most accurate scoring system remains an elusive target and to the extend of our knowledge, there is no systematic review that analyses each scoring system in depth. Therefore, this study will quantitatively compare which scoring system has the best predictive accuracy for mortality in trauma patients.

Author, Year

Study Location

Javali et al.,

India

20196 Eryilmaz et al.,

Turkey

20097 Arikan et al.,

Total Patients TRISS NISS RTS Patients Characteristics Mean ± SD (M/F) (Trauma and Injury Severity Score) (New Injury Severity Score) (Revised Trauma Score) Study Design Age (Survivor/NonMechanism of % AUC AUC % AUC AUC % AUC AUC % Prev Cut-off % Sn % Sp Cut-off % Sn % Sp Cut-off % Sn % Sp Survivor) Trauma or Injury (95% CI) p- value (95% CI) p- value (95% CI) p- value 200 Prospective (148/52) 66.4 ± 6.9 Blunt trauma 100 ≤ 91.6 97.2 97.06 87.95 < 0.0001 > 17.0 97 91.18 93.37 < 0.0001 ≤ 7.11 94.7 97.06 80.12 < 0.0001 Cohort (166/34) 87 Retrospective Blunt trauma (fall (64/23) 26.9 ± 9.1 100 73.5 99.1 88.9 98.7 0.01 31.5 91.5 100.0 69.2 0.001 1.04 N/A 100.0 5.1 < 0.001 Cross-sectional from height) (78/9) Retrospective Cohort

Turkey

20208

Germany Lefering, Retrospective Austria Cohort 20093 Switzerland Tan et al.,

Malaysia

20179

Retrospective Cohort

Shotgun wound Stab wound Other sharp materials injuries

77 (62/15) (56/21)

28.7 ± 10.7

1206 (892/314) (1006/200)

38.2 ± N/A

2208 (1957/251) (1970/238)

Blunt trauma 36.0 ± 16.0 Penetrating trauma Blast trauma

Blunt trauma Penetrating trauma

47 41

7.6

94.3

95.2

92.2

< 0.001

19.0

95 5

0.5

86.2 (83.0–89.0)

41.0

96.0

N/A

90.5 9.2 0.2

< 0.96

N/A

89.6

85.7

74.0

< 0.001

6.27

49.0

80.0 49.0 (77.0–84.0)

90.0

N/A

> 24.0

87.8 86.6 (86.4–89.2)

74.3

N/A

91.5

90.5

92.9

< 0.001

4.10

77.0 44.0 (73.0–80.0)

89.0

N/A

< 7.81

80.2 72.4 (78.5–81.8)

82.8

N/A

81.2 94.14 48.90 (79.5–82.8)

Sensitivity (95% CI) Javali et al. 2019 Eryilmaz et al. 2009 Arikan et al. 2020 Lefering 2009 Tan et al. 2017

0,97 0,89 0,95 0,41 0,94

(0,85 - 1,00) (0,52 - 1,00) (0,76 - 1,00) (0,34 - 0,48) (0,90 - 0,97)

Sensitivity 1

SROC Curve

Sy AU SE Q SE

0,9

0,8

0,7

0,2

0,4 0,6 Sensitivity

0,8

Pooled Sensitivity = 0,73 (0,69 to 0,77) Chi-square = 183,94; df = 4 (p = 0,0000) 1 Inconsistency (I-square) = 97,8 %

0,6

0,5

Specificity (95% CI)

Sensitivity 1

METHODS

0,88 (0,82 - 0,92) SROC Curve

Javali et al. 2019 Eryilmaz et al. 2009 Arikan et al. 2020 Lefering 2009 Tan et al. 2017

0,99 0,93 0,96 0,49

(0,93 - 1,00) (0,83 - 0,98) (0,95 - 0,97) (0,47 - 0,51)

0,9

0,4

0,3

Symmetric SROC AUC = 0,9542 SE(AUC) = 0,0299 Q* = 0,8962 SE(Q*) = 0,0416

0,2

0,1

Pooled Specificity = 0,67 (0,66 to 0,69)

Identification

A systematic data searching based Chi-square = 914,11; df = 4 (p = 0,0000) Records identified through 0,80,4 database searching 0 0,2 0,6 0,8 1 Inconsistency (I-square) = 99,6 % on the PRISMA statement (Figure (n = 261) Specificity PubMed (n = 23) 1) was conducted in PubMed, Figure 3. Pooled Sensitivity, Specificity, and AUC of Trauma and Injury Severity Score (TRISS) for Trauma Mortality Prediction. Additional records Scopus (n = 26) identified through ProQuest (n = 106) 0,7 Sensitivity (95% CI) Scopus, ProQuest, ScienceDirect, other sources ScienceDirect (n = 93) (n = 0) CINAHL Plus in EBSCOhost (n = 13) Javali et al. 2019 0,91 (0,76 - 0,98) and CINAHL Plus (EBSCOhost), up Eryilmaz et al. 2009 1,00 (0,66 - 1,00) Arikan et al. 2020 0,86 (0,64 - 0,97) to March 25, 2021. Boolean 0,6 Records after duplicates removed Lefering 2009 0,49 (0,42 - 0,56) (n = 213) Tan et al. 2017 0,87 (0,82 - 0,91) operators were used to broaden and narrow the search result using Records excluded 0,5 Records screened (n = 152) (n =213) the keywords: "TRISS", "NISS", Inappropriate title (n = 79) Pooled Sensitivity = 0,72 (0,68 to 0,76) Inappropriate abstract (n = 63) Chi-square = 91,66; df = 4 (p = 0,0000) "RTS", "mortality", and its No full-text available (n = 10) 0 0,2 0,4 0,6 0,8 1 Inconsistency (I-square) = 95,6 % Articles assessed for 0,4 Sensitivity synonyms. Risk of bias assessment eligibility Specificity (95% CI) Articles excluded, with reasons (n = 61) (n = 56) of the studies was conducted using Javali et al. 2019 0,93 (0,88 - 0,97) Sensitivity SROC Curve Inappropriate population Eryilmaz et al. 2009 0,69 (0,58 - 0,79) 1 (n = 0) QUADAS-2 Tool. Statistical analyses 0,3 Arikan et al. 2020 0,73 (0,60 - 0,84) Studies included in Unmeasured indicator (n = 13) Lefering 2009 0,90 (0,88 - 0,92) qualitative synthesis No outcome of interest (n = 9) were performed using the software Tan et al. 2017 0,74 (0,72 - 0,76) (n = 5) Non-English or Indonesian Symmetric SROC 5 full-text (n = 4) Meta-DiSc version 1.4. Z-test was 0,9 AUC = 0,8730 Conference abstracts or books 0,2 SE(AUC) = 0,0113 (n = 10) Studies included in adopted to compare the pooled Review (n = 13) Q* = 0,8034 quantitative synthesis Pooled Specificity = 0,80 (0,79 to 0,81) Editorial (n = 7) (meta-analysis) AUCs (AUSROCs) of TRISS, NISS, SE(Q*) = 0,0113 Chi-square = 140,69; df = 4 (p = 0,0000) 0,8 (n = 5) 0 0,2 0,10,4 0,6 0,8 1 Inconsistency (I-square) = 97,2 % and RTS with p < 0.05 indicating a Specificity Figure 1. PRISMA Flowchart. statistical significance. Figure 4. Pooled Sensitivity, Specificity, and AUC of New Injury Severity Score (NISS) for Trauma Mortality Prediction. 0,7 Sensitivity (95% CI) 0 Inclusion criteria: Exclusion criteria: 0 0,2Javali et al. 2019 0,4 0,97 (0,85 - 1,00)0,6 0,8 1 1. Observational study 1. Inappropriate population, indicators, 1-specificity Eryilmaz et al. 2009 1,00 (0,66 - 1,00) Arikan et al. 2020 0,90 (0,70 - 0,99) 0,6 2. Hospitalized patients due to any or outcome Lefering 2009 0,44 (0,37 - 0,51) Tan et al. 2017 0,72 (0,66 - 0,78) types of trauma 2. Non-extractable data 3. TRISS, NISS, RTS as indicators 3. Not written in English or Indonesian 0,5 with cut-off, AUC, sensitivity, 4. No full-text available Pooled Sensitivity = 0,64 (0,60 to 0,68) Chi-square = 78,72; df = 4 (p = 0,0000) and specificity values 5. Review, report, editorial, conference 0 Inconsistency (I-square) = 94,9 % 0,2 0,4 0,6 0,8 1 0,4Sensitivity 4. Mortality as outcome abstracts or books Specificity (95% CI) 0

0,2

0,4

0,6

0,8

1-specificity

Sensitivity 1

SROC Curve

Screening

0,9

0,8

Sy AU SE Q SE

0,7

Eligibility

0,6

0,5

0,4

0,3

Included

0,2

0,1

0,2

0,4

0,6

0,8

1-specificity

Sensitivity 1

SROC Curve

0,9

0,8

0,7

0,6

0,5

Table 1 provides a summary of the studies included in this meta-analysis. The five studies included 3,778 trauma patients in total (82.7% were male) with the mean age of 38. Four studies3,6,8,9 were cohort and one by Eryilmaz et al.7 was a cross-sectional study. Mechanism of trauma varied between studies with blunt trauma being the most prevalent (90.8%). The risk of bias assessment summary Figure 2. QUADAS-2 Summary is provided in Figure 2. The pooled sensitivity and specificity of TRISS to predict mortality (Figure 3) were 73% (95% CI = 69%–77%) and 67% (95% CI = 66%–69%), respectively. The pooled results for NISS (Figure 4) were 72% (95% CI = 68%–76%) for sensitivity and 80% (95% CI = 79%–81%) for specificity, whereas the pooled results for RTS (Figure 5) were 64% (95% CI = 60%–68%) for sensitivity and 83% (95% CI = 82%– 84%) for specificity. The pooled AUC of TRISS to predict mortality (Figure 3) (AUSROC = 95.4%) was significantly higher compared to NISS (Figure 4) (AUSROC = 87.3%; p = 0.01) and RTS (Figure 5) (AUSROC = 86.1%; p = 0.005). However, statistical significance was not observed when comparing the pooled AUCs of NISS and RTS (p = 0.54). References : 1. World Health Organization. The top 10 causes of death - Factsheet. WHO reports. 2018;(May 2018):6–13. 2. Galvagno SM, Massey M, Bouzat P, Vesselinov R, Levy MJ, Millin MG, et al. Correlation Between the Revised Trauma Score and Injury Severity Score: Implications for Prehospital Trauma Triage. Prehospital Emerg Care. 2019;23(2):263–70. 3. Lefering R. Development and validation of the Revised injury severity classification score for severely injured patients. Eur J Trauma Emerg Surg. 2009;35(5):437–47. 4. Orhon R, Eren ŞH, Karadayi Ş, Korkmaz I, Coşkun A, Eren M, et al. Comparison of trauma scores for predicting mortality and morbidity on trauma patients. Ulus Travma ve Acil Cerrahi Derg. 2014;20(4):258–64.

Javali et al. 2019 Eryilmaz et al. 2009 Arikan et al. 2020 Lefering 2009 Tan et al. 2017

Sensitivity 0,3 1

RESULT

5. 6. 7. 8.

0,80 (0,73 - 0,86) SROC Curve 0,05 0,93 0,89 0,83

(0,01 - 0,13) (0,83 - 0,98) (0,87 - 0,91) (0,81 - 0,84)

0,2 0,9

0,2

0,4

0,3

Symmetric SROC AUC = 0,8614 SE(AUC) = 0,0152 Q* = 0,7921 SE(Q*) = 0,0147

0,2

0,8 0,1 0,4

0,6 Specificity

0,8

Pooled Specificity = 0,83 (0,82 to 0,84) Chi-square = 266,17; df = 4 (p = 0,0000) 1 Inconsistency (I-square) = 98,5 %

0,1

0,2

0,4

0,6

0,8

1-specificity

Figure 5. Pooled Sensitivity, Specificity, and AUC of Revised Trauma Score (RTS) for Trauma Mortality Prediction. 00,7

0,2

0,4

DISCUSSION AND LIMITATION 1-specificity

0,6

0,8

Our study 0,6 showed a better accuracy for TRISS than NISS and RTS, as indicated by the pooled AUC, whereas the pooled specificity of TRISS was found to be lower than NISS and RTS. However, according to the Cochrane 0,5 Handbook10, estimating the pooled sensitivity and specificity may not be the best way to compare accuracies since cut-off values were different between studies. Therefore, estimating and comparing0,4 the summary ROCs (AUSROCs), as we did in our study, are more recommended and will provide more informative approach.10 TRISS also evaluates both anatomical and physiological factors in patients, while NISS and RTS assess only one of either. Scores which include both factors are useful in patient’s prognosis 0,3 in any type of trauma.11 There are several limitations in our study. First, the number of included studies is still limited. Second, there were differences regarding the types of trauma among the patients. 0,2

CONCLUSION TRISS has the 0,1 highest and better accuracy for predicting mortality in trauma patients compared to NISS and RTS, which suggests the utility of TRISS in clinical settings. Further studies are warranted to confirm our 29 findings and determine the best scoring system for patients based on their specific type of trauma. 0 0

0,2

0,4

0,8 1 population. Burn Trauma. 2017;5:1–6. 9. Tan0,6 JH, Tan HCL, Noh NAM, Mohamad Y, Alwi RI. Validation of the trauma mortality prediction scores from a Malaysian 10. Macaskill P, Gatsonis C, Deeks JJ, Harbord RM, Takwoingi Y. Chapter 10: Analysing and Presenting Results. In: Deeks JJ, Bossuyt PM, Gatsonis C (editors), Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 1.0. The Cochrane Collaboration, 2010. Available from: http://srdta.cochrane.org/. 1-specificity 11. Beuran M, Negoi I, Pǎun S, Runcanu A, Gaspar B, Vartic M. Trauma Scores: A review of the literature. Chir. 2012;109(3):291–7.

Zamora J, Abraira V, Muriel A, Khan K, Coomarasamy A. Meta-DiSc: A software for meta-analysis of test accuracy data. BMC Med Res Methodol. 2006;6:1–12. Javali RH, Krishnamoorthy, Patil A, Srinivasarangan M, Suraj, Sriharsha. Comparison of injury severity score, new injury severity score, revised trauma score and trauma and injury severity score for mortality prediction in elderly trauma patients. Indian J Crit Care Med. 2019;23(2):73–7. Eryilmaz M, Durusu M, Menteş Ö, Özer T, Killç S, Ersoy G, et al. Comparison of trauma scores for adults who fell from height as survival predictivity. Turkish J Med Sci. 2009;39(2):247–52. Arikan AA, Selçuk E, Bayraktar FA. Predicting outcomes of penetrating cardiovascular injuries at a rural center by different scoring systems. Brazilian J Cardiovasc Surg. 2020;35(2):198–205.

Sy AU SE Q SE

The Potential of Biodegradable Magnesium Screw as an Alternative Implant for Internal Fixation in Orthopaedic Trauma : A Systematic Review Brenda Kristi1a, Audrey Patricia Tandayu1, Amandus Michael Martin1, Vincentius Mario Yusuf1 Undergraduate Medical Program, Faculty of Medicine, Universitas Brawijaya 1

ABSTRACT

Introduction:Orthopaedic injuries as the most common type of trauma have a high morbidity and mortality rate that still become an unsolved problem in both developed and developing countries. Open Reduction and Internal Fixation(ORIF) is often needed with titanium as common implant, but they induce foreign body reaction and stress shielding because of different mechanical properties with cortical bone. Moreover, secondary operation is required which indicates not cost-effective. Recently, it is known that magnesium alloys as biodegradable materials possess mechanical properties such as strength, osteoanabolic activity, and elastic modulus similar to cortical bone. Objective:This systematic review aims to evaluate the effectiveness of biodegradable magnesium screw as an alternative implant for internal fixation in orthopaedic trauma. Method:Journal selection process, using the electronic primary database "PubMed", “Cochrane Library", and “Science Direct” with 2017-2021 publication range, was selected based on inclusion criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) was used in this review. Journals quality was analyzed using Joanna Briggs Institute(JBI) Critical Appraisal Tools Guideline. Result:Among 815 articles screened, eight valid and reliable journals were included. From radiographic imaging, magnesium screws showed less artifact, decreased radiolucency, and same mineral density with cortical bone. It also significantly increased osteoblasts activity and decreased osteoclast activity that promotes bone healing process and growth near the implanted area than titanium. Most patients did not have to undergo secondary operation because of its degradation process. It also relieved pain and improved patients Range of Motion(ROM). It is considered safe based on normal patients’ Mg serum level. However, corrosion occurs in 3 studies. Conclusion:The use of biodegradable magnesium screw is effective as an alternative implant for internal fixation in orthopaedic trauma with many advantages and corrosion risk. More studies about coatings as a reductor of high corrosion rates in human trial is needed.

Keywords:internal fixation, magnesium implant, trauma

The The Potential Potential of of Biodegradable Biodegradable Magnesium Magnesium Screw Screw as as an an Alternative Alternative Implant Implant for for Internal Internal Fixation Fixation in in Orthopaedic Orthopaedic Trauma Trauma :: A A Systematic Systematic Review Review Brenda Kristi, Audrey Patricia Tandayu, Amandus Michael Martin, Vincentius Mario Yusuf Undergraduate Program, Faculty of Medicine, Universitas Brawijaya

INTRODUCTION

RESULTS & DISCUSSION

World Health Organization stated that every hour 570 people die worldwide due to trauma with orthopaedic injuries as the most common type.1 Orthopaedic injuries have still become an unsolved problem in both developed and developing countries causing high burden in many aspects including disability, quality of life, and economy. Appropriate orthopaedic management is required to reduce mobility impairment, deformity, discomfort or disability, and pain.2

Some conditions such as nonunion, unstable, and unreduced fractures that can not be conventionally reduced will undergo a procedure called Open Reduction and Internal Fixation (ORIF).3 Steel and titanium-based implants are commonly used in ORIF because of their biocompatibility, stability, and mechanical strength. Nevertheless, these nonbiodegradable materials may induce stress shielding, foreign body reactions, and slower bone-healing processes due to the difference of its mechanical properties with cortical bone.4 Moreover, secondary operations for implant removals are expensive, often causing pre-operative anxiety and complications with limited success rate. In this COVID-19 era, surgery is also restricted in order to limit exposure.5 Recently, there is a new implant candidate which has the potential to not undergo secondary operations. Biodegradable materials will be degraded inside the body and excreted in the form of urine, feces, and respiratory process. Magnesium alloys as biodegradable materials possess mechanical properties such as strength, osteoanabolic activity, and elastic modulus similar to cortical bone.6 Moreover, its corrosion rate are also controllable in vivo which shows that the intermediate corrosion products are absorbed and metabolized inside the body. It is also reported that magnesium implants promote the growth of new bones.7 Based on these problems, we have an initiation to identify the outcomes, advantages compared to other materials, risks and obstacles in the implementation of magnesium implant in orthopaedic trauma. Therefore, this systematic review aims to evaluate the effectiveness of biodegradable magnesium screw as an alternative implant for internal fixation in orthopaedic trauma.

Author (year) and Study Design

Patient Group

Sample Number

Windhagen et al., (2013), RCT

Symptomatic Hallux Valgus

-12 Mg group (magnesium-based MgYREZr screws) -12 Ti group (standard titanium screws)

Yu et al., (2015), RCT

Displaced femoral neck fracture

-19 Mg group (biodegredable magnesium screws combined with vascularized iliac grafting)

Zhao D et al., (2016), RCT

Osteonecrosis femoral head with Autologous vascularized bone grafting

-23 (Mg alloy screw fixation) -25 without Mg (without fixation)

Plaass et al., (2016), Prospective Case-Series

Symptomatic hallux valgus with Chevrontype osteotomy indication

Plaass et al., (2017), RCT

Symptomatic Hallux Valgus

Kose et al., (2018), Retrospective Case-series

Medial Malleolar Fracture (Herscovici type C and type B fractures)

Acar et al., (2019), Retrospective Case-Series

Atkinson et al., (2019) Retrospective Case-Series

Osteochondral Lesions of the Talus

Hallux Valgus Deformity

Summary of Findings During 6 months follow up : - Improvement in AOFAS score for hallux, reduction in VAS for pain assessment, minimum passive ROM of 60° and minimum active ROM of 50° at the MTPJ. No significant differences were found between groups. - No foreign body reactions, avascular necrosis, bone erosion, osteolysis, or systemic inflammatory reactions were detected. The healing rate was 100%. - Mg group shows lower incidence of postoperative sickness (1 vs 2) and pneumonia (0 vs 1). - Delayed wound healing in superficial wound (2 in TI group and 1 in Mg group). During average 16 months (range 8-24 months) follow-up dengan p<0,05: - In 18 cases (94.7 %), the hip union was achieved at an average duration of 4.1 months. - The nonunion was observed in 1 hip (5.3 %) and subjected to the revision to a hip replacement after twelve months of operation. - The average of HHS was 93.5. The average length of the limb was shortened by 1.1 cm. - No patient developed avascular necrosis of femoral head after operation.

JBI Score

10 of 13 (High)

9 of 13 (Moderate)

During 1 year follow-up: -Mg screw degraded ( from 3.7±0.4 % until 25.2±1.8 % left). -No bone flap displacement or prolapsing in Mg group, while control showed 12% of prolapsing rate and 28% of displacement rate. Mg screws also promoted mineral density. -HHS score in Mg group was higher than control (95.7% vs 84 %). -Serum level of Mg, Ca, and P within normal physiologic ranges.

11 of 13 (High)

-During 6 weeks, 12 weeks, and last follow up (mean: 21.4 weeks), AOFAS Score and FAAM-ADL increased (p=0.71; p=0.052). NRS for pain decreased (from 3.7 to 0.3). -The x-rays showed a significant improvement of all HV-parameters, including the HVA (p < 0.001) and the IMA (p < 0.001). -Bony healing could be seen in 79% after 6 weeks and 90% of the feet after 12 weeks.

10 of 13 (High)

-8 Mg group (magnesium-based MgYREZr screws) -6 Ti group (standard titanium screws)

During 3 years follow-up: - Improvement of post-operative AOFAS, VAS, and MTP-1-ROM in both groups with no significant difference between the groups (p= 0.285, 0.94, and 0.604). -Mg implants showed significantly less artifacts in the MRI, degraded but are not fully remodeled in 3 years. - No significant differences in time to full rehabilitation between the groups (p=0.887). -Few patients in Ti group reported some residual swelling and reduced mobility, while not in the Mg group.

9 of 10 (High)

-11 Mg (magnesiumbased MgYREZr screws)

During 1 year follow-up: - The mean of AOFAS and VAS score were 94.9 ± 5.7 and 0.4 ± 1.2 points - The ankle ROM reached the normal range (20° dorsiflexion–45° plantar flexion) - Radiographic solid union was achieved in all patients and no signs of post-traumatic osteoarthritis were shown - No patients required implant removal nor revision surgery

8 of 10 (High)

-11 Mg group (magnesium-based MgYREZr screws) -11 Ti group (standard titanium screws)

During at least 1 year (range 12-49 months) follow-up: -Clinically significant improvements in AOFAS and VAS were obtained in both groups with no statisticallysignificant difference between the groups (p 0.079 and 0.107). -Complete union of the osteotomy was obtained in all patients. -No significant complication was found in Mg group, one Ti group patient required implant removal due to complications.

9 of 10 (High)

-11 Mg group (magnesium-based MgYREZr screws) -25 Ti group (standard titanium screws)

During a median of 19 months (range 12-30 months) follow-up: -Patients in both groups demonstrated significantly improved scores of foot pain and function following the surgery (p < 0.05). -All scoring systems parameters improved significantly with no significant differences of post-operative scores between the groups for any individual scoring parameter. -No impairment to quality of life,no intra or post-operative complications were found.

8 of 10 (High)

40 Mg (magnesiumbased MgYREZr screws)

*AOFAS: American Orthopaedic Foot and Ankle Society Score; VAS: Visual Analog Scale; ROM: Range of Motion; MTP: metatarsophalangeal; FAAM: Foot and Ankle Ability Measurement; HHS: Harris Hip Score; NRS: Numeric Rating Scale Table 1. Characteristics of Included Studies

MATERIALS & METHODS SEARCH STRATEGY PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement rules KEYWORDS “Magnesium OR Magnesium Screw”, “Biodegradable Implant”, “Internal Fixation”, “Orthopaedic Trauma”

EXCLUSION CRITERIA 1. Unfound full text articles 2. Non-research articles

QUALITY ASSESSMENT Joanna Briggs Institute (JBI) Critical Appraisal Tools

INCLUDED

ELIGIBILITY

SCREENING

IDENTIFICATION

INCLUSION CRITERIA 1. Empirical studies that show the use of magnesium screw as an implant for patients with all types of orthopaedic trauma 2. Study published in the last 10 years (2012-2021) 3. Study were written in English

Records identified through database searching (n=815) Pubmed= 86 Sciencedirect= 329 MEDLINE=6 Proquest= 330 Cochrane= 64

Records after duplicates removed (n=588)

Titles and abstract screened (n=331)

Full-text articles assessed for eligibility (n=27)

Records excluded (n=304) -published before 2012 (n=19) -not correlated (n=236) -non-research articles (n=49) Full-text articles excluded (n=19) -8 full text irretrievable -7 non human trials -4 dental samples

Valid and reliable studies based on inclusion criteria (n=8) Figure Figure1.1.Diagram DiagramFlow Flowof ofLiterature LiteratureSearch SearchStrategy Strategy

REFERENCES

Figure 2. MRI after 3 years using Ti implant (a,b) shows more artifacts compared with Mg implant (c,d) in distal metatarsal.11

Figure 3. Decreasing amount of radiolucency around screws. At 2 years follow-up showed same density with cortical bone.12

Figure 4. (A) Preoperative CT showing Garden III fracture. (B) Postoperative CT showing magnesium screw (red ring) and two cannulated screws. (C) 12 months postoperative CT showing the fracture healing.8

Eight valid and reliable clinical studies were reviewed with the total sample of 214 patients. According to a study by Windhagen et al4, the use of magnesium screw as an internal fixation implant in orthopaedic trauma has been proven effective because it increases mineral density and bone healing process, relieves pain, and improves patients ROM. Study by Zhao et al9 showed that most patients did not have to undergo secondary operation in order to remove implants because of its degradation process so that it is considered more cost-effective than other materials. Moreover, based on studies conducted by Yu et al8 and Plaass et al10 showed that it also increases patients quality of life and prevents complications. This happened due to the elastic modulus of Magnesium range from 38 GPa to 45 GPa which is close to cortical bone (E=40-57 GPa). There is also a significant increased activity of the osteoblasts and decreased activity of osteoclast that promotes bone healing process and growth near the implanted area.8,10 The use of magnesium implant for ORIF is considered safe according to study conducted by Zhao et al.9 After one year follow up, the serum levels of Mg, Ca, and P in all patients who use Mg implant were within the normal physiological ranges. Mg screw also degrades inside the body through corrosion rather than undergo hydrolysis as in conventional implants. This corrosion mechanism reduces the inflammatory response associated with screw absorption and is less irritant to surrounding tissues, thus minimizing osteolysis.14 However, 3 out of 8 studies showed that hydrolysis reactions still occurred in few patients, producing hydrogen gas that was observed in radiological findings of soft tissue around the surgical site, but without any local inflammation and it absorbed overtime without interfering the healing process.11,13,14 In order to improve Mg resistance to corossion inside the body and increase surface biocompatibility, tryethoxy(octyl)silane and calcium phosphate has been used as coatings.15 Biodegradable Mg implant also has a great potential for antibacterial orthopedic implant applications. In an in vivo and in vitro study by Li et al16, Mg was highly effective against methicillin-resistant Staphylococcus aureus, as the cause of progressively increasing postoperative infection and improved new peri-implant bone formation, compared to the Ti group. The bacterial assays demonstrated that Mg implant significantly reduced bacterial adhesion (in CFU) and prevented biofilm formation due to the increased local alkalinity (p<0.01).16 Despite the promising result, several studies still have limited sample size and relatively short follow-up time, therefore further study should be focused on long-term outcome and larger sample size.

CONCLUSION

The use of biodegradable magnesium screw is effective as an alternative implant for internal fixation in orthopaedic trauma because of its cortical bone-like mechanical strength, biocompatibility, osteoanabolic activity, faster bone healing process, and antibacterial properties. Secondary operation is not needed so that it is considered more cost-effective than other materials. More studies about coatings as a reductor of its high corrosion rates in human trials is needed so that Mg implants can mimic the physiological processes well which lead to better outcome.

1. World Health Organization. Global status report on orthopaedic trauma. World Health Organization; 2018. 2. The University of Texas Southwestern Medical Center. Trauma and Fractures. [Internet]. Texas: UTS Medical Center; [updated 2020; cited 2021 Apr 01]. Available from: https://utswmed.org/conditions-treatments/trauma-and-fractures/ 3. Yongu WT, Amaefula T, Elachi IC, Mue DD, Songden ZD, Kortor JN. Indications and Outcome of Open Reduction and Internal Fixation of Long Bones in Benue State North Central Nigeria. Sudan Journal of Medical Sciences. 2014 Jun 19;9(1):15-20.

9. Zhao D, Huang S, Lu F, Wang B, Yang L, Qin L, et al. Vascularized bone grafting fixed by biodegradable magnesium screw for treating osteonecrosis of the femoral head. Biomaterials. 2016;81:84–92. 10. Plaass C, Ettinger S, Sonnow L, Koenneker S, Noll Y, Weizbauer A, et al. Early results using a biodegradable magnesium screw for modified chevron osteotomies. J Orthop Res. 2016;34(12):2207–14. 11. Plaass C, von Falck C, Ettinger S, Sonnow L, Calderone F, Weizbauer A, et al. Bioabsorbable magnesium versus standard titanium compression screws for fixation of distal metatarsal osteotomies – 3 year results of a randomized clinical trial. J Orthop Sci. 2017;23(2):321–7.

4. Windhagen H. Biodegradable magnesium implants for orthopedic applications. Journal of Materials Science. 2013 Jan 1;48(1):39-50. 5. Stinner DJ, Lebrun C, Hsu JR, Jahangir AA, Mir HR. The orthopaedic trauma service and COVID-19: practice considerations to optimize outcomes and limit exposure. Journal of orthopaedic trauma. 2020 Apr 13. 6. Luo Y, Zhang C, Wang J, Liu F, Chau KW, Qin L, Wang J. Clinical translation and challenges of biodegradable magnesium-based interference screws in ACL reconstruction. Bioactive Materials. 2021 Oct 1;6(10):3231-43. 7. Windhagen H, Radtke K, Weizbauer A, Diekmann J, Noll Y, Kreimeyer U, et al. Biodegradable magnesium-based screw clinically equivalent to titanium screw in hallux valgus surgery: Short term results of the first prospective, randomized, controlled clinical pilot study. Biomed Eng Online. 2013;12(1). 8. Yu X, Zhao D, Huang S, Wang B, Zhang X, Wang W, et al. Biodegradable magnesium screws and vascularized iliac grafting for displaced femoral neck fracture in young adults. BMC Musculoskelet Disord. 2015;16(1):1–6.

12 Kose O, Turan A, Unal M, Acar B, Guler F. Fixation of medial malleolar fractures with magnesium bioabsorbable headless compression screws: short-term clinical and radiological outcomes in eleven patients. Arch Orthop Trauma Surg. 2018;138(8):1069–75. 13. Acar B, Kose O, Unal M, Turan A, Kati YA, Guler F. Comparison of magnesium versus titanium screw fixation for biplane chevron medial malleolar osteotomy in the treatment of osteochondral lesions of the talus. Eur J Orthop Surg Traumatol. 2020;30(1):163–73. 14. Atkinson HD, Khan S, Lashgari Y, Ziegler A. Hallux valgus correction utilising a modified short scarf osteotomy with a magnesium biodegradable or titanium compression screws - a comparative study of clinical outcomes. BMC Musculoskelet Disord. 2019;20(1):334. 15. Gu XN, Guo HM, Wang F, Lu Y, Lin WT, Li J, Zheng YF, Fan YB. Degradation, hemolysis, and cytotoxicity of silane coatings on biodegradable magnesium alloy. Materials Letters 2017; 193, 266-269. 16. Li Y, Liu G, Zhai Z, Liu L, Li H, Yang K, Tan L, Wan P, Liu X, Ouyang Z, Yu Z. Antibacterial properties of magnesium in vitro and in an in vivo model of implant-associated methicillin-resistant Staphylococcus aureus infection. Antimicrobial agents and chemotherapy. 2014 Dec 1;58(12):7586-91.

Emergency Box as A Solution to Reduce Early Death Caused by Trauma from Traffic Accidents on Highways Gabriella Sachiko Jannesha Sudirman*, Jeremy Abednego*, Michael Daniel*, Calista Yudhi Artasya** * Atma Jaya Catholic University of Indonesia, **Sebelas Maret University Introduction In trauma care, there’s a term called the golden hour. The golden hour is the first 60 minutes after trauma which aims to prevent early death.[1] In these few minutes, paramedics’ early management could be crucial to the patient’s life. Without adequate equipment, early management of trauma can’t be done properly. When a traffic accident happens on a highway, it surely takes a long time to wait for the paramedics to arrive, leading to a high level of early death. To solve this problem, our group offers innovation to put up an emergency box, especially for trauma patients containing the equipments that are needed to do early management and first aid that commoners can do without having to wait for paramedics. Objective Our innovation aims to prevent early death in trauma patients because of traffic accidents, especially on highways. Method This study used a randomized controlled trial. It consists of the average number of traffic accidents on highways in 2018-2019 from the Central Bureau of Statistics in Jakarta and common factors that result in early death from an article. To reduce early death, we also search for the early management of trauma from some trusted websites. Result This study shows that the average number of traffic accidents on highways in 2018-2019 is 785, with the average number of deaths being 59.[2] These accidents are commonly caused by the driver, such as drowsiness and lack of anticipation.[3] Based on the number of deaths, trauma is the leading cause of it.[4] There is a trimodal peak of death, and the first peak occurs within seconds to minutes. It is usually due to laceration of the brain stem, heart, aorta, and other large vessels. The second peak occurs within minutes to hours later and can be due to various injuries. Lastly, The third peak of death occurs several days to weeks after the initial injury and is most often due to sepsis and multiple organ system failures.[1] To overcome this, there is a need to do early management of trauma and basic life support. Early management of trauma can be done by doing airway management, respiratory distress management (breathing), and shock management (circulation), which are the primary assessment. Airway can be done by suctioning of mouth and nose with a chin lift and always assume that every patient has a cervical spine injury. Breathing can be done by using an oxygen mask/reservoir bag. Circulation can be done by checking the patient’s pulse then insert three large-bore cannulae or intravenous lines. But, since paramedics will do the circulation assessment, we won’t include the equipment in the box. For basic life support, people need to move the patient out of the vehicle to a safe place if possible and resuscitate with AED if the patient is not breathing. If the patient is bleeding, wear gloves and apply dressing to the wound.[5] [6] Conclusion This emergency box can be a solution to reduce early death in trauma patients because of traffic accidents on highways. The box will contain a list of instructions and emergency telephone numbers, and the equipment required for the early management of trauma and basic life support. Besides the emergency box, there will also be a phone box that directly connects to the nearest hospital with an ambulance, and on top of the box, there will also be CCTV to ensure security. Key findings : golden hour, early management of trauma, emergency box, traffic accident

Serum Biomarkers as Diagnostic and Prognostic Tools in Patients with Traumatic Spinal Cord Injury: a Systematic Review Kellyn Trycia Zenjaya1a, Santika Danubrata1, Evelyn1, Vincentius Mario Yusuf2 Undergraduate Program, Faculty of Medicine, Universitas Hang Tuah1 Undergraduate Program, Faculty of Medicine, Universitas Brawijaya2 a

kellyn.trisenjaya@gmail.com

ABSTRACT

Introduction: Traumatic spinal cord injury (SCI) continues to be a devastating worldwide problem leading to motor and sensory deficits associated with permanent disability and death. Quick diagnosis and prognostic approaches are essential to prevent injury progression and provide better clinical interventions. Current clinical assessments are found to be imprecise predictors of neurologic recovery and are often difficult to be applied in acute settings. Serum biomarkers provides a promising alternative solution, safe and easily accessible biofluid to determine SCI diagnostic and prognostic value. Objective: This study aimed to examine the potential of serum biomarkers to determine diagnostic and prognostic values of traumatic SCI. Methods: Systematic review about serum biomarkers in traumatic SCI patients was carried out through electronic databases such as PubMed, Plos One, MedlinePlus, Science Direct and Trip Database. The inclusion criteria include papers published in English between 2016-2021. The studies went through a selection process based on PRISMA statement. Critical appraisal of included papers was conducted using CEBM ‘Levels of Evidence’. Results: Seven prospective and retrospective cohort studies with 390 patients were analyzed, and increase in various proteins in peripheral blood serum were inferred. Eight out of eighteen biomarkers of the studies proved to be serum biomarkers reliable for both diagnosis and prognosis in the clinical settings. The aforementioned transpires because the biomarker profile was correlated with short- or long-term prognosis, such as survival rate or sensory and motor function. The accretion of these proteins contributes in the diagnosis, while other proteins ascertain a patient's prognosis because it reflects the severity of SCI, and the concentration of proteins are directly correlated with the AIS grade. Conclusion: Various proteins obtained from peripheral blood serum post SCI have high potential as future diagnostic and prognostic tools in patients with traumatic SCI.

Keywords: traumatic spinal cord injury, blood serum, biomarker

EFFECT OF MANDATORY MOTORCYCLE HELMET LAWS FOR ALL-AGES VS UNDERAGES IN THE PREVENTION OF TRAUMATIC BRAIN INJURY: A SYSTEMATIC REVIEW

Authors: M. Lutfi Maudi

(22095)

Muhammad Dewangga Putra Laksana

(22503)

Muhammad Arkan Ramadhan

(22657)

Shin Salsabila Harukirana

(22518)

AMSA-Universitas Gadjah Mada

INTRODUCTION Every year, there are 50 million traumatic brain injuries around the world. Meanwhile, around half the population of the world who have never suffered traumatic brain injuries (TBI) will experience it in the future. (Maas et al, 2017). Various references have stated that traffic accidents are one of the main causes of TBI in various parts of the world. Among motorbike users who do not wear helmets, TBI also contributes significantly to causing death (Striker et al, 2016) OBJECTIVE To investigate the effect of mandatory motorcycle helmet laws for all-ages underages in the

prevention of traumatic brain injury METHOD We conducted a systematic review (SR) that has inclusion criteria: using mandatory helmet law for all ages or underages, outcomes provide the amount of traumatic brain injury patients, and the studies published in 2016-2021 also exlusion criteria: cranial bone fracture without traumatic brain injury, using non-English, and full text irretrievable. RESULT Study states that the incident caused a two-fold increase in the number of trauma patients who were not wearing helmets and a significant increase in TBI cases. Several other references who carried out a similar study found an increase in the percentage of trauma patients who were not wearing helmets, from 6.1-8% to 28.8-30.5% (Saunders et al, 2017). CONCLUSION Various studies agree that the replacement to the partial helmet law has led to a decrease in helmet use among motorcyclists and an increase in traumatic brain injury patients

KEY FINDINGS • •

The use of helmet as a form of protection has limited effectiveness if it is not applied to all motorcyclists Replacement to partial helmet law has led to a decrease in helmet use and an increase in traumatic brain injury patients

EFFECT OF MANDATORY MOTORCYCLE HELMET LAWS FOR ALLAGES VS UNDERAGES IN THE PREVENTION OF TRAUMATIC BRAIN INJURY: A SYSTEMATIC REVIEW M. Lutfi Maudi, Muhammad Dewangga P L, Muhammad Arkan R, Shin Salsabila H

Introduction Every year, there are 50 million traumatic brain injuries around the world. Meanwhile, around half the population of the world who have never suffered traumatic brain injuries (TBI) will experience it in the future. (Maas et al, 2017). Various references have stated that traffic accidents are one of the main causes of TBI in various parts of the world, such as the USA (Wagner et al, 2021; Johnsohn and Subramanian, 2020), China (Jiang et al, 2019), India (Marya et al, 2017; Wagner et al, 2021). Latin America, the Caribbean, sub-Saharan Africa (Wagner et al, 2021), and Cambodia (Venturini et al, 2019). TBI can cause death (Johnsohn and Subramanian, 2020) and has a big contribution in causing moderate and severe disabilities (Saunders et al, 2017). Among motorbike users who do not wear helmets, TBI also contributes significantly to causing death (Striker et al, 2016) This systematic review aims to study the effect of mandatory motorcycle helmet laws for all-ages vs mandatory motorcycle helmet laws only for underages in traumatic brain injury patient

Method

Method INCLUSION CRITERIA EXCLUSION CRITERIA Using mandatory Cranial bone helmet law for all ages fracture without or underages traumatic brain Outcomes provide the injury case Using non-English amount of traumatic Full text brain injury patients Studies published in irretrievable 2016-2021

AMSA-Universitas Gadjah Mada

Discussion Mandatory Motorcycle Helmet Law for All-Ages Vs Mandatory Motorcycle Helmet Law for Underages The mandatory use of a helmet as a form of protection has limited effectiveness if it is not applied to all motorcyclists (Johnsohn and Subramanian, 2020). In the US, states that enforce universal helmet laws have a higher percentage of helmet use than states with a partial helmet law and no helmet law. Consecutively, the percentage of helmet use in states with a universal helmet law, partial helmet law, and without helmet law is 90%, 61%, and 53% (Saunders et al, 2017). Another study has compared states with mandatory motorcycle law of helmet for all age (MMLHA) and states with mandatory motorcycle law of helmet for underages (MMLHU) using a database covering 95% of the US population. As a result, states with MMLHU show higher TBI rates and mortality (Hassan et al, 2017). Apart from being able to increase the use of helmets more effectively, community compliance with MMLHA can also be observed directly. On the other hand, MMLHU is difficult to monitor its implementation because of the existence of law enforcement based on age which cannot be identified only by observation. Even though it is focused on young bikers, MMLHU still cannot compete with MMLHA in suppressing TBI rates among young bikers. TBI in states with MMLHU has a 38% higher percentage of TBI when compared to states with MMLHA. Besides, MMLHA is also superior if the mortality rate of the two is compared, that is, with a 31% lower mortality rate (Nolte et al, 2017). MMLHA can also be implemented more effectively than MMLHU for teenage motorcyclists. Based on a study conducted in the US, adolescent non-compliance with mandatory helmet use was about 3 times higher for MMLHU than for MMLHA. This phenomenon is thought to occur for several reasons. First, MMLHA is more convincing in conveying the message that helmets can act as protectors. Second, adolescents can respect MMLHA more because it appears as a benefit-based law that is enforced for safety reasons. On the other hand, MMLHU can be interpreted as an effort to exercise youth control because of the age specifications for young motorcyclists (Berrick and Gkritzab, 2021).

Traumatic Brain Injury Patient Studies agree that the replacement of the universal helmet law by the partial helmet law, which is similar to the MMHLU in the US, has led to a decrease in helmet use among motorcyclists. This decrease is not only observed from the number of helmet use on a national scale (Wagner et al, 2021), but also from data collection among trauma patients. It is stated that the decline reached 39% (Peng et al, 2017). Another study states that the incident also occurred in Michigan in April 2012 and caused a twofold increase in the number of trauma patients who were not wearing helmets and a significant increase in TBI cases. Meanwhile, several other references who carried out a similar study found an increase in the percentage of trauma patients who were not wearing helmets, from 6.1-8% to 28.8-30.5% (Saunders et al, 2017).

Conclusion Various studies agree that the replacement of the universal helmet law by the partial helmet law has led to a decrease in helmet use among motorcyclists and an increase in traumatic brain injury patients

Reference

A Review of Quality of Life in Elderly Patient with Hip Fracture Following Post-Operative Treatment and Rehabilitation Marchelie Putri T.D., Moh. Fahmi Akbar, Husna Fitria M. Introduction The incidence of hip fractures in elderly patients is increasing every year. Globally, the number of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050. Approximately 90% of hip fractures are attributed to falls from standing height. One of the most threatening complication of a hip fracture is a threat of immobilization of the patient or a lost of ability to do an activity which involve the hip bone, i. e. walking. A hip fracture is defined as a break that occurs in the upper part of the femur (thigh bone). It is usually the results of fall and include symptoms such as pain around the hip, relatively with movement and shortening of the leg. Risk factors can include osteoporosis, medications, alcohol abuse, and metastatic cancer. A hip fracture is diagnosed by the use of X-Ray, MRI-Scan, a CT Scan, or a bone scan. Management of hip fracture may include surgery and is generally recommended within two days. Hip fracture if treated properly can lead to improvement in Quality of Life (QoL). Especially in elderly patient, they can recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, which in another better case can lead to independence for basic activities of daily living. Objectives ● To review the effectiveness of post-operative treatment in elderly patient based on improvement in the patient’s Quality of Life. ● To compare similar studies or researches as to synthesize the methods and analyze the results. ● As a reference to achieve successful treatment for elderly patient with hip fracture in general.

Materials and Methods A literature review of studies, articles, or researches done by comparing and analyzing the results of said literatures. We searched works of literatures published in ScienceDirect, by using keyword: hip fractures quality of life. Inclusion criteria of the studies includes 1) Those which are analyzing the quality of life of elderly patient with hip fracture, 2) The results involving

scoring of the Quality of Life instruments, such as EQ-5D and and CDC HRQOL. We evaluated the said literatures using objective methods to find any kinds of inconsistencies or consistencies between the results that are provided. Results From 6,534 published papers, we choose three (n=3) eligible studies that fits our inclusion criteria and therefore are valids to be reviewed. The final eligible and valid studied were reviewed here and the results were summarized in Table 1. Table 1. Summary of Studies Comparing Quality of Life in Hip Fracture Elderly Patients Following Post Operative Surgery

Study

Gjertsen et al[1]

Amarilla et al[2]

Amphansap et al[3]

Country

Norwegia

Spain

Thailand

Year

2016

2020

2018

Study Design

Retrospective Observational Study

Prospective Observational Study

Participants

10,324

224

136

Conclusion

QoL Score slightly improve in months following post-operative treatment

Decline in the HRQOL is effective in the first month and lasts at least 12 months

QoL Score slightly improve but didn't return to pre-fracture condition

Follow up

4 and 12 months post operation

1, 6. and 12 months post operation

preinjury, 3, 6, and 12 months post operation

Discussion

Hip fractures in elderly population have a significant effect on all aspects of their life. A hip fracture in an elderly patient does not only affect mobility over a period of several months, but also affects another aspects, such as psychological, self-care, comfort, and general functionality. Instruments that are commonly used in such studies are the EQ-5D scoring. This instruments has been effectively used in clinical practice for assessment for general geriatric patients in hospital. One interesting result we found between three eligible studies that we reviewed are the fact that the one study by Amarilla et al[2] show a static declining of QoL score during process of rehabilitation post surgical operation in the very least 12 months. Similar study done by Alexiou et al[4] in 2018, shows a more or less the same results with significantly better QoL score that didn’t return to normal condition at the 12 months. While the other studies show a slightly improvement of the QoL Score in 4 to 12 months post operation, the study done by Amphansap et al[3] conclude that the final score in the 12th month didn’t return to normal condition prefracture injury. There are possibly some factors that can make the difference in those results i.e. age of the participants, general lifestyle of the elderly in the country, comorbidities, and or surgical methods that were used to treat the patients themselves. Conclusion Quality of life in elderly patient with hip fracture following post-operative treatment experience slightly and relatively improvement but does not return to their pre-fracture conditions. Further studies is required in order to find out any significant factors that can affect these results and can cause any inconsistencies following the assessment of QoL scoring. This results show that in general, the operative treatment for hip fracture in clinical practice are actually able to at the very least maintain a stable yet relative score of improved Quality of Life in elderly patients. References 1. Jan-Erik Gjertsen, Valborg Baste, Jonas M. Fevang, Ove Furnes,and Lars Birger Engesæter. 2016. Quality of life following hip fractures:results from the Norwegian hip fracture register. BMC Musculoskeletal Disorders. 17:265 2. Francisco Javier Amarilla-Donoso, Raul Roncero-Martin,Jesus Maria Lavado-Garcia, Rosaura Toribio-Felipe,Jose Maria Moran-Garcia, and Fidel Lopez-Espuela. 2020. Quality of life after hip fracture: a12-month prospective study. PeerJ. 8:e9215 3. TanawatAmphansap, PuttapoomSujarekul. 2018. Quality of life and factors that affect osteoporotic hip fracture patients in Thailand. Osteoporosis and Sarcopenia. Vol (4) Issue (4). 140-144.

4. Konstantinos I Alexiou, Andreas Roushias, Sokratis e varitimidis, Konstantinos N Malizos. 2018. Quality of life and psychological consequences in elderly patients after a hip fracture: a review. Clinical Interventions in Aging 2018:13 143–150

Marchelie Putri T. D., Moh. Fahmi Akbar, Husna Fitria M. AMSA-Universitas Bosowa, Makassar, Indonesia.

INTRODUCTION

Table 1. Summary of Studies Comparing Quality of Life in Hip Fracture Elderly Patients Following Post Operative Surgery

The incidence of hip fractures in elderly patients is increasing every year. Globally, the number of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050. Approximately 90% of hip fractures are attributed to falls from standing height. One of the most threatening complication of a hip fracture is a threat of immobilization of the patient or a lost of ability to do an activity which involve the hip bone, i. e. walking. A hip fracture is defined as a break that occurs in the upper part of the femur (thigh bone). It is usually the results of fall and include symptoms such as pain around the hip, relatively with movement and shortening of the leg. Risk factors can include osteoporosis, medications, alcohol abuse, and metastatic cancer. A hip fracture is diagnosed by the use of X-Ray, MRI-Scan, a CT Scan, or a bone scan. Management of hip fracture may include surgery and is generally recommended within two days. Hip fracture if treated properly can lead to improvement in Quality of Life (QoL). Especially in elderly patient, they can recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, which in another better case can lead to independence for basic activities of daily living.

DISCUSSION Hip fractures in elderly population have a significant effect on all aspects of their life. A hip fracture in an elderly patient does not only affect mobility over a period of several months, but also affects another aspects, such as psychological, self-care, comfort, and general functionality. Instruments that are commonly used in such studies are the EQ-5D scoring. This instruments has been effectively used in clinical practice for assessment for general geriatric patients in hospital.

MATERIALS AND METHODS A literature review of studies, articles, or researches done by comparing and analyzing the results of said literatures. We searched works of literatures published in ScienceDirect, by using keyword: hip fractures quality of life. Inclusion criteria of the studies includes 1) Those which are analyzing the quality of life of elderly patient with hip fracture, 2) The results involving scoring of the Quality of Life instruments, such as EQ-5D and and CDC HRQOL. We evaluated the said literatures using objective methods to find any kinds of inconsistencies or consistencies between the results that are provided.

CONCLUSION Quality of life in elderly patient with hip fracture following postoperative treatment experience slightly and relatively improvement but does not return to their pre-fracture conditions. Further studies is required in order to find out any significant factors that can affect these results and can cause any inconsistencies following the assessment of QoL scoring. This results show that in general, the operative treatment for hip fracture in clinical practice are actually able to at the very least maintain a stable yet relative score of improved Quality of Life in elderly patients.

RESULT From 6,534 published papers, we choose three (n=3) eligible studies that fits our inclusion criteria and therefore are valids to be reviewed. The final eligible and valid studied were reviewed here and the results were summarized in Table 1.

REFERENCES 1. Jan-Erik Gjertsen, Valborg Baste, Jonas M. Fevang, Ove Furnes,and Lars Birger Engesæter. 2016. Quality of life following hip fractures:results from the Norwegian hip fracture register. BMC Musculoskeletal Disorders. 17:265 2. Francisco Javier Amarilla-Donoso, Raul Roncero-Martin, Jesus Maria Lavado-Garcia, Rosaura Toribio-Felipe,Jose Maria Moran-Garcia, and Fidel Lopez-Espuela. 2020. Quality of life after hip fracture: a 12-month prospective study. PeerJ. 8:e9215 3. Tanawat Amphansap, Puttapoom Sujarekul. 2018. Quality of life and factors that affect osteoporotic hip fracture patients in Thailand. Osteoporosis and Sarcopenia. Vol (4) Issue (4). 140-144. 4. Konstantinos I Alexiou, Andreas Roushias, Sokratis e varitimidis, Konstantinos N Malizos. 2018. Quality of life and psychological consequences in elderly patients after a hip fracture: a review. Clinical Interventions in Aging 2018:13 143–150

Scientific Paper Competition PCC AMSC 2021 COMPARING THE EFFECT OF ERYTHROPOIETIN AND ATORVASTATIN FOR TRAUMATIC BRAIN INJURY: A SYSTEMATIC REVIEW Muhammad Naufal Rozaan*, Nabila Rikke Febriyanti*, Indah Gilang Permatasari*, Ryan Mario Christian* *Faculty of Medicine, Jenderal Achmad Yani University, Cimahi, Jawa Barat, Indonesia

Introduction : Traumatic Brain Injury (TBI) is a brain condition caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. TBI is a major cause of death and life-long disability around the world. Pharmacological therapies such as neuroprotective agents have been employed in order to enhance the quality of life of TBI patients. Erythropoietin and statins are neuroprotective drugs that are commonly used in patients with TBI who have undergone surgery. Erythropoietin (EPO) is a kidney hormone which functions to maintain the number of erythrocytes. Erythropoietin not only plays a role in erythropoiesis but also has a brain protective effect by stimulating reparatory proteins, reducing neuronal excitotoxicity, reducing inflammation, inhibiting neuronal apoptosis and stimulating neurogenesis and angiogenesis in experimental studies regarding ischemic injury, hypoxia and toxic injury. Statins are often used for management of acute brain injury. Statins influence a variety of acute and secondary neurological injury pathways. In TBI, statins reduce intravascular thrombocytosis and decrease inflammatory mediators like TNF α, IL-6 and IL-1β.

Objective : This study aimed to compare the effect of Erythropoietin and Atorvastatin in their use as neuroprotective agents in TBI.

Material and Methods : Data are collected from Online Resources that have Open Access, which includes PubMED, Science Direct, and PMC. Keywords: Traumatic Brain Injury, Treatment, Erythropoietin, Atorvastatin, Experiment.

Results and Discussion : By using the inclusion and exclusion criteria, we have found 5 studies that consist of 2 experimental studies of EPO and 3 experimental studies of atorvastatin. Robinson et al, Blixt et al stated in their studies that extended EPO treatment in TBI restores executive function and prevents microstructural brain abnormalities, indicating that EPO

reduced traumatic cytotoxic edema. EPO has many positive effects on traumatic brain edema. Qi et al, Xu et al, Bidet et al stated in their studies that atorvastatin treatment in TBI significantly reduced brain water, apoptosis, provided neuroprotection against TBI via antiinflammatory and immunomodulatory effects and decreased in serum cholesterol and lowdensity lipoprotein (LDL) concentration.

Conclusions : All of the studies that we have analysed have found that both erythropoietin and atorvastatin have positive effects in the treatment for traumatic brain injury with different mechanisms. The same effect applied to TBI patients needs further studies.

Abstract a. Title : Role of Mobile Application for First Aid in Indonesia b. Name authors and amsa university : Renalta Yunita and Lavenia Pangestu From AMSA Universitas Atma Jaya Jakarta c. Introduction During this time period, the amount of accidents happening in Indonesia are considered high. In 2020 alone, the prevalence of accidents in Indonesia reached 83.715 cases. The early minutes after a person is injured or in an accident are the most important. These minutes will determine the fate of the victim in the future, whether a person will be saved or not. Therefore, first aid is needed quickly, one of which is through application. It is hoped that this application can help the community to understand and understand the initial handling method accident victim. d. Objective i.

To know the role of first aid mobile application in reducing the number of deaths due to traffic accidents.

ii.

To increase public awareness of the importance of first aid mobile application

e. Method The information gathered through PubMed, google scholar, and government institution databases, using the term “Indonesia”, “Trauma care”, “Trauma center”, “Application”. f.

Result Some examples regarding first aid mobile applications are Mobile Rapid Assessment (MRA) and PMI-FirstAid. The main function of first aid application is to enable the public to report emergency events to emergency contact numbers. Apart from this, this application can also provide up-to-date information about emergency events or other accidents with information on impacts, needs, displacement, and coordinates. When used properly, this application can certainly save many lives at once during emergency status.

g. Conclusions Mobile applications have a big potential to play as a role for first aid especially for traffic accidents in Indonesia. As an example, Palang Merah Indonesia (Indonesia Red Cross) has launched applications that help people to perform first aid during traffic accidents. Through this application, we can learn about information related to emergency situations. h. Key findings Mobile applications have a potential as first aid in traffic accidents.

ROLE OF MOBILE APPLICATION FOR FIRST AID IN INDONESIA BY RENALTA YUNITA AND LAVENIA PANGESTU FROM AMSA UNIVERSITAS ATMA JAYA JAKARTA

INTRODUCTION During this time period, the amount of accidents happening in Indonesia are considered high. In 2020 alone, the prevalence of accidents in Indonesia reached 83.715 cases. Approximately 30 people every day die from accidents while driving. However, this figure can increase by two to three people every hour so that a total of 72 people die as a result of accidents every day. According to the Police of Indonesian Republic, the highest cause of traffic accidents is due to human factors, which is 61 %. In addition, 9 % of accidents are due to vehicles and 30 % are due to infrastructure and environment. The early minutes after a person is injured or in an accident are the most important. These minutes will determine the fate of the victim in the future, whether a person will be saved or not. Therefore, first aid is needed quickly, one of which is through application. It is hoped that this application can help the community to understand and understand the initial handling method accident victim.

METHOD 1. To know the role of first aid mobile application in reducing the number of deaths due to traffic accidents. 2. To increase public awareness of the importance of first aid mobile application

RESULTS & DISCUSSION Currently, humanitarian social organizations in Indonesia have two smartphone-based applications that can be accessed anytime and anywhere, to accelerate the response to humanitarian problems. Those applications are Mobile Rapid Assessment (MRA) and PMI-FirstAid. The main function of first aid application is to enable the public to report emergency events to emergency contact numbers. Apart from this, this application can also provide up-to-date information about emergency events or other accidents with information on impacts, needs, displacement, and coordinates. When used properly, this application can certainly save many lives at once during emergency status. Other than that, the application can be useful to overcome events that may be related to the occurrence of injuries, sprains, or injuries while doing activities. The application can make it easier to learn first aid, the first aid mobile application can be a solution to provide information on how to deal with victims of accidents well.

CONCLUSION Mobile applications have a big potential to play as a role for first aid especially for traffic accidents in Indonesia. As an example, Palang Merah Indonesia (Indonesia Red Cross) has launched applications that help people to perform first aid during traffic accidents. Through this application, we can learn about information related to emergency situations.

LIMITATION Limitations include the lack of visual elements such as pictures and diagrams, first aid information on incomplete accident, data update is not maximal because you have to install latest APK (Android Package) to get update information.

ACKNOWLEDGEMENT We would like to thank AMSA-UAJ for giving us information about PCC AMSC UK 2021

CONFLICT OF INTEREST There is no conflict of interest

STUDY BACKGROUND Currently trauma care is a problem that needs attention. Especially the large number of traffic accidents that occur in Indonesia, therefore it is important to know the procedures for first aid quickly and can help reduce the death rate.

REFERENCE 1. [Internet]. 2021 [cited 2 April 2021]. Available from: https://www.researchgate.net/publication/322452172_Development_of_a_First_Aid_Smartphone_App_for_Use_by_Untrained_Healthcare_Workers/fulltext/5a597fcc0f7e9b5fb 384090a/Development-of-a-First-Aid-Smartphone-App-for-Use-by-Untrained-Healthcare-Workers.pdf 2. Dwiputra. 2 Aplikasi dari Palang Merah Indonesia untuk Selamatkan Nyawa [Internet]. klikdokter.com. 2021 [cited 2 April 2021]. Available from: https://www.klikdokter.com/info-sehat/read/3614416/2-aplikasi-dari-palangmerah-indonesia-untuk-selamatkan-nyawa 3. Rakyat P. Angka Kematian Kecelakaan di Indonesia Lebih Tinggi Dibandingkan Covid-19, Capai 72 Korban Tiap Hari - Pikiran-Rakyat.com [Internet]. Pikiran-Rakyat.com. 2021 [cited 2 April 2021]. Available from: 48 https://www.pikiran-rakyat.com/otomotif/pr-01632020/angka-kematian-kecelakaan-di-indonesia-lebih-tinggi-dibandingkan-covid-19-capai-72-korban-tiap-hari 4. View of ANALISIS FAKTOR PENYEBAB KEMATIAN PADA KECELAKAAN LALU LINTAS [Internet]. Ejournal.delihusada.ac.id. 2021 [cited 2 April 2021]. Available from: http://ejournal.delihusada.ac.id /index.php/JK2M/article/view/403/299

Efficacy of Therapeutic Hypothermia on Intracranial Pressure or Cerebral Perfusion Pressure in Pediatric Patients with Severe Traumatic Brain Injury: A Systematic Review

AUTHORS:

Jacky Klemens Owen Rivaldi Ruby Venna Bella Sabatina Hepyta Valerie

School of Medicine and Health Science Atma Jaya Catholic University of Indonesia Asian Medical Students’ Association-Indonesia 2021

ABSTRACT Introduction: Traumatic Brain Injury (TBI) is one of the leading causes of the highest mortality and disability in patients, especially in pediatric centers. Most severe disability outcomes are neurocognitive deficits. Objectives: This study aims the Therapeutic Hypothermia (TH) efficacy in lowering intracranial pressure (ICP) or cerebral perfusion pressure (CPP) for pediatric TBI to prevent further disability outcomes. Method: Systematic review was conducted with the PRISMA statement guideline to identify TH in reducing ICP and CPP in Children TBI. The literature search was done using five databases: PubMed, ProQuest, ScienceDirect, EBSCO, and CENTRAL with "Hypothermia," "Children," "Traumatic Brain Injury," and “Intracranial Pressure” as the main keywords. Cochrane RoB tool 2.0 was utilized in the quality assessment of the studies. Result and Discussion: Search strategy identified 70 studies. Five relevant full-text articles met our inclusion criteria. Overall, studies had a low risk of bias. Main findings occurring that late TH group experiences decreased values of ICP gradually and also statistically different with normothermia group at 8, 24, 48, and 72 h (p<0.05). The significant findings on CPP elevation arise in 25-72 hours after interventions that analyzed with p < 0.001. Conclusion: This systematic review based on authors' analysis revealed that therapeutic hypothermia still can be another alternative for a more efficacious effect with less adverse events in reducing ICP or elevating CPP children Traumatic Brain Injury. Further development is recommended through larger population and hazard ratio analysis regarding safety and effectivity. Keywords: Children, Intracranial Pressure, Systematic Review, Therapeutic Hypothermia, Traumatic Brain Injury

EFFICACY OF THERAPEUTIC HYPOTHERMIA ON INTRACRANIAL PRESSURE OR CEREBRAL PERFUSION PRESSURE IN PEDIATRIC PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY : A SYSTEMATIC REVIEW Rivaldi Ruby, Jacky Klemens Owen, Venna Bella Sabatina, Hepyta Valerie Atma Jaya Catholic University of Indonesia MAIN RESULTS

INTRODUCTION

Table 1. Study Characteristic

Traumatic Brain Injury (TBI) is one of the leading causes that conduct the highest mortality and disability in patients, especially in pediatric centers. Most

disability

deficits.

outcomes

are

SCAN HERE !

Abbreviation

neurocognitive

CPP

promising interventions with least Therapeutic hypothermia (TH).

: Cerebral Perfusion Pressure

One of the

ICP

invasiveness and Adverse Events is

HYPO : Hypothermia Group IV

to analyze the TH efficacy in lowering ICP or increasing CPP for pediatric TBI. The

objective

our

systematic

review

: Intracranial Pressure

: Intravenous

NORM : Normothermia Group RCT TH

: Randomized Controlled Trial : Therapeutic Hypothermia

To read our

MATERIALS & METHODS

full paper

Systematic review was

PRISMA statement guideline to conducted with the

STRENGTH AND LIMITATION

DISCUSSION

identify TH in reducing ICP and CPP in Children TBI. The literature search was done using

four databases:

Therapeutic Hypothermia Advantages This systematic review shows a

All five studies summarized

promising result of TH as feasible interventions in reducing ICP or increasing CPP

somewhat similar results regardless of each study's strengths and limitations.

Hutchison et al. (2008)

Large samples showed the superiority of the study

prevent the secondary outcomes of TBI.

PubMed, ProQuest, ScienceDirect, EBSCO, and

Hypothermia," "Children," "Traumatic Brain Injury," and “Intracranial Pressure” as the main keywords. Cochrane RoB tool 2.0 was utilized in the quality CENTRAL with "

assessment of the studies.

Figure 1. PRISMA chart for selection

Therapeutic Hypothermia: Methodology of Intervention and Measurement All five studies also

induce therapeutic hypothermia with different methods,

Beca, et al. (2015)

three studies using a blanket, surface cooling,

and one study used a localized cooling cap in the head region. The included study also

ways, two

measured the temperature in different

studies took data from the rectal probe, two studies from the esophageal probe, and one study from the indwelling

catheter, measuring intracranial temperature.

Slight differences from various measurements did not interfere with the

results.

Li, et al (2009) The study

Therapeutic Hypothermia: Onset of Interventions

Time is a crucial factor when dealing with TBI, in case of primary and secondary injury related to worsening outcomes. The secondary outcomes usually exist within 6-8 hours after TBI and worsen up to weeks. Fortunately, almost all studies were maintained within an 8 hours time frame, even though some studies came close. Comparison between Each Study Intervention Time

studies

successfully apply a protocol to avoid clinical compromises in CPP, furthermore, they also make some suggestions regarding their limitation in the amount of sample. Unfortunately, they used a pilot study so that it could not detect any extensive effect of the hypothermia treatment and their randomization rate is low only 7.2 % (55 patients out of 764 patients). They

Another factor associated with time is the time required to successfully achieve the hypothermic condition.

The

cooling period varies from one to 11 hours and the rewarming time varies from 14 to 21.5 hours.

had a high risk of bias in selection criteria due to the inappropriate randomization method that used only arrival date as a unavailable data that mentions supporting authors’ judgment.

randomization parameter. Besides that, there is

Adelson, et al. (2005) The

use of a safety trial study design makes the sample size is limited. Biswas et. al (2002)

They

suggest to have further investigation to determine the ICP threshold in children, another study’s strength is even though their they successfully maintain the CPP at > 50 mmHg in both group.

protocol was ICP targeted and not specifically CPP targeted,

Comparison of Additional Intervention of Each Study

use similar guidelines to handle pre-hypothermic intervention. However, two studies did additional procedures in the trial including giving hypertonic saline, vasoactive drug, and operative

Almost all studies

procedure.

RECOMMENDATION Future development for therapeutic hypothermia regarding effectiveness and safety

CONCLUSION

Figure 2. Risk of bias graph and

still need to be assessed through larger samples, adjusted clinical settings, and hazard ratio analysis through more RCT.

summary: review authors' judgements about each risk of bias item presented as percentages across all included studies

significant results of therapeutic hypothermia in reducing intracranial pressure in children with Traumatic Brain Injury. Cerebral Perfusion Pressure itself can’t be concluded because of the lack of qualitative and quantitative data to analyze. Despite that, therapeutic hypothermia still can be another alternative for a more efficacious effect with less adverse events in children with severe Traumatic Brain Injury. This systematic review based on the authors' analysis revealed that the compiled study concluded

REFERENCES 1. Hussain E. Traumatic Brain Injury in the Pediatric Intensive Care Unit. Pediatr Ann. 2018;47(7):e274-e279. doi:10.3928/19382359-20180619-01 2. Anderson V, Godfrey C, Rosenfeld JV, et al: Predictors of cognitive function and recovery 10 years after traumatic brain injury in young children. Pediatrics. 2012; 129:e254–e261 3. Dietrichs ES, Dietrichs E. Neuroprotective effects of hypothermia. Tidsskr Nor Laegeforen. 2015;135(18):1646-1651. Published 2015 Oct 6. doi:10.4045/tidsskr.14.1250

CONFLICT OF INTEREST The author declares that there are

no competing interests in this study.

ć J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. Published 2019 Aug 28. doi:10.1136/bmj.l4898

6. Sterne JAC, Savovi

7. Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med. 2008;358(23):2447-2456. doi:10.1056/NEJMoa0706930 8. Adelson PD, Ragheb J, Kanev P, et al. Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery. 2005;56(4):740-754. doi:10.1227/01.neu.0000156471.50726.26

9. Biswas AK, Bruce DA, Sklar FH, Bokovoy JL, Sommerauer JF. Treatment of acute traumatic brain injury in children with moderate hypothermia improves intracranial hypertension. Crit Care Med. 2002;30(12):2742-2751. doi:10.1097/00003246-200212000-00020 10. Li H, Lu G, Shi W, Zheng S. Protective effect of moderate hypothermia on severe traumatic brain injury in children. J Neurotrauma. 2009;26(11):1905-1909. doi:10.1089/neu.2008.0828

4. Lewis SR, Evans DJ, Butler AR, Schofield-Robinson OJ, Alderson P. Hypothermia for traumatic brain injury. Cochrane Database Syst Rev. 2017;9(9):CD001048. Published 2017 Sep 21. doi:10.1002/14651858.CD001048.pub5

11. Beca J, McSharry B, Erickson S, et al. Hypothermia for Traumatic Brain Injury in Children-A Phase II Randomized Controlled Trial. Crit Care Med. 2015;43(7):1458-1466. doi:10.1097/CCM.0000000000000947

5. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097

12. Schur, S., Martel, P., & Marcoux, J. (2020). Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account. World neurosurgery, 137, e430–e436.

The Use of Tissue Plasminogen Activator as Frostbite Treatment Tamara Atmogo1, Jois Mauren Lumbantobing2, Shindie Dona Kezia Lethulur3, Azarya Sihite4 Faculty of Medicine, Krida Wacana Christian University

Abstract Introduction

Frostbite is the most common cold injury in mountaineering and is frequently seen in high altitude climbers. Frostbite is a thermal injury and the clinical features of frostbite relate to the initial freezing and the subsequent thawing of tissue, and the severity is dependent upon the temperature and duration of exposure.Local cold injury may or may not be associated with hypothermia. Although frostbite is the most common cold injury, in civilian life, frostbite is uncommon despite populations of about 100 million at risk in areas where sub-zero temperatures occur at some period of the year.1 Although frostbite is rare in tropical countries, it may happen in particular those who partake in extreme cold activity such as mountain climbing and winter sports. Frostbite injury occurs through two mechanisms: cellular death at the point of cold exposure and deterioration and tissue necrosis from dermal ischemia. Tissue freezing initially results in the development of extracellular ice crystals. The crystals damage the cellular membrane and alter the osmotic gradient, causing intracellular dehydration and cell death. Intracellular ice crystals form as the temperature of the tissues decreases, provoking further mechanical cellular disruption. The body responds to such cold-related thermal insults with alternating cycles of vasoconstriction and vasodilation. This repeated partial thawing and refreezing from vasodilation causes further damage, which eventually leads to a progressive thrombotic phase. The clinical management of frostbite injuries has remained basically unchanged. Traditional management primarily involves tissue rewarming, prolonged watchful waiting, and often delayed amputation. In this conventional clinical algorithm of frostbite injury management, diagnostic radiologists, surgeons, and emergency and critical care physicians have made up the core clinical team central to diagnosis and treatment. However, recent studies have shown promising results using tissue plasminogen activator (tPA) to treat severe frostbite injuries. In such reports, patients with severe frostbite injury evidenced by perfusion injury on

triple-phase bone scans or on diagnostic angiography have received significant clinical benefit from the use of intraarterial (IA) or IV tPA infusion therapy.3 Patients with poor prognostic findings within 24 hours are considered for selective diagnostic angiography. Indications include severe acute extremity frostbite with poor or absent digit perfusion after rewarming, or presence of hemorrhagic bullae. Relative contraindications are listed demonstrates the appearance of a normal angiogram, and these patients do not receive thrombolytics. If the angiogram is abnormal, the level of arterial occlusion is recorded for each involved digit and thrombolytic therapy is initiated. A majority of patients received thrombolytic treatment. The percentage of patients requiring amputation was lower and the salvage rate was higher in patients treated with thrombolytics. Keywords : frostbite, tissue plasminogen activator, digit amputation Material & Methods Eligibility Primary research articles that reported on the use of tPA for the treatment of extremity frostbite were included in our review. The inclusion criteria allowed retrospective studies, including case series and case reports. Case series and case reports were included due to the limited amount of research that has been done on the topic. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Strategy We searched Goggle scholar, MEDLINE (PubMed) and Proqur. The search terms were “frostbite” linked with “tissue plasminogen activator” OR tPA OR amputation OR anti-platelet therapy OR extremity salvage.” One authors independently screened the articles by title and then by the contents of the abstracts for inclusion. The other author was available to mediate conflicts. All authors reviewed the final article. Data Extraction Data extracted from the studies included (s), journal, year of publication, treatment group size, control group size, criteria for treatment, route of tPA administration, radioimaging for factor risk, diagnostic studies, outcome measures, outcomes. The reviewers used a data collection spreadsheet to collect data. Inclusion : Study Published between 2017- 2021, Case Report , A systematic search was conducted in selected databases (PubMed, Google Scholar, ProQuest).

Exclusion : Non Human Study. Result Study 1 A retrospective review was performed of patients admitted to the regional burn center with frostbite injury from 1994 to 2007. Patients with severe frostbite, without contraindications to thrombolytic therapy, underwent diagnostic angiography of the affected extremities. Limbs with perfusion defects received intraarterial thrombolytic therapy according to protocol and the response was documented. Delayed amputation was performed for mummified digits. Angiogram results and amputation rates were tabulated. In this 14-year review, 114 patients were admitted for frostbite injuries. There was a male predominance (84%) and the mean age was 40.4 years. Of this group, 69 patients with severe frostbite underwent angiography; 66 were treated with intraarterial thrombolytic therapy. Four treated were excluded due to incomplete data. In the remaining 62 patients, angiography identified 472 digits with frostbite injury and impaired arterial perfusion. At the termination of thrombolytic infusion, a completion angiogram was performed. Partial or complete amputations were performed on only four of 198 digits (2.0%) with distal vascular blush, and in 71 of 75 digits (94.7%) with no improvement. Amputations occurred in 73 of 199 digits (36.7%) with partially restored flow. Overall complete digit salvage rate was 68.6%. 5 Study 2 A retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8–62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9–83 mo). Of 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12–48 mg) over a mean period of 34 hours (range, 12–72 h). Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation (P = .007). There was no significant correlation between amputation rates and duration of cold exposure (P = .9), time to rewarming therapy (P = .88), and time to thrombolysis (P = .56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma.6

Study 3 From the available data, 209 patients in the analyzed series were treated with IA or IV tPA. A total of 1109 digits were at risk of amputation. Of 1109 digits, 293 digits were amputated (26.4%) and 816 digits were salvaged (73.6%). A total of 116 patients received IA tPA, and 77 patients received IV tPA. The bases on which decisions to administer IA or IV tPA were made was not clearly stated in the reviewed papers. Direct comparison of the outcomes of IA versus IV tPA therapy or the associated algorithm governing the selection of one or the other was not possible because of the lack of a well-designed randomized study. In addition, catheter-directed IA thrombolysis has a more direct effect than IV thrombolysis but carries a risk of catheter-related complications. Conversely, IV thrombolysis carries no risk of catheter-related complication but has a less direct effect than IA thrombolysis and an increased risk of major hemorrhage. However, given that vascular injury and the related thrombosis were critical mechanisms thought to determine the impact of cold exposure, we hypothesized that pursuing either IV or IA thrombolytic therapy with tPA paired with heparin might ameliorate the degree of potential injury. A total of 926 digits at risk were treated with IA tPA and resulted in amputation of 222 digits with a salvage rate of 76%. Twenty-four of 63 patients underwent amputation after IV tPA, resulting in a salvage rate of 62%.7 Study 4 A total of 208 patients were included in the treatment groups. Only 1 randomized, prospective study was found (16 treated patients, 31 controls). Three studies included a control group (59 treated patients, 73 controls). None of the control groups were well matched. The 8 case series reported on 128 patients. Three studies were case reports. A total of 208 patients were included in the treatment groups. In all the studies, the authors reported that the use of tPA was or may have been useful based on reducing amputation rates or increasing tissue salvage.There was no uniformity in inclusion criteria or outcome measures. Inclusion criteria included the clinical diagnosis of severe frostbite, with some articles using angiography, triple-phase bone scan, or both for diagnosis. The tPA was given either by the intra-arterial or intravenous route. Successful outcomes criteria in the studies included amputation rate of digits and/or the number of patients requiring amputation, change in pretreatment prediction of outcome, response to treatment on angiogram, and response to treatment on bone scan. Complication rates ranged from 0% to 100%. Overall combined complication rate was 13%. Complications included bleeding at the catheter sites, femoral pseudoaneurysm, and a retroperitoneal hematoma. Complication rates

were the same for protocols administering tPA intravenously compared with intra-arterially. There were no deaths reported. 8

Tabel 1. Study Summary 8

Discussion The goal of thrombolytic therapy in frostbite injury is to address microvascular thrombosis. For deep frostbite injury with potential significant morbidity, angiography and use of either IV or intraarterial tissue plasminogen activator (tPA) within 24 hours of thawing may salvage some or all tissue at risk. The retrospective, single-center review by Bruen et al demonstrated a reduction in digital amputation rates from 41% in those patients who did not receive tPA to 10% in those patients receiving tPA within 24 hours of injury. The 20-year series presented by the Regions Hospital group showed that two-thirds of those who received intraarterial tPA responded well and that the amputation rate correlated closely with angiographic findings. When considering thrombolytics, a risk-benefit analysis should be performed by a physician with experience in the use of thrombolytics in frostbite. Only deep injuries with the potential for significant morbidity (eg, extending proximally to the proximal interphalangeal joints of the digits) should be considered for thrombolytic therapy. The potential risks of tPA include systemic and catheter-site bleeding, compartment syndrome, and failure to salvage tissue. The long-term, functional consequences of digit salvage using tPA have also not been evaluated. Thrombolytic treatment should be undertaken in a facility with intensive-care monitoring capabilities. If a frostbite patient is being cared for in a remote area, transfer to a facility with tPA administration and monitoring capabilities should be considered if tPA could be started within 24 hours of the injury thawing. Use of tPA in the field setting is not recommended because it may be impossible to detect and treat bleeding complications. Angiography or pyrophosphate scanning should be used to evaluate the initial injury and monitor progress after tPA administration as directed by local protocol and resources (angiography scanning for intraarterial, and pyrophosphate scanning for IV). Although further studies are needed to determine the absolute efficacy of tPA for frostbite injury and to compare intraarterial tPA to IV prostacyclin, we recommend IV or intraarterial tPA within 24 hours of injury as a reasonable choice in a proper facility. Recommendation grade for thrombolytic therapy: 1C. Third and fourth degree frostbite injuries are associated with a strong likelihood of circulatory compromise, as evidenced on physical examination by absence of pulses on Doppler sonography evaluation, and black or deep purple discoloration of affected digits. Shows a bone scan and corresponding gross image of a patient with third degree frostbite.

Patients with deep frostbite injuries (third or fourth degree) have increased risk of amputation and are considered for thrombolytic therapy In patients with delayed presentation (>24 hours from the time of the frostbite thawing), noninvasive imaging with technetium pyrophospate12 or magnetic resonance angiography can be used at an early stage to predict the likely levels of tissue viability for amputation. Cauchy et a described the use of the combination of a simple clinical scoring system and technetium scanning to successfully predict the subsequent level of amputation on day 2 after frostbite rewarming. If available, appropriate imaging should be used to assess tissue viability and guide timing and extent of amputation. Recommendation grade: 1C. There is limited high-level evidence supporting use of tPA for the treatment of frostbite. Treatment with tPA presumably increases costs due to the need for advanced imaging, the medication, and the need for care in the ICU. Before the use of tPA becomes widespread or standardized in treatment protocols, better studies, including randomized, prospective studies, need to be performed. These studies will be difficult to design, as it is difficult to assign the risk of amputation prior to early treatment. If the efficacy of tPA is to be demonstrated, further studies need to define which degree of frostbite should be treated; the proper starting point, end point, and duration of treatment; the preferred route of administration; and the cost. The potential benefit of early treatment needs to be assessed. In addition, the effects of anticoagulation and other associated adjuvant medications and treatments will need to be analyzed. Treatment with tPA also needs to be rigorously compared to treatment with iloprost. Consideration should be given to limiting its use to research protocols.. Some areas for improving and optimizing thrombolytic infusion therapy for frostbite include addressing the lack of randomized studies and standardized protocols. Hutchinson et al noted all but one of the studies provided only level 3b (individual case-control series) or 4 (case series or report) evidence according to the Oxford Centre criteria [31]. Therefore, randomized prospective studies are needed to evaluate the efficacy of tPA. The main question of IA versus IV tPA therapy in effectiveness and clinical outcome has not been fully explored. As these topics continue to be investigated, algorithms for the optimal use of catheter-directed thrombolysis will become clearer as interventional radiologists play a progressive interprofessional

role

treating

patients

with

severe

frostbite

injuries.3,5,6,7,8

Conclusion

Intra-arterial thrombolysis reduces digital amputation rates and hospital (length of stay) LOS in the setting of severe frostbite. Intraarterial catheter-directed thrombolysis should be included in initial management of frostbite injury, as it may prevent delayed amputations. The degree of angiographic response to thrombolysis can potentially predict amputation outcomes For deep frostbite injury with potential significant morbidity, angiography and use of either IV or intraarterial tissue plasminogen activator (tPA) within 24 hours of thawing may salvage some or all tissue at risk. The retrospective, single-center review by Bruen et al demonstrated a reduction in digital amputation rates from 41% in those patients who did not receive tPA to 10% in those patients receiving tPA within 24 hours of injury. Successful thrombolytic therapy begins with a careful consideration of selection and exclusion criteria as discussed. Although not absolute contraindications, potentially confounding factors such as alcohol or drug intoxication and medical conditions such as vascular disease and diabetes should be considered before proceeding with thrombolytic therapy. Although multiple studies have excluded patients with drug or alcohol intoxication. Many individuals with severe frostbite injuries are intoxicated, so careful consideration and further studies are needed to better establish guidelines that are inclusive of these at-risk patient populations.

Reference 1. Sudrajat TE, Nugroho W,Nata’atmadja BS. Clinical Profiles Of Frostbite In University Airlangga Teaching Hospital Surabaya – A Case Report. 2019;4(1) : 5. DOI : https://ejournal.unair.ac.id/JRE/article/viewFile/24348/13236 2. Polle A, Gautier J. Treatment of severe frostbite with iloprost in northern Canada. .2016; 188 :1255-58. DOI: https://doi.org/10.1503/cmaj.151252 3. Lee J, Higgins MC. What Interventional Radiologists Need to Know About Managing Severe Frostbite: A Meta-Analysis of Thrombolytic Therapy. American Journal of Roentgenology. 2020;214(4): 930-37. DOI: 10.2214/AJR.19.21592 4. Carceller A, Javierre C, Ríos M, Viscor F. Amputation Risk Factors in Severely Frostbitten Patients. 2019 ; (16) 1351.DOI :10.3390/ijerph16081351 www.mdpi.com/journal/ 5. Gonzaga TP, Jenabzadeh, Anderson KCP, Mohr WJ,Etc. Use of Intra-arterial Thrombolytic Therapy for Acute Treatment of Frostbite in 62 Patients with Review of Thrombolytic Therapy in Frostbite. Journal of Burn Care & Research. July-August 2016; 37 (4), Pages 323–e334, https://doi.org/10.1097/BCR.0000000000000245 6. Tavri S, Ganguli S, Bryan RG, Liu R, Irani Z, Walker TG. Catheter-Directed

Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury - Journal of Vascular and Interventional Radiology). 2016;27(8). DOI :https://doi.org/10.1016/j.jvir.2016.04.027

7. Mclntosh SE, Opacic M, Freer L, Johnson E, Dow J, Etc. Wildnerness Medical Society Practice Guidelines For The Prevention and Treatment of Frosbite. Wildness Medical Society Gudelines. 2017;25 (4): p 43-54. DOI : https://www.wemjournal.org/article/S1080-6032(14)00280-4/fulltext 8. Hutchison RL, Miller HM, Michalke SK. The Use of tPA in the Treatment of Frostbite: A Systematic Review. 2018(1) ; 1-6. https://doi.org/10.1177/1558944718800731

THE USE OF TISSUE PLASMINOGEN ACTIVATOR AS FROSTBITE TREATMENT INTRODUCTION Frostbite is the most common cold injury in mountaineering and is frequently seen in high altitude climbers. Frostbite is a thermal injury and the clinical features of frostbite relate to the initial freezing and the subsequent thawing of tissue, and the severity is dependent upon the temperature and duration of exposure.Local cold injury may or may not be associated with hypothermia. Although frostbite is the most common cold injury, in civilian life, frostbite is uncommon despite populations of about 100 million at risk in areas where sub-zero temperatures occur at some period of the year.1 Although frostbite is rare in tropical countries, it may happen in particular those who partake in extreme cold activity such as mountain climbing and winter sports. Frostbite injury occurs through two mechanisms: cellular death at the point of cold exposure and deterioration and tissue necrosis from dermal ischemia. Tissue freezing initially results in the development of extracellular ice crystals. The crystals damage the cellular membrane and alter the osmotic gradient, causing intracellular dehydration and cell death. Intracellular ice crystals form as the temperature of the tissues decreases, provoking further mechanical cellular disruption. The body responds to such cold-related thermal insults with alternating cycles of vasoconstriction and vasodilation. This repeated partial thawing and refreezing from vasodilation causes further damage, which eventually leads to a progressive thrombotic phase. The clinical management of frostbite injuries has remained basically unchanged. Traditional management primarily involves tissue rewarming, prolonged watchful waiting, and often delayed amputation. In this conventional clinical algorithm of frostbite injury management, diagnostic radiologists, surgeons, and emergency and critical care physicians have made up the core clinical team central to diagnosis and treatment. However, recent studies have shown promising results using tissue plasminogen activator (tPA) to treat severe frostbite injuries. In such reports, patients with severe frostbite injury evidenced by perfusion injury on triple-phase bone scans or on diagnostic angiography have received significant clinical benefit from the use of intraarterial (IA) or IV tPA infusion therapy.3 Patients with poor prognostic findings within 24 hours are considered for selective diagnostic angiography. Indications include severe acute extremity frostbite with poor or absent digit perfusion after rewarming, or presence of hemorrhagic bullae. Relative contraindications are listed demonstrates the appearance of a normal angiogram, and these patients do not receive thrombolytics. If the angiogram is abnormal, the level of arterial occlusion is recorded for each involved digit and thrombolytic therapy is initiated. A majority of patients received thrombolytic treatment. The percentage of patients requiring amputation was lower and the salvage rate was higher in patients treated with thrombolytics.

MATERIAL & METHOD We searched Google scholar, MEDLINE (PubMed) and Proquest. The search terms were “frostbite” linked with “tissue plasminogen activator” OR tPA OR amputation OR anti-platelet therapy OR extremity salvage.” Inclusion criteria include studies initiated within the last 5 years, clinical trials, systematic reviews, and observational studies, and case reports. We also include English and exclude nonhuman studies.

RESULTS AND DISCUSSION Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation (P = .007). There was no significant correlation between amputation rates and duration of cold exposure (P = .9), time to rewarming therapy (P = .88), and time to thrombolysis (P = .56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma.6 From the available data of another study, 209 patients in the analyzed series were treated with IA or IV tPA. A total of 1109 digits were at risk of amputation. Of 1109 digits, 293 digits were amputated (26.4%) and 816 digits were salvaged (73.6%). A total of 116 patients received IA tPA, and 77 patients received IV tPA. The bases on which decisions to administer IA or IV tPA were made was not clearly stated in the reviewed papers. In addition, catheter-directed IA thrombolysis has a more direct effect than IV thrombolysis but carries a risk of catheter-related complications. Conversely, IV thrombolysis carries no risk of catheter-related complication but has a less direct effect than IA thrombolysis and an increased risk of major hemorrhage. However, given that vascular injury and the related thrombosis were critical mechanisms thought to determine the impact of cold exposure, we hypothesized that pursuing either IV or IA thrombolytic therapy with tPA paired with heparin might ameliorate the degree of potential injury. A total of 926 digits at risk were treated with IA tPA and resulted in amputation of 222 digits with a salvage rate of 76%. Twenty-four of 63 patients underwent amputation after IV tPA, resulting in a salvage rate of 62%.7 A total of 208 patients were included in the treatment groups. Only 1 randomized, prospective study was found (16 treated patients, 31 controls). Three studies included a control group (59 treated patients, 73 controls). None of the control groups were well matched. The 8 case series reported on 128 patients. Three studies were case reports. A total of 208 patients were included in the treatment groups. In all the studies, the authors reported that the use of tPA was or may have been useful based on reducing amputation rates or increasing tissue salvage.There was no uniformity in inclusion criteria or outcome measures. Inclusion criteria included the clinical diagnosis of severe frostbite, with some articles using angiography, triple-phase bone scan, or both for diagnosis. The tPA was given either by the intra-arterial or intravenous route.Successful outcomes criteria in the studies included amputation rate of digits and/or the number of patients requiring amputation, change in pretreatment prediction of outcome, response to treatment on angiogram, and response to treatment on bone scan. Complication rates ranged from 0% to 100%. Overall combined complication rate was 13%. Complications included bleeding at the catheter sites, femoral pseudoaneurysm, and a retroperitoneal hematoma. Complication rates were the same for protocols administering tPA intravenously compared with intraarterially. There were no deaths reported.8

CONCLUSION Intra-arterial thrombolysis reduces digital amputation rates and hospital LOS in the setting of severe frostbite.

RESULTS AND DISCUSSION A retrospective review was performed of patients admitted to the regional burn center with frostbite injury from 1994 to 2007. Patients with severe frostbite, without contraindications to thrombolytic therapy, underwent diagnostic angiography of the affected extremities. Limbs with perfusion defects received intraarterial thrombolytic therapy according to protocol and the response was documented. Delayed amputation was performed for mummified digits. Angiogram results and amputation rates were tabulated. In this 14-year review, 114 patients were admitted for frostbite injuries. There was a male predominance (84%) and the mean age was 40.4 years. Of this group, 69 patients with severe frostbite underwent angiography; 66 were treated with intraarterial thrombolytic therapy. Four treated were excluded due to incomplete data. In the remaining 62 patients, angiography identified 472 digits with frostbite injury and impaired arterial perfusion. At the termination of thrombolytic infusion, a completion angiogram was performed. Partial or complete amputations were performed on only four of 198 digits (2.0%) with distal vascular blush, and in 71 of 75 digits (94.7%) with no improvement. Amputationn occurred in 73 of 199 digits (36.7%) with partially restored flow. Overall complete digit salvage rate was 68.6%. 5 Another retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8–62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9–83 mo) of 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12–48 mg) over a mean period of 34 hours (range, 12–72 h).6 61

References 1. Sudrajat TE, Nugroho W,Nata’atmadja BS. Clinical Profiles Of Frostbite In University Airlangga Teaching Hospital Surabaya – A Case Report. 2019;4(1): 5. DOI :https://ejournal.unair.ac.id/JRE/article/viewFile/24348/13236 2. Polle A, Gautier J. Treatment of severe frostbite with iloprost in northern Canada. .2016; 188 :1255-58. DOI: https://doi.org/10.1503/cmaj.151252 3. Lee J, Higgins MC. What Interventional Radiologists Need to Know About Managing Severe Frostbite: A Meta-Analysis of Thrombolytic Therapy. American Journal of Roentgenology. 2020;214(4): 930-37. DOI: 10.2214/AJR.19.21592 4. Carceller A, Javierre C, Ríos M, Viscor F. Amputation Risk Factors in Severely Frostbitten Patients. 2019 ; (16) 1351.DOI :10.3390/ijerph16081351 www.mdpi.com/journal/ 5. Gonzaga TP, Jenabzadeh,Anderson KCP, Mohr WJ,Etc. Use of Intra-arterial Thrombolytic Therapy for Acute Treatment of Frostbite in 62 Patients with Review of Thrombolytic Therapy in Frostbite. Journal of Burn Care & Research. July-August 2016; 37 (4), Pages 323–e334, https://doi.org/10.1097/BCR.0000000000000245 6. Tavri S, Ganguli S, Bryan RG, Liu R, Irani Z, Walker TG. Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite InjuryJournal of Vascular and Interventional Radiology). 2016;27(8). DOI: https://doi.org/10.1016/j.jvir.2016.04.027 7. Lee J, Higgins CSS. What Interventional Radiologists Need to Know About Managing Severe Frostbite: A Meta-Analysis of Thrombolytic Therapy. American Journal of Roentgenology. 2020;214: 930-937. DOI 10.2214/AJR.19.21592. https://www.ajronline.org/doi/10.2214/AJR.19.21592 8. Hutchison RL, Miller HM, Michalke SK. The Use of tPA in the Treatment of Frostbite: A Systematic Review. 2018(1) ; 1-6. Https://doi.org/10.1177/1558944718800731

WHIT

VIDE

TE PAPER AND EOGRAPHY

TESTIMONY

AMINO | PCC AMSC: United Kingdom 2021

Tatyana Milenia AMSA-Universitas Padjajaran 1st Winner of White Paper and Videography Category Becoming part of AMSA is the best decision I’ve ever made. AMSA is a home that provided tons of resources for you to develop. I have never thought I would like to join PCC AMSC 2021. However, one of the Academic Teams approached me to apply for the competition. Afterwards, I looked at AMINO and the theme for this year, making me more interested and hesitant due to a lack of experiences. Then I encourage myself to give it a shot. As I mentioned above, I have never joined the competition. Therefore, as a step forward due to my nescience, I was looking for a mentor. Another tip is consistently doing the research. Indeed, you might encounter boredom and stress; hence creating a supportive team might help in this situation. PCC AMSC 2021 taught me how to write a white paper and make videography that I have never done before. It was hectic back then when I prepared for this competition. We made the white paper and video intensively for limited days and tried to give the best shot we could make. Despite the hectic and nescience, we enjoyed the process of the competition itself.

AMINO | PCC AMSC: United Kingdom 2021

Prudence Lucianus AMSA-Universitas Diponegoro 2nd Winner of White Paper and Videography Category PCC AMSC was the ﬁrst international competition that I participated in. After some time as an AMSA member, I felt that I should try to join some competitions held by AMSA, PCC AMSC being one of them. By joining this competition, I was hoping to get experience in writing a paper and also having some fun discussing ideas with my teammates. After some thought, my team decided to participate in the white paper branch of this competition. We didn’t have much experience in writing papers, yet we decided that we would try and go for it anyway. In this kind of competition, I believe that the most important aspect is to choose the correct combination of teammates. My teammates were not a bunch of genius people, yet we were those with talents in our own areas. Put together, our strengths and weaknesses complete each other to create the desired masterpiece. Of course, another important factor is to have friends and seniors who are more experienced to give us feedback on our work in order to polish it to become even better. Big shoutout to my awesome teammates! And for you guys, don’t hesitate! Just go for it!

AMINO | PCC AMSC: United Kingdom 2021

Nathaniel Gilbert Dyson AMSA-Universitas Indonesia 3rd Winner of White Paper and Videography Category Hello People of Tomorrow! My name is Nathaniel Gilbert Dyson as the representative of our team in White Paper Competition PCC AMSC 2021. At ﬁrst, we were interested in the competition as it is a huge opportunity to be able to represent AMSA-Indonesia in AMSC 2021 London. Other than that, we would like to challenge ourselves to give contribution for the future with our ideas. To be honest we feel like we don’t really have some tips and tricks to win this competition. I think the most important thing is to ﬁnd a topic you're really interested and passionate about. While making our paper, we learned a lot and came to care a lot about the topic, and I think that contributes to making a good and impactful work. Having our ideas recognized in this prestigious competition is such a valuable learning experience for us. In conclusion, this competition is such an enjoyable and precious learning experience for us, and we are grateful for the chance AMSA have given for us to participate and win in this competition. So, don't hesitate to participate, and most of all, good luck and have fun!

MASTERPIECE

Improving Emergency Medical System using Machine Learning (ML) through E-mergency to Overcome Trauma Care Problems in Indonesia Tatyana Milenia, Shaffana Hidayat, Anis Rohmasari, Haya Shabrina Eka Putri Asian Medical Students’ Association Universitas Padjadjaran

Abstract In Indonesia, the number of road traffic accidents in 2019 shows an increasing trend. The road traffic accidents (RTA) caused nearly 26.000 deaths, 13.000 seriously injured people, and 138.000 slightly injured people. The first 60 minutes after a traumatic injury is considered a crucial period due to its large influence on patients’ health outcome and quality of life, hence the term “golden time.” Therefore, it is crucial to establish adequate early management of RTA victims by shortening the time needed to mobilize the victims into nearby health facilities and for the bystanders to perform first aid care. Despite its importance, the knowledge of first aid in Indonesian citizens seems to be average to low and there are no current systems capable of solving RTA prehospital care-related problem gaps. This situation calls for a need to build an easy-to-use platform where Indonesian citizens can use their smartphones to report any nearby RTAs and be skillful enough to perform basic first aid care. Thus, we propose an application called E-mergency that will use Machine Learning in its back-end to provide features for (1) reporting RTAs based on their precise location, (2) sending the best suggestion to the integrated networks of nearby ambulances, trauma centers, health facilities, or hospitals, (3) describing the overall situation of RTAs and status of the victims, (4) BPJS insurance payment options via digital wallets to the assigned hospital that would accept the patients, and (5) providing instructional first aid videos that the users can watch as guidance for them to help the victims before paramedics come. Therefore, E-mergency can be used to optimize golden hour usage and thus, prevent most of the mortality and morbidity rate caused by RTA in Indonesia. Key findings: Road Traffic Accident, first aid, prehospital care, smartphone, machine learning

Improving Emergency Medical System Using Machine Learning (ML) Through E-Mergency to Overcome Trauma Care Problems in Indonesia White Paper

Authors Tatyana Milenia

130110180202

Shaffana Hidayat

130110180049

Anis Rohmasari

130110180269

Haya Shabrina Eka Putri

130110190114

Asian Medical Students’ Association Universitas Padjadjaran Faculty of Medicine 2021

INTRODUCTION Trauma is one of the leading causes of worldwide mortality and morbidity. According to WHO Global Health Estimates, injuries caused more than 4.4 million deaths in 2019 alone. Out of all injury causes, road traffic accidents (RTA) remains the first cause of injuries, with its number of death cases rising to 1.3 million. Besides, road injury ranks 6th as the highest disability-adjusted life year (DALY), illustrating its heavy disease burden.1,2 Based on the study literature, it is shown that approximately 90% of injury-related deaths mostly occur in poorer countries, where most of them are comprised of Asian countries, especially those categorized into low- and middle-income countries.3,4 The high number of deaths is mainly due to inadequate prehospital trauma care, resources, training, and lower quality of trauma centre.5,6 In Indonesia, the number of road traffic accidents in 2019 is recorded as 116,411, which has increased 6.59 percent compared to 2018. The road traffic accidents caused nearly 26,000 deaths, 13,000 seriously injured people, and 138,000 slightly injured people.7 Besides, a study done by Khairani et al. describing characteristics of motor vehicle accident patients presenting to Hasan Sadikin National Hospital in West Java, Indonesia, shows that more than half of the patients were uninsured8. Another study from Makassar, Indonesia, found that the average cost for a road traffic accident-related mild injury case was Rp 1,565,990 (USD 103.90) and the average cost for a severe injury case was Rp 60,058,599 (USD 4,089.18). 9 These high numbers flaunt the necessity to address the proper care management of road traffic accidents to save millions of lives and prevent material losses. The first 60 minutes after a traumatic injury is considered a crucial period due to its enormous influence on patients’ health outcome and quality of life, hence the term “golden time.” Therefore, it is crucial to establish adequate early management of trauma. The focus of early management of traumatic injury should be essentially on patients with compromised airway, breathing, or circulation.10 Unfortunately, in RTA, the golden hour is not always utilized effectively due to inadequate management at the accident location or prehospital care. One of the prehospital care that can be tremendously helpful to the road crash victims is the act of help by the bystanders, and other drivers on the road primarily comprise the bystanders of RTA. The other drivers can help RTA victims when they are in the vicinity of the accidents and sustain the benefits of golden hour before paramedics come to the location of accidents. Therefore, they are the ideal layperson to conduct first aid care to road crash victims. Despite the importance of bystander’s actions in helping road crash victims, the knowledge of first aid in Indonesian citizens seems to be average to low. Besides, further concrete study concerning the basic knowledge of first aid care, especially in vehicle drivers in Indonesia, is very limited compared to other Asian countries. This suggests the country’s lack of focus and interest in this critical matter. This situation calls for a need to build a platform where Indonesian citizens can report any nearby RTAs and be skillful enough to perform basic first aid care whilst waiting for paramedics. Even though

there might be any emergency-designed applications being developed, none of them has the combined qualities for (1) reporting RTAs based on their precise location, (2) describing the overall situation of RTAs and general status of the victims, (3) sending the input to the integrated networks of nearby ambulances, trauma centers, health facilities, or hospitals, (4) Badan Penyelenggaraan Jaminan Sosial (BPJS) payment options via M-Banking or any digital wallets to the assigned hospital that would accept the patients, and (5) providing educational first aid videos that the users can watch as guidance for them to help the victims before paramedics come. Besides, none of these emergency-designed applications are widely used by Indonesian citizens as far as we know, showing that the mass launching, in-application features, user interface familiarity, and machine learning support are still lacking. Thus, we need a solid one-for-all application that can tackle all road traffic accident-related problems.

METHODS We identified our initial ideas from analyzing several studies and reports regarding RTA and its significance, especially in Indonesia, published in several journals and books. We looked for any studies concerning Indonesian citizens knowledge about first aid care. Besides, we also examined several proposals that discussed the possibility of emergency-designed applications and point down several points that we thought were lacking and could be improved further. We design the method’s umbrella with Action Research using a mixed-method design comprising qualitative and quantitative methods. Figure 1 depicts the methods from initiating until implementing the final graphical user interface (GUI).

Figure 1 Hybrid approach (action research principal and mixed-method research design). Picture is fully taken from Rinawan, FR., et al., 2021 https://www.researchsquare.com/article/rs-15584/v3.11

It is essential to complete the back-end (“kitchen”) of the application with a data flow diagram (DFD). Herewith the data flow diagram: Ambulance provider: Receiving information from patient/helper, verification, answering the availability to pick up

Patient: ID information, time, location, ambulance need, trauma information, insurance/payment, receiving nearest hospital location

Hospital: E-mergency database: Machine learning to find the nearest ambulance and hospital; the fastest direction to the hospital

Receiving information from patient/helper, ambulance, insurance; verification, sending agreement to serve the patient

Helper/bystander If patients is not possible to fill the app, the helper fill the above data, plus how to help

Health insurance company: Receiving information from patient/helper, verification

Figure 2 Data flow diagram (DFD) Figure 2 represents the flow of data through the system of E-mergency application. The application will process inputs from users posing as helper or patient. The process’s resulting outcomes will get sent to the ambulance provider, hospital, and health insurance company. Simultaneously, the E-mergency application collects data to update its database and uses machine learning to improve its services.

Figure 3 Roadmap of E-mergency

Figure 3 depicts the strategic plan roadmap overview of E-mergency application with major milestones to be achieved within the specific time frame. It is planned to be implemented stepwise in the iterative cycle and is carefully applied to the software development process. Continuous feedback from users (patients, helper/bystander, insurance or other payment, ambulance provider, and hospital) is taken to refine the app. We strongly believe that the E-mergency app, which uses machine learning in the back-end, can fill the RTA prehospital care-related problem gaps. FINDINGS Our initial findings showed high numbers of RTA in Asian countries, and the number of RTAs in Indonesia shows an increasing trend, supporting our ideas even more. There were also no concrete studies examining the knowledge of Indonesian citizens about first aid care. Furthermore, we found that no proposals regarding emergency-designed applications had all the qualities we look for. Thus, we decided to propose the idea of making one. PROPOSED SOLUTION Technological developments offer many solutions to various types of problems in this modern era. One of them is in the medical world. As explained earlier, the lack of public knowledge about first aid in RTA is partly due to a lack of access to reliable and comprehensive information. Here, we offer a solution to this problem through the use of the E-mergency application. Through E-mergency, we will provide features for (1) reporting RTAs based on their precise location, (2) sending the input to the integrated networks of nearby ambulances, trauma centers, health facilities, or hospitals, (3) describing the overall situation of RTAs and general status of the victims, (4) BPJS insurance payment options via M-Banking or any digital wallets to the assigned hospital that would accept the patients, and (5) providing instructional first aid videos that the users can watch as guidance for them to help the victims before paramedics come. E-mergency can be an effective platform to shorten the transport time during the golden hours, improve Indonesian citizens’ knowledge regarding first aid in RTA, and remind them once again that RTA may occur anytime and that they have to always be prepared. We propose an idea to connect E-mergency app with the Global Positioning System (GPS) in the user’s smartphone and GPS of nearby ambulances, trauma centers, health facilities, or hospitals. Through this connection, E-mergency could send the precise location towards nearby ambulances, trauma centers, health facilities, or hospitals and, therefore, decrease the amount of time needed to mobilize the victim. Not only that, we offer using the Machine Learning (ML) in Artificial Intelligence (AI) subject. Good data quality is a significant pillar to support the ML. Machine Learning in healthcare uses algorithms, data, and software modules in its back-end to mimic human cognition in the analysis, presentation, and comprehension of complex medical data without direct human intervention. It can still be supervised in the analysis and always improved continuously to approach the real situation, suggesting the best solutions.

When users report any RTAs, be it as bystanders or victims of the RTA itself, they will be asked to input the location (where they can choose their own device location), the identity of the RTA victims (such as name or ID number or NIK, if possible), and general description of the situation as well as the condition of the victim by answering questions from the application. This is where Machine Learning’s (ML’s) role in the application is enhanced, as it will detect users’ inputs to the application, process them, and adjust them to the type of instructional video that will be presented to the user so that they can perform basic first aid care while waiting for paramedics to come. The result of ML processing will also be sent to the nearby ambulances, trauma centers, health facilities, or hospitals to inform them of the condition of the patients they are coming for to be more prepared upon arrival at the location. Visualization depicting mechanism of how E-mergency application works for users can be seen in Figure 4 . To make ML work effectively, we have to improve the variable database quality of the application back-end. The tutorial of using the app is vital to provide good data quality. Therefore, besides relying on keywords of certain conditions fixed by the application developer and medical experts, the application will also learn from the users’ experiences. There will be a neural network that works similar to cognitive computing, where it would consist of several data sets on each type of injury in RTA that allows the application to process data faster and more effectively. For this reason, precise input of current RTAs condition by users is essential, as it allows the data processing and outcome provided by the application to be right on target. After analyzing the input from users, the ML system, apart from presenting a first aid video, will also make a medical service history on the BPJS accounts of RTA victims to cover their medical expenses. This can only be done if 1). The victims are registered in BPJS program, and 2). The victims can be identified through their names, ID number or NIK, or BPJS card numbers. In addition, users can also pay their monthly BPJS bills via this application by any digital wallets, as the users can also set a reminder on this application to pay their bills. To ensure that the application’s objectives are achieved, we need to initiate collaboration with the Ministry of Health and every health facility, trauma center, or hospital in Indonesia to support us by integrating their ambulances or emergency departments with our application. Furthermore, to make sure that the application’s information is credible and reliable, the application will hold hands with first aid training institutions to create educational first aid videos and medical experts to create the right orders of questions to guide users’ input to the application. This way, we can see that it takes many collaborations from several stakeholders for this application to succeed in improving the RTA prehospital care in Indonesia. CONCLUSION Good prehospital care, especially comprehension and capability of doing first aid by bystanders and the victim themselves, could be an effective way to optimize golden hour usage and thus, prevent most of

the mortality and morbidity rate caused by RTA in Indonesia. The lack of knowledge regarding first aid and RTA victim mobilization time in Indonesia could be resolved by developing E-mergency application by utilizing smartphone technology. The E-mergency application will (1) reporting RTAs based on their precise location, (2) sending the input location to the integrated networks of nearby ambulances, trauma centers, health facilities, or hospitals, (3) describing the overall situation of RTAs and general status of the victims, (4) BPJS insurance payment options via any digital wallets to the assigned hospital that would accept the patients, and (5) providing instructional first aid videos that the users can watch as guidance for them to help the victims before paramedics come, could be a new solution to increase public knowledge about first aid and overcome the trauma problems in Indonesia. To ensure this innovation works well, we need support and collaboration from several stakeholders to develop E-mergency. ACKNOWLEDGEMENT We thank dr. Fedri Ruluwedrata Rinawan, MScPH., Ph.D. (Padjadjaran University) for assistance, revisions, and feedback on the paper. RECOMMENDATION Of course, this idea requires further research and study and support from various institutions such as the government, the community, and also several parties that are related in the actualization of the E-mergency application: 1. The University, where students or researchers in health science fields, software engineering, information, visual design, and other related fields can collect supporting data by advanced action research using a mixed-method design to develop the application. 2. Multipentahelix partnerships such as the government, private institutions, non-governmental organizations (NGO), academics, community, and media can support this idea by collaborating their support in the action research for developing the E-mergency application and serving the data of competent human resources needed to develop the application. 3. The government, especially the BPJS party and Minister of Health, facilitates the implementation of this innovation, helps the E-mergency development scale-up use from a smaller to a larger area. 4. In this case, medical experts develop the correct orders of questions to guide users’ input to the application, predict the victim’s condition accurately, and socialize it to society. 5. The first aid institution provides credible and reliable information needed in developing the application, especially first aid instruction videos. 6. As the user, the community uses the application according to proper usage, maximizes features available, and disseminates the importance of knowing how to do first aid to save lives for the public.

Figure 1(a) : E-mergency opening view

Figure 1(f) : The app notifies nearby hospital to prepare ambulances and bed in Emergency Room

Figure 1(b) : Choosing either as bystander or victim

Figure 1(c) : Insert device location through GPS or manually

Figure 1(g) : Insert type of collisions

Figure 1(h) : Insert any fire or explosion

Figure 1(d) : Insert victim’s identity

Figure 1(i) : Insert visibility and number of victim

Figure 4 Mechanism of 70E-mergency User

Figure 1(e) : Insert type of RTA that is happening

Figure 1(j) : Notification of ambulance availability and estimation time of ambulance arrival

Figure 1(k) : Insert victim’s current condition

Figure 1(p) : Sending specific sign if the ambulance couldn’t see the victim/bystanders

Figure 1(l) : Predicted condition of the victim

Figure 1(m) : Several instruction videos of first aid in RTA

Figure 1(n) : Instruction video is played

Figure 1(q) : Mission accomplished. The user could send rate and feedback

Figure 4 Mechanism of E-mergency User 71

Figure 1(o) : Ambulance has arrived

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World Health Organization (WHO). Global health estimates: Leading causes of death [Internet]. 2020 [cited 2021 Feb 28]. Available from: https://www.who.int/data/gho/data/themes/mortalityand-global-health-estimates/ghe-leading-causes-of-death

World Health Organization (WHO). Global Health Estimates 2019: DALYs by cause and region, 2019 and 2000 [Internet]. 2020 [cited 2021 Feb 28]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/global-healthestimates-leading-causes-of-dalys

Choi SJ, Oh MY, Kim NR, Jung YJ, Ro YS, Shin S Do. Comparison of trauma care systems in Asian countries: A systematic literature review. EMA - Emerg Med Australas. 2017;29(6):697– 711.

WHO. INJURIES VIOLENCE THE FACTS The magnitude and causes of injuries. Geneva World Heal Organ [Internet]. 2014;20. Available from: http://www.who.int/violence_injury_prevention/media/news/2015/Injury_violence_facts_2014/en/

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Khairani AF, Azka AN, Faried A, Amelia I, Ardisasmita MN, Tanzilah S, et al. Characteristic of Motor Vehicle Accident Patients Presenting to a National Referral Hospital in West Java, Indonesia. Southeast Asian J Trop Med Public Health. 2018;49(5):887–93.

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Rinawan FR, Susanti AI, Amelia I, Ardisasmita MN, Dewi RK, Ferdian D, Purnama WG, Purbasari A. Understanding mobile application development and implementation to monitor Posyandu data in Indonesia: a 3-years hybrid action research to build “a bridge” from the community to national use. Under review by BMC Public Health, preprint: https://www.researchsquare.com/article/rs-15584/v3

AN INNOVATION DEALING WITH THE LACK OF FIRST AID READINESS AMONG NONMEDICAL CITIZENS TO IMPROVE EMERGENCY MEDICAL SERVICES

Prudence Lucianus, Qinanti Akhilla Zayda, Arlo Gunawan Utama, Kevin Christian Tjandra Medical Faculty, Diponegoro University Abstract. Trauma is one of the major causes of deaths in the world with millions of deaths annually. With trauma as one of the leading causes of death annually worldwide, prehospital emergency medical services are of utmost importance. An important part of trauma care is the golden hour, which is the immediate time after the injury happens. Ineffective use of the golden hour could lead to less favorable outcomes after, or even before, the patient finally gets appropriate medical treatment in the hospital. Although some countries already have sufficient trauma care systems, there are many countries that still have incomplete trauma care. The biggest problem in countries without proper emergency medical services is the lack of first aid knowledge among civilians. Trauma being a leading cause of death worldwide and insufficient first aid affecting a patient’s health outcome after a traumatic injury calls for an innovation to overcome this problem and improve emergency medical services. We would like to propose a solution to help the lack of first aid readiness when it is needed by non-medical professionals in the form of an application that provides guidance videos to assist civilians to do proper first aid when they are in emergency situations. When needed, this application will also connect civilians to the nearest hospital to get an ambulance and be connected to a medical professional from that same hospital in case of unexpected incidents. With this solution, we hope to increase first aid readiness among civilians to help improve emergency medical services in their country. Keywords: Trauma care, Prehospital time, Golden Hour, First Aid, Guidance video

AN INNOVATION DEALING WITH THE LACK OF FIRST AID READINESS AMONG NONMEDICAL CITIZENS TO IMPROVE EMERGENCY MEDICAL SERVICES

By: Prudence Lucianus Qinanti Akhilla Zayda Arlo Gunawan Utama Kevin Christian Tjandra

AMSA-Universitas Diponegoro 2021

INTRODUCTION Trauma is one of the major causes of deaths in the world, especially at a young age. Annually, there are 5.8 million deaths caused by trauma. This number is expected to rise up to 8.4 million deaths annually in the year 2020. In low- and middle-income countries, mortality related to trauma before 70 years of age happens more often than in high-income countries. Attention should be given to trauma care to improve treatment of trauma patients, preventing trauma itself, and developing emergency medical services to reduce preventable trauma care.1 First aid is the assistance given immediately to an injured person before professional help arrives to give proper medical treatment. First aid interventions seek to “preserve life, alleviate suffering, prevent further illness or injury and promote recovery.”2 First aid plays a major role in adequate trauma care to decrease morbidity and mortality, which is gained by fast, systematic, and effective treatment of the injured patient. Injuries are usually diagnosed and treated by the ABCDE principle consisting of airway, breathing, circulation, disability, and exposure.3 An important part of trauma care is the “Golden Hour”, which is the immediate time after the injury happens. Ineffective use of the golden hour could lead to the less favorable outcome after, or even before, the patient finally gets appropriate medical treatment in the hospital. With trauma as one of the leading causes of death annually worldwide, prehospital emergency medical services are of utmost importance. However, low- and middle-income countries tend to lack provision in emergency medical services. Furthermore, when an emergency trauma case happens, there is a big chance that there are no medical professionals nearby. Citizens nearby such a case should be ready to help give first aid when needed, yet most citizens do not know how to give the proper first aid for those patients who are in emergency cases without a medical professional nearby. This white paper and video aim to propose a solution to increase efficient use of golden hours by non-medical civilians who happen to be nearby in an emergency trauma situation. METHOD This white paper was written by acquiring sources from Google Scholar, PubMed, and ScienceDirect. Keywords used to search for literature include “Trauma Care”; “Prehospital Time”; and “First Aid”. The literatures are included if they meet certain criterias such as: (1) written in English, (2) published in between the year 2011 - 2021, and (3) relevant to the topic. Studies are excluded if they are: (1) written with incompatible language or written before the year 2011 and (2) not correlated to the aim of this study.

FINDINGS/OUTLINED PROBLEM Millions of people each year die as a result of traumatic injuries. Emergency Medical Services (EMS) worldwide are continuously improving to reduce these numbers and give better medical care to victims of traumatic injuries. Prehospital time after an injury takes place proves to be an important part of trauma care. This is also known as the “Golden Hour”, the immediate time after injury where resuscitating, stabilizing, and rapidly transporting patients are proven to be beneficial to the patient. Treatment given to the patient during this time will greatly determine the outcome of the patient after, or even before, getting professional medical care in hospitals.4 Prehospital time, which includes response time, on-scene time and transport time, is an important parameter of emergency medical services and plays an important role in trauma care. Although some countries already have sufficient trauma care systems, there are many countries that still have incomplete trauma care. A study in Asian countries did not show the association of an increased 30-days mortality after with an inefficient use of prehospital time. However, inefficient use of prehospital time does show great association with increased risk of poor functional outcome. Functional outcome is an index of neurological status that shows the quality of life and the ability of a person to return to normal life and work. This is a crucial index of outcome as achieving a favorable functional outcome should be prioritized in patient care.5 The biggest problem in countries without proper emergency medical services is the lack of first aid knowledge among civilians. Trauma cases do not always happen when a medical professional is around to help, yet there are usually other non-medical people who are around at that time. Civilians hold the key to potential life-saving of patients in emergency trauma cases, yet such potential is lost because of their lack of knowledge regarding first aid. A study in Great Britain shows that 85% of trauma victims that died before reaching the hospital were probably because of airway obstruction. A large amount of pre-hospital deaths can be prevented by simple first aid techniques that can be taught to society. Several other studies show that many deaths caused by trauma were due to the lack of first aid. Simple first aid interventions such as changing posture, opening an airway, and controlling bleeding are very important actions that can be done by anyone and have the potential to save lives.6 Trauma being a leading cause of death worldwide and insufficient first aid affecting a patient’s health outcome after a traumatic injury calls for an innovation to overcome this problem and improve emergency medical services. Certainly, such an innovation requires the help of the government as funders, hospitals as

medical centers, and healthcare professionals as trained experts to be recognized as a qualified and efficient solution to such a problem. SOLUTION The lack of first aid readiness among society calls for an innovation in providing sufficient first aid guidance when needed as the first aid given to patients before they arrive at the hospital to get professional care is of utmost importance. We would like to propose a solution to help the lack of first aid readiness when it is needed by non-medical professionals. We would like to propose an application that provides guidance videos to assist civilians to do proper first aid when they are in emergency situations. The application will ask quick multiple-choice questions to identify the emergency that is taking place. All kinds of emergencies will be included in this application such as traffic accidents, heart attacks, seizures, burns, choking, intoxication, drowning, common injuries, and many more. It will then provide a short video to show the proper technique of giving first aid according to the situation. It will also give crucial information on things that should and should not be done to prevent further unwanted injuries. The video would be very short so that first aid can immediately be given to the patient to reduce the chance of loss before the patient can be taken to a medical professional. When needed, this application will also connect civilians to the nearest hospital to get an ambulance heading toward their location as fast as possible. They will also be connected to a medical professional on standby in the emergency department from that same hospital to get assistance on what to do when an unexpected incident comes up and to keep encouraging them until the ambulance comes to help. We believe that the development of this application will be of great use since many emergency trauma cases happen when there are no medical professions nearby that can give immediate medical care. Therefore, we need civilians who are nearby to be able to give necessary first aid to increase the patient’s ability to have better functional outcomes after receiving medical care in the hospital. CONCLUSION Trauma being a leading cause of deaths worldwide and insufficient first aid affecting a patient’s health outcome after a traumatic injury calls for an innovation to overcome this problem and improve emergency medical services. We would like to propose a solution to help the lack of first aid readiness when it is needed by non-medical professionals in the form of an application to provide guidance videos to assist civilians to do proper first aid when they are in emergency situations. When needed, this application will also connect civilians to the nearest hospital to get an ambulance and be connected to a medical professional

from that same hospital in case unexpected incidents occur. With this solution, we hope to increase first aid readiness among civilians to help improve emergency medical services in their country. RECOMMENDATION We hope that the government would support funding allocations on the development of this application. Hospitals should also collaborate with this application so that those in emergency situations can have an ambulance headed their way immediately and easily get connected to medical professionals on standby at the nearest hospital. We also hope that those trained in the medical field would be willing to help make these videos to assist those in need and also help make qualified questions that would lead to the proper and accurate identification of the emergency situation. In order for this to work, the participation of society is also needed as active users of this application and also as a means to socialize and further spread this application. ACKNOWLEDGEMENTS AND CONFLICT OF INTEREST The authors acknowledge all sources used for excellent information and data provided concerning first aid and prehospital time in different countries. The authors would also like to thank AMSA-Indonesia for the opportunity to write this paper and all parties that were willing to take part in the making of this paper and video

REFERENCES 1.

Byun CS, Park IH, Oh JH, Bae KS, Lee KH, Lee E. Epidemiology of Trauma Patients and Analysis of 268 Mortality Cases: Trends of a Single Center in Korea. Yonsei Med J. 2015;56(1):220.

International Federation of Red Cross and Red Crescent Societies, Geneva [Internet]. Koninklijke Brill NV; [cited 2021 Apr 3]. Available from: https://primarysources.brillonline.com/browse/humanrights-documents-online/international-federation-of-red-cross-and-red-crescent-societiesgeneva;hrdhrd98132015012

Dn K, Kiran A. Emergency Trauma Care: ATLS. Journal of Advanced Oral Research. 2011 Jan;2(1):13–6.

Harmsen AMK, Giannakopoulos GF, Moerbeek PR, Jansma EP, Bonjer HJ, Bloemers FW. The influence of prehospital time on trauma patients outcome: A systematic review. Injury. 2015 Apr;46(4):602–9.

Chen C-H, Shin SD, Sun J-T, Jamaluddin SF, Tanaka H, Song KJ, et al. Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study. PLoS medicine. 2020;17(10):e1003360.

Arbon P, Hayes J, Woodman R. First Aid and Harm Minimization for Victims of Road Trauma: A Population Study. Prehosp Disaster med. 2011 Aug;26(4):276–82.

M-PUTEE: A MENTAL HEALTH-BASED APPLICATION AS A PROMISING SOLUTION TO BOOST PSYCHOLOGICAL RESILIENCE OF POST LIMB AMPUTATION PATIENTS IN INDONESIA Nathaniel Gilbert Dyson, Priscilla Geraldine, Violine Martalia, Arden Gabrian AMSA-Universitas Indonesia ABSTRACT Amputations are still highly prevalent, with an estimated 300-500 amputations performed daily and an amputee population of nearly 2 million in the United States, and this number is predicted to be higher in developing countries including Indonesia. Traumatic limb amputations cause distress and lowering of quality of life not only physically but also psychologically, shown by a high prevalence of psychiatric comorbidities such as MDD (71.2%), MDD with suicidality (30.5%), and PTSD (20.3%) which all causes further negative outcomes. Therefore, emotional support, counseling, and support groups are crucial. Despite this, proper psychological care is only received by 50% of patients and is further complicated by the impacts of COVID-19 restrictions towards post-trauma care. Furthermore, this is aggravated by the massive financial burden due to healthcare costs and reduction in pay after returning to work. Due to these problems, we are proposing a mobile application called M-Putee which promises to enhance the psychological resilience of amputees in Indonesia by providing low-cost rehabilitation programs from doctors, nurses, and volunteers from non-governmental organizations (M-rehab), assess mental health condition using a DASS-21 questionnaire then providing psychiatric consultation which is also free for low economic status users (M-pathy), recommending amputee-friendly activities to motivate recovery (MActivity), and connecting users to support groups and other amputees to share their conditions and motivate each other (M-Friends). Through this application, we hope that post-trauma care of amputees may be improved to achieve better quality of life. We hope that through governmental support in enabling policies to develop M-Putee and active participation of healthcare facilities and mental health organizations in this project, this application can offer a solution for rehabilitation in post limb amputation patients in Indonesia. Keywords: limb amputation, post-trauma care, mental health, rehabilitation, mobile application

M-PUTEE: A MENTAL HEALTH-BASED APPLICATION AS A PROMISING SOLUTION TO BOOST PSYCHOLOGICAL RESILIENCE OF POST LIMB AMPUTATION PATIENTS IN INDONESIA

Authors: Nathaniel Gilbert Dyson Priscilla Geraldine Violine Martalia Arden Gabrian

Asian Medical Students’ Association Universitas Indonesia 2021

INTRODUCTION An estimated 300 to more than 500 amputations occur every day, resulting in a population living with limb loss reaching nearly 2 million people just in the United States, and this number is projected to be doubled by 2050.1 Furthermore, it is alarming that this is a gross underestimate, considering that significantly more amputations occur in developing countries where the prevalence of amputation is not monitored, including Indonesia. These amputations are performed due to a wide variety of causes, with trauma accounting for 45% of all cases.2 Traumatic limb amputation is an emotionally devastating occurrence which causes incredible distress in amputees, not only due to the physical consequences of body part loss, but also due to the role limitation, lifestyle change requirements, and the resulting psychiatric comorbidities often affecting amputees. Studies have found that the mental distress caused by traumatic limb amputation is perceived to be equal to a loss of spouse, loss of one’s perception of wholeness, symbolic castration, and even death. Furthermore, amputees tend to feel debilitating loss, self-stigma, and difficulty in coping with impairment due to amputation. These emotional experiences can cause severe emotional disturbance and a poor quality of life among amputees.3 Due to the psychological consequences mentioned above, post-amputation patients are at an alarmingly high risk for developing psychiatric comorbidities such as major depressive disorder (MDD), posttraumatic stress disorder (PTSD), impulse control disorder, generalized anxiety disorder, and panic disorder. Studies have found that among amputees, 71.2% suffered from MDD, 30.5% displayed MDD with suicidality, and 20.3% experienced PTSD. Another study even found that up to 63% of amputees suffered from depressive disorder. Additionally, these disorders present with a wide variety of negative outcomes such as increased pain intensity, activity restriction, public self-consciousness, body image anxiety, and reduced quality of life. The restriction in activity and changed role responsibilities also caused a feeling of worthlessness and helplessness in a majority of amputees. This alarming situation is even more severe for patients amputated due to traumatic injury, as they are not prepared or consulted psychologically before the emergency amputation procedure.4 The situation above shows that emotional support and counseling is crucial for full recovery of amputees. Counseling and pastoral care is found to help offset the psychological stress after trauma, resulting in a decrease in anxiety and depression by 16% and 66% respectively in patients. Amputees reported that the most valuable parts during rehabilitation are being able to talk and to be heard, receiving reassurance when needed, seeing friendliness and interest from the provider, having a connection to the outside world, and receiving motivation for physical rehabilitation. Support networks and groups also enhance the long term

health of the trauma survivor by connecting them to a network of people with similar experiences or injuries. However, 50% of severe musculoskeletal injuries often leading to amputation do not receive this care. This untreated psychological stress then causes more complications and lowering in quality of life. 5,6 This is also likely to be compounded by the difficulty in accessing post-trauma care due to restrictions imposed by the current COVID-19 pandemic. Besides the psychological comorbidities, amputees are also at a higher risk for multiple health complications such as obesity, cardiovascular disease, osteoarthritis, residual limb pain, and low back pain which all further decreases their quality of life. 7 Another potential consequence of amputation is a low rate of returning to work (RTW). Literature reviews found that the RTW rate following amputation is as low as 43-70%. Other studies also found significant differences in employment status and occupation before and after amputation, with most amputees changing in employment to unskilled occupations, resulting in reductions in pay and social status associated with psychosocial adjustment and quality of life.6,7 Lastly, another major problem faced by amputees are the costs of healthcare due to amputation. Annually, the immediate health care costs total nearly $8 billion in total just in the US. Additionally, it is estimated that the 5- year health care costs associated with limb loss are more than $500,000 per person, nearly double the lifetime healthcare costs of an average person, not including prosthetics. The 5-year prosthetic costs meanwhile can be as high as $450,000. These costs put an immense financial burden which is further aggravated by the care of comorbidities associated with limb amputation.1,6 In summary, amputation has a profound and lasting impact not only physically, but also emotionally, psychologically, and socioeconomically. Therefore, this calls for a solution to support and improve the psychological and emotional resilience and outcomes of amputees in Indonesia by providing professional counseling, support groups and networks, and rehabilitation programs with low cost and high accessibility to help them achieve a higher quality of life after amputation.

METHOD First, we thought about the basics of trauma care, which consists of pre-hospital care, in-hospital care, and post-hospital care. Next, we picked an area we want to focus in. We took interest in post-hospital care as it is an area most often forgotten after the initial pre-hospital and in-hospital care. We conducted a literature search about the most prevalent problem within post-hospital care and found that poor mental health and

low quality of life are some of the most prevalent problems in patients with a history of trauma. Moreover, this is especially evident in patients who had to undergo amputation. We designed a solution by taking the physical burden, lack of access, and social and financial state of those who underwent amputation into consideration. Thus, we came up with a mobile app, a widely accessible tool that can provide mental health services and rehabilitation for amputees.

Figure 1. Thinking process FINDINGS Amputations are still highly prevalent, with an estimated 300 to more than 500 amputations performed daily and a population of amputees of nearly 2 million just in the United States which is predicted to double by 2050.1 This number is likely to be an underestimate compared to the amputations occurring in developing countries including Indonesia. Trauma is a major cause of these amputations, accounting for 45% of all cases.2 Traumatic limb amputation causes distress not only due to the physical consequences, but also due to role limitation, lifestyle change requirements, and psychiatric comorbidities, causing emotional disturbance and

poor quality of life among amputees. Post amputation patients have an alarmingly high prevalence of psychiatric comorbidities such as MDD (71.2%), MDD with suicidality (30.5%), and PTSD (20.3%). 3 These disorders in turn cause significant negative outcomes such as increased pain intensity, activity restriction, public self-consciousness, body image anxiety, and reduced quality of life, especially in traumatic amputation patients.4 Emotional support and counseling, including support groups and networks among other coping aids, are shown to be crucial for full recovery, with data showing that counseling and pastoral care results in a decrease in anxiety (16%) and depression (66%) compared to control. However, about 50% of severe orthopedic trauma patients including amputees do not receive this care, and continue to endure the consequences of untreated psychological stress. 5,6 Accessibility to this post traumatic care and rehabilitation is further complicated by the restrictions due to the COVID-19 pandemic. Amputees are also at a higher risk for multiple health complications such as obesity, cardiovascular, disease, osteoarthritis, residual limb pain, and low back pain. 7 This adds to their emotional and already massive financial burden of healthcare, with a 5-year healthcare cost associated with limb loss reaching $500,000 per person, double the lifetime health care costs of an average person, not including prosthetics and those additional comorbidities mentioned before.1,6 Further aggravating the financial and physical burdens caused by amputation, amputees show a lower rate of returning to work after amputation due to the physical and psychological consequences, difficulty in readjusting and reintegrating, and the social stigma which is also present in the workplace. This results in a shift to unskilled occupations or even unemployment, resulting in a reduction in pay and socioeconomic status associated with lower quality of life.6,7 In conclusion, amputation causes massive and extensive psychological, emotional, physical, and socioeconomic impact on its recipients, and this is still not adequately addressed and mitigated. Therefore, this calls for an equally extensive solution that helps amputees in doing daily activities and improving their quality of life after amputation by integrating patients, healthcare providers, and mental health volunteers.

SOLUTIONS As mentioned before, loss of a limb after an amputation procedure has impacted the patient’s self-esteem and independence in daily activities, thus, may cause mental health issues. Rehabilitation of the amputee is very essential to help them return to their highest functioning level and improve the overall quality of life,

both physically and emotionally. Regarding the problems that we are facing right now, especially due to ineffective rehabilitation programs at hospitals during COVID-19 pandemic, we have analysed that mobile platforms are the most suitable solution. Several studies have found that mental health intervention by mobile applications are as effective as clinic-based intervention with just half of the cost.8 Therefore, we proudly came up with an idea to develop a mental health-based application named M-Putee, a promising solution to enhance psychological resilience of post limb amputation patients in Indonesia. As the name suggested, M-Putee will be a multifunctional solution for amputees in doing daily activities. MPutee integrates patients, healthcare providers, and mental health volunteers, to ensure that post limb amputation patients receive adequate rehabilitation programs with low cost and equal effectiveness. In addition, patients are also facilitated with several features to help them achieve better quality of life, even years after amputation. To achieve these goals, M-Putee is developed based on current evidence-based recommendation of holistic mobile application. At least seven basic features are needed to be considered in the application, which were: 1.

Online and offline availability,

Size of mobile application less than 50 MB,

Available for free without subscription needed,

Provide educational content,

Shared user’s data with other platforms,

Automated data entry, and

Advisory function9

M-Putee has four main features for the users, namely M-Rehab, M-Pathy, M-Activity, and M-Friends. These main features are developed based on evidence that amputees have high risk of depression and loneliness and thought that they should hide from their society. M-Rehab facilitates a complete physiotherapy program as needed by patients to improve their functioning level as high as possible. Doctors or nurses from healthcare facilities may give instruction to patients and monitor their condition via video conference included in this feature. Additionally, for those who have not got enough money to pay for the official rehabilitation program, M-Rehab also includes volunteers from many non-governmental organizations and other professional health activists to give free rehabilitation programs for them.

Figure 2. User interface for M-PUTEE

M-Pathy is a special segment where users may assess their mental health condition, including depression, anxiety, or stress, by the DASS-21 questionnaire provided. The results will be used to preceed for the next phase of consultation with professional psychiatrist or mental health volunteers. Parallel to previous features, there will be free consultation provided for those who have less budget. M-Activity is another feature where users may get full instruction and recommendation on what kind of activities they have to do, along with an interactive video showing how to do the activities. This feature is developed due to current data that amputees tend to have less activity because they are less motivated. Activities also can be done with their friends that may be in the same condition to motivate them even greater. M-Friends connect users via chat and video conference to share their conditions and motivate each other to keep their spirit on adapting to their new condition. Within this feature, users are also provided space to share their experiences in using prosthetic limbs, especially to new amputees. This mobile application will be made available and free for all users of iOS and Android operating systems to ensure that it will benefit users from any economical background. Moreover, the application system itself will use voice recognition control in order to facilitate users that are not able to use their upper limbs to click on the application. We have also developed motion sensor to be integrated in the application to detect any improper movements during the user’s activities. As one of the most challenging problems that might be faced by patients after amputation, namely falling from imbalance posture, the application will also send notification and alarm to the user’s families or care giver so they might help them. From the other side, healthcare providers, such as doctors, physiotherapists, or nurse, will be assigned from their healthcare facilities databases, to participate in the application and help the patients. Meanwhile volunteers are required to sign up and attach their resume to be qualified as physiotherapist or mental health consultant. In addition, to ensure that this idea can be implemented successfully, we have planned a thorough publication and socialization strategy, including cooperation with government and non governmental organizations. To recapitulate, M-Putee is expected to be the first solution of mobile application targeting post-traumatic limb amputation management that covers patients from all background, focusing on their mental health and quality of life improvement. The voice recognition features and volunteer-based consultation are highly believed to be suitable for all users in Indonesia. We hope that this idea may serve as an answer to boost the quality of life of amputees, for better and healthier Indonesia

CONCLUSION The COVID-19 pandemic has impacted post-trauma care, especially the rehabilitation program of post limb amputation patients. Despite the urgent need of rehabilitation programs to improve their quality of lives and functioning level, most patients are not motivated due to their hopeless feelings of their future after amputation. Therefore, we proudly present our novel innovation of mobile application, M-Putee, which serves as a complete solution to facilitate online physiotherapy program, along with mental health consultation and special features of sharing sessions with other amputees. Through the application, we hope that post-trauma care of amputees may be improved to achieve better quality of life. The recruitment of volunteers also ensures low cost to support users from low to middle income backgrounds. All in all, the voice recognition features are highly suitable for the users as currently there are very few mobile applications that support this feature.

RECOMMENDATION We realize that one of the spearheads of this project is through governmental support, especially by enabling policies to allow M-Putee to be developed. Governments are also desired to give more attention and support on mobile application development due to its high efficacy and efficiency to enhance people’s health, especially during this pandemic era. Furthermore, we urge all healthcare facilities and mental health organizations to join and participate in this project. Lastly, by the cooperation of all stakeholders and supporting companies in the future, we hope that this application could be a once and for all solution of rehabilitation in post limb amputation patients for a better and healthier Indonesia.

ACKNOWLEDGEMENTS AND CONFLICT OF INTERESTS The authors declare there are no competing interests or funding in the making of this white paper.

REFERENCES 1. Sheehan T, Gondo G. Impact of limb loss in the United States. Physical Medicine and Rehabilitation Clinics of North America. 2014;25(1):9-28. 2. Varma P, Stineman M, Dillingham T. Epidemiology of limb loss. Physical Medicine and Rehabilitation Clinics of North America. 2014;25(1):1-8. 3. Ma V, Chan L, Carruthers K. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the united states: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Archives of Physical Medicine and Rehabilitation. 2014;95(5):986-995.e1. 4. Sagar R, Sahu A, Gupta R, Sagar S, Kumar M. A study of psychiatric comorbidity after traumatic limb amputation: a neglected entity. Industrial Psychiatry Journal. 2017;26(2):228. 5. Vincent H, Horodyski M, Vincent K, Brisbane S, Sadasivan K. Psychological distress after orthopedic trauma: prevalence in patients and implications for rehabilitation. PM&R. 2015;7(9):978-989. 6. Belon H, Vigoda D. Emotional adaptation to limb loss. Physical Medicine and Rehabilitation Clinics of North America. 2014;25(1):53-74. 7. Darter B, Hawley C, Armstrong A, Avellone L, Wehman P. Factors Influencing Functional Outcomes and Return-to-Work After Amputation: A Review of the Literature. Journal of Occupational Rehabilitation. 2018;28(4):656-665. 8. Ben-Zeev D, Razzano LA, Pashka NJ, Levin CE. Cost of mHealth Versus Clinic-Based Care for Serious Mental Illness: Same Effects, Half the Price Tag. Psychiatr Serv. 2021; 9. Ming LC, Untong N, Aliudin NA, Osili N, Kifli N, Tan CS, et al. Mobile health apps on COVID19 launched in the early days of the pandemic: Content analysis and review. JMIR MHealth UHealth. 2020;8(9):e19796.

EFAST “EMERGENCY FRACTURE AUTOMATED SYSTEM AND TOOLS” AS A SOLUTION FOR ACCURATE PREHOSPITAL TREATMENT OF ROAD TRAFFIC INJURIES Rachmanin Aldilla, Shuffa Chilla Mayhana, Muhammad Kevin Ardian, Andito Mohammad Wibisono AMSA-Universitas Indonesia Abstract Road traffic injury can be defined as fatal or non-fatal accidents on a public road. There are more than 3,400 people die because of road traffic injuries each day, making it the ninth leading cause of death worldwide. The World Health Organization (WHO) stated that Southeast Asia has the second-highest traffic death rates. Statistics show that Indonesia has the highest traffic fatality rate with a 0.77 increase annually. WHO also reported that around 40 % of road traffic injuries lead to fractures in the extremities. In such life-threatening conditions, ambulance services are not readily available. Besides that, there is also a lack of public knowledge to treat them. Consequently, road traffic injury victims are usually taken to the hospital using private vehicles and are not yet stabilized. After thoroughly looking into various literatures, we found that road traffic accidents are one of the most prevalent causes of death worldwide. This happens due to the lack of knowledge to give a correct treatment as well as the ineffective implementation of the EMS system, where it is claimed to be very complex, and is still unfamiliar to the public. To solve these problems, we designed a solution: EFAST. EFAST, or Emergency Fracture Automated System and Tools is a device that is practical, accessible, and understandable for the public use. It is attributed with an array of emergency equipment and a step-by-step guide on how to give the correct prehospital treatment, especially to stabilize fracture patients in road traffic injuries. EFAST is also equipped with an automated system to call the emergency units and will be strategically placed in Red Zones, specifically in a police station nearby. We highly recommend collaborating and integrating with all society and government to maximize the benefit of our devices. Key Findings: road traffic injury, emergency medical system (EMS), prehospital treatment, automated EMS call, all-in-one equipment

EFAST “EMERGENCY FRACTURE AUTOMATED SYSTEM AND TOOLS” AS A SOLUTION FOR ACCURATE PREHOSPITAL TREATMENT OF ROAD TRAFFIC INJURIES

By: Rachmanin Aldilla Shuffa Chilla Mayhana Muhammad Kevin Ardian Andito Mohammad Wibisono

AMSA-UNIVERSITAS INDONESIA 2021

INTRODUCTION Road traffic injury can be defined as fatal or non-fatal accidents that occur on a public road involving a minimum of one moving vehicle.1 There are more than 3,400 people that die because of road traffic injuries each day, making it the ninth leading cause of death worldwide. The World Health Organization (WHO) stated that Southeast Asia has the second-highest traffic deaths per capita at 20.7 for every 100,000 population. Statistics show Indonesia has the highest traffic fatality rate caused by 2 to 3-wheeled vehicles. In addition to that, these numbers continually grow, with a 0.77 increase annually.2 According to Bachani, et al around 20 to 50 million people who experienced road traffic accidents suffer from non-fatal injuries, meanwhile about 78.7 million people suffer from fatal and disabling injuries.1 WHO also reported that around 40% of road traffic injuries lead to fractures in the extremities.3 According to the regulations set by the Indonesian law, individuals who are involved in a road traffic accident are expected to report to the police officer. While waiting, injured victims are not able to be treated directly. In such life-threatening conditions, ambulance services are not readily available to transport the victims to the hospital. Thus, victims are usually taken to the hospital using taxis or private vehicles. However, these patients are not yet stabilized, as they have not received a proper preliminary treatment at the location of the accident.4 Before we implement our innovations to decrease the amount of untreated fractures victims caused by road traffic injuries, we believe that recognizing where and how road traffic accident typically occur is very important.5 To do so, we will utilize the term Red Zones to refer to two or more continuous road segment that show a higher average accident rate.6 We obtain the traffic accident’s data from Badan Pusat Statistik Prov. Jakarta which presents the number of accident and location of the accident.7 We will apply the same methodology as used by Loo, et al; where a threshold value of three or more traffic crashes per 200-meter is classified into the Red Zone.8 Based on the problems listed above, victims of road traffic injuries must be treated rapidly, effectively, and efficiently. Thus, we propose a solution with an all-in-one device that includes equipment and guides to give prehospital treatment for patients before transporting them to the nearest hospital. Eventually, we want to decrease the fatality rate and mortality caused by road traffic injuries.

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OUTLINED PROBLEMS The World Health Organization has projected that the number of deaths caused by road traffic accidents to reach up to 80% in the year 2020. In addition to that, the number of injuries caused by road traffic accidents is also projected to increase significantly in the same year. Considering the magnitude of the event, an immediate intervention is essential to save victims suffering from road traffic injuries. Preliminary relief is needed to stabilize the patient before being transported to the hospital. However, the public still lacks the understanding to do so. This is shown by a study conducted by Taanvik, et al where among 10.7% to 65% patients who received first aid in road traffic accidents, 83.7% among them claim to have received an incorrect treatment. This data shows that there is still a lack of basic knowledge of first aid in the community.9 Besides the lack of knowledge to apply a correct preliminary treatment for these victims, there is also a limited amount of resources readily available to use on the site of the accident to allow a preliminary intervention to be performed.10

The Emergency Medical System (EMS) is an

integrated service applied in Indonesia that is able to provide prehospital treatment in emergency conditions. However, a study conducted by Amad, et al has shown that Indonesians have not implemented the system effectively due to various factors. The problem lies in the lack of socialization of the system from government authorities, thus it remains unknown too many. Besides that, the complex procedure needed to operate the system makes it difficult for the public use.4 METHOD First, we think about the basic management of trauma care that includes prehospital care, in-hospital care, and post-hospital care. As a medical student, with a limitation of certification and authorization, we propose the innovation in the prehospital site due to the feasibility of running the project. Based on the literature search we conducted to find the most prevalent problems in traffic accidents, we found that fractures occurring in the extremities take 40% of all burden caused by road traffic accidents. Moreover, the most important aspect in the preliminary treatment of a traffic accident injury is to give the right treatment in the critical time. Firstly, it is essential for the helper to give a primary assessment before calling the ambulance. Secondly, preliminary treatment is given to stabilize the patient’s condition before transporting the patient to the hospital. Thus, we designed an innovative solution to help the victim as fast as possible by providing the equipment needed to conduct a preliminary treatment while also providing a simple but essential guide to do so.

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Figure 1. Thinking Process. FINDINGS After thoroughly looking into various literatures, we found that road traffic accidents are the major causes of death in the world. In Indonesia, there is a 0.77 fatality rate increase every year.2 This happens due to the lack of knowledge to give a correct treatment.9,10 In addition to that, the EMS system applied by the Indonesian government has not been effectively implemented, as it is very complex, and is not publicized enough to the public.4 SOLUTION It is evident that the lack of public knowledge, minimum equipment readily available, as well as the limited access to EMS contributes to the inaccurate treatment of traffic accident victims. Thus we would like to offer a solution: EFAST. A device that is practical, accessible, and understandable for the public use as shown in Figure 2. EFAST is an abbreviation for Emergency Fracture Automated System and Tools, where it is attributed with an array of equipment that is needed to give a proper emergency treatment, especially to stabilize fracture patients in road traffic injuries. In addition to that, EFAST is also 4 95

equipped with an automated system to call the emergency units. EFAST will be strategically placed in Red Zones, which we determine based on data from Badan Pusat Statistik Prov. Jakarta and threshold set from Loo, et al study. Specifically, it will be placed in a police station nearest from the Red Zones as shown in Figure 3. Each EFAST equipment include: 1. Automated EMS Call To solve the complex EMS system, EFAST is equipped with a device that automatically rings the EMS system to call for an ambulance and get professional assistance from nearby medical centers to the exact location as shown in Figure 4. This is possible with the use of Global Positioning System (GPS), as well as developing partnerships with hospitals, emergency care units, as well as other medical centers that are located in the Red Zone. 2. Fracture Stabilization Equipment Previously, it is very unlikely that emergency equipment was readily available at the location of the accident. This also hindered the helper to conduct the correct preliminary intervention to treat victims of road traffic injuries. Thus, we make an innovation to put emergency equipment needed to stabilize the patients in one bag. Our innovation, EFAST, will be filled with disinfectants, scissors, sterile cotton, a piece of fabric for the primary wound dressing, splint, and a collar neck as shown in Figure 2. 3. Video Guide using Barcode and Booklet EFAST provides a step-by-step guide on how to conduct the correct preliminary treatment. Inside, there is a booklet, as shown in Figure 5, that is filled with instructions to conduct a primary assessment as well as further treatments to stabilize the patient before an ambulance arrives. In addition to that, the user could follow through a video guide that could be accessed through scanning the barcode inside the booklet. The booklet and video guide is made based on WHO and Advanced Trauma Life Support (ATLS) Guidelines to avoid any errors. Lastly, a variety of instructions are provided to cater to possible injuries in a road traffic accident, consisting of instructions on how to stabilize patients with low extremity fracture, upper extremity fracture, massive bleeding, nose bleeding, spinal injury, and etc. Therefore, EFAST provides a barcode that the user can scan to obtain a step-by-step guide on how to conduct a correct emergency treatment. There will be multiple videos that the user could use and adjust to the traffic injury happening before their eyes. These videos are produced or are made based on WHO or Advanced Trauma Life Support (ATLS) Guidelines to avoid any errors.

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Figure 2. EFAST (Emergency Fracture Automated System and Tools)

Figure 3. Red Zones Map.

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Figure 4. Automated EMS call for hospital.

Figure 5. Prehospital treatment guide with integrated video.

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CONCLUSION Road traffic injuries, especially one that results in extremity fractures, one of the leading causes of death occurring from road traffic accidents. In addition to that, the lack of public knowledge and the complex EMS system applied in Indonesia hinder traffic accident victims from obtaining the correct prehospital treatment. To decrease these fatality rates, we proudly designed a solution: EFAST. EFAST or Emergency Fracture Automated System and Tools is a device that comprises a piece of complete equipment to stabilize the victim and a step-by-step guide on how to assess and correct conduct the preliminary treatment to the victim while also integrating the Emergency Medical Services (EMS). EFAST provides a guideline that includes a video about the treatment itself. Integration with EMS directly calls and sends the accident's location by utilizing a GPS. We believe that EFAST is the solution to continuously increasing road deaths. In addition to that, we hope to raise the public's awareness and encourage the public to use Emergency Medical Services and save lives actively. Furthermore, we feel that massive publications and integration into public policy are also essential to ensure that EFAST can benefit humanity. RECOMMENDATION For EFAST to be implemented and recognized, we will need complete publication and socialization from government authorities. We also aim to work for hand in hand with Governmental Organizations (GO), Non-governmental organizations (NGOs), and medical student organizations to advocate this device. The utilization of social media involving medical influencers and building partnerships with medical companies and pharmaceuticals is also essential to further publicize our product for public use. We also highly appreciate the collaboration and integration made among all stakeholders in Indonesia to ensure our device can reach its maximum potential and give the impact as we planned to. ACKNOWLEDGEMENTS AND CONFLICT OF INTEREST There was no conflict of interest nor funding in the process of making this white paper and video.

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REFERENCES 1.

Bachani AM, Peden M, Gururaj G, et al. Road Traffic Injuries. In: Mock CN, Nugent R, Kobusingye O, et al., editors. Injury Prevention and Environmental Health. 3rd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017 Oct 27. Chapter 3. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525212/ doi: 10.1596/978-1-4648-0522-6_ch3

Badan Pusat Statistik Republik Indonesia. Statistik Transportasi Darat. BPS-Statistics Indonesia. Jakarta; 2018 November.

World Health Organization. Global status report on road safety 2018 [Internet]. Geneva: World Health Organization; 2018 [cited 2021 Apr 4]. Available from: http://www.freefullpdf.com/#gsc.tab=0&gsc.q=traffic%20safety%20ISBN%202019&gsc.sort=

Bureau of Diplomatic Security, U.S. Department of State.Indonesian 2020 Crime & Safety Report: Jakarta [Internet]. 2020. [cited 2021 Apr 4]. Available from: https://www.osac.gov/Content/Report/4c6d89b4-5214-4bb0-aa48-180df9f9e648

Satria R, Tsoi KH, Castro M, Loo BPY. A combined approach to address road traffic crashes beyond cities: hot zone identification and countermeasures in Indonesia. Sustainability. 2020;12(1801).

Loo, B.P.Y.; Yao, S. The identification of traffic crash hot zones under the link-attribute and event-based approaches in a network-constrained environment. Comput. Environ. Urban Syst. 2013, 41, 249–261.

Jumlah kejadian kecelakaan lalu lintas, korban, dan kerugian di Provinsi DKI Jakarta, 2018. BPS Provinsi DKI Jakarta [ cited 2021 Apr 4]. Available from: https://jakarta.bps.go.id/dynamictable/2020/02/10/295/4-4-8-jumlah-kejadian-kecelakaan-lalu-lint as-korban-dan-kerugiannya-di-provinsi-dki-jakarta-2018.

Loo, B.P.Y. The identification of Hazardous Road Locations: A comparison of the blacksite and hot zone methodologies in Hong Kong. Int. J. Sustain. Transp. 2009, 3, 187–202.

Prasetyawan RD, Firti LE. Both Peer Education and Demonstration Method Improve Student’s Knowledge in First Aid of Traffic Accident. [Internet]. 2019 Jul 1 [cited 2021 Apr 4]; 11(01): 63-7. Available from: https://ejournal.lucp.net/index.php/mjn/article/view/bothpeereducation/765

10.

Anita F, Hariyanti T, Suharsono T. First Responders While Administering Unrealized Integrated Pre-Hospital. 2020;2(3):13.

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Abstract Burn injury is a major global public health problem accompanied by a high risk of mortality and morbidity. A burn is a skin and tissue damage caused by agents like fire, scald, electricity, sunlight, and chemical or nuclear radiation. In burn injury, survival is no doubt the immediate concern, it is the restoration to pre-injury status, and return to society becomes important for the victim and the treating team. An understanding of the burn wound healing is fundamental not only to the management of the acute burn wound, but also for the prevention, minimisation and treatment of post-burn scars and scar contractures. Experiencing a burn injury and enduring the painful treatment is often traumatizing to children and adolescents. With conventional methods such as patients doing normal exercises while being accompanied by Intensive Care Unit team, is proved to be insufficient to maintain children’s range of movements. Therefore, a solution is needed to solve pediatric patients fearness on rehabilitation by using a more fun rehabilitation method. As our world will always evolve, the development of technologies are going further ahead. In physical medicine and rehabilitation field, a lot of changes has been made since the use advanced technology. The most used technology is virtual reality (VR) and Wii. Wii is a type of active video game with console produced by Nintendo in 2006. the objective of this white paper is to propose a solution for pediatric burn injury using Wii video game to help them overcome their fear and encourage them to do rehabilitation routine. The method that used is surfed the internet to look for literatures regarding our theme, using several search engines such as googlescholar. The game’s theme will require patients to do movements that are adjusted to rehabilitation routine to prevent scar contractures and limb deformities. Key findings: Burn injuries, Rehabilitation, Video game, Wii

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WHITE PAPER The Use of Wii Video Game to Enhance Rehabilitation Outcome of Pediatric Burn Injury Patients in Indonesia AMSA-Diponegoro University

Authors: Ausi Syazana Manurung I Nyoman Sebastian Sudiasa Muh. Arifqi Rustam Adinda Alfiyunisa Selaniar

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The Use of Wii Video Game to Enhance Rehabilitation Outcome of Pediatric Burn Injury Patients in Indonesia AMSA-Diponegoro University Ausi Syazana Manurung, I Nyoman Sebastian Sudiasa, Muh. Arifqi Rustam, Adinda Alfiyunisa Selaniar Introduction Burn injury is a major global public health problem accompanied by a high risk of mortality and morbidity. Globally, nearly 96,000 children under the age of 20 were fatally injured as a result of a fire-related burn. Of this, the majority of burn injuries occur in low- and middle-income countries (LMIC). The World Health Organization (WHO) estimates that the annual death due to burns is over 310,000, and LMIC accounts for 95% of all annual burn deaths. These injuries were rated as the second most common cause of accidental death among Indonesian children younger than 5 years of age. In Indonesia, it is estimed that between 18,000 and 30,000 children under the age of 18 died annually as a result of burn-related injuries.1 A burn is a skin and tissue damage caused by agents like fire, scald, electricity, sunlight, and chemical or nuclear radiation. Scald burn is the most common type, and home constituted the commonest place of occurrence of burn injury Burn can be assessed using the estimate of the depth, and total body surface area burned (TBSA). Additionally, burns are classified as superficial, partial, and full thickness, depending on the depth of injury to the skin. Furthermore, it can vary from mild to severe, depending on the total body surface area burned (TBSA), depth, and location of the burn. Burns in children differ in multiple aspects from adults and may result in a more sever devastating injuries. These injuries include, acute life-threatening complications (fluid loss, airway obstruction, renal failure, super-infection) and chronic complications (significant disfigurement, disability and psychological trauma). Additionally, Burns account for the greatest length of stay (LOS) of all pediatric hospital admission injuries and the management of pediatric burns remains complicated, challenging and extremely costly even in wellequipped and modern burn units. The epidemiological patterns of burns vary significantly based on age, sex, economic status, local customs, social, and environmental circumstances.2 In burn injury, survival is no doubt the immediate concern, it is the restoration to pre-injury status, and return to society becomes important for the victim and the treating team. A healed burn patient may be left with scars have varying degrees of functional and aesthetic components. Post-burn scars are inevitable even with the best of treatment because they depend upon the depth of burn injury. Except for the superficial dermal burns, all deeper burns (2nd degree deep dermal and full

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thickness) heal by scarring. This scarring can only be minimised by various physical therapy measures and plastic surgical procedures but not eliminated completely. An understanding of the burn wound healing is fundamental not only to the management of the acute burn wound, but also for the prevention, minimisation and treatment of post-burn scars and scar contractures. The healing of a burn wound is accomplished either by restitution (complete regeneration) or substitution. Restitution is possible only if the skin is burnt as deep as the stratum papillare and all the specialised cells of the organ are preserved. If the skin is affected deeper in the zone of stratum reticulare, the defect is covered by substitutive unspecialised connective tissue. The final result is demonstrated by a lesser or more extensive formation of the cicatrix. With full thickness loss of skin, wound contraction and epithelialisation from the margins occurs leading to contractures. Contraction is an active biological process by which an area of skin loss in an open wound is decreased due to concentric reduction in the size of the wound. Scar contracture, on the other hand, is the end result of the process of contraction. In addition, the deeper tissues may be affected either due to their involvement in the initial burn injury (e.g., electrical burns) or secondary to the presence of a skin contracture over a prolonged period of many years, which leads to shortening of musculotendinous units and neurovascular structures. The joints may be subluxated or dislocated, with joint capsule and ligaments becoming tight in the direction of the contracture. The bones may be deformed, especially in growing children, e.g., mandibular deformity in cases of post-burn contractures of the neck. Maintenance of released/corrected position is mandatory until the graft has become stable (usually 3 weeks) or till the flap margins have healed. Post-operative use of static or dynamic splints, interspersed with a routine of daily physical therapeutic exercises is required to keep the joints in full range of motion especially if static splintage is used. This therapy is continued till the grafts have matured and complete range of motion is achieved.3 Therefore, we could conclude that rehabilitation is crucial for burn injury patients to prevent chronic complications such as scar contracture, mostly in joints. The greatest recovery in upper limb function is achieved in the 6 months following a burn injury, and this period offers the best opportunity for rehabilitation interventions. The main predictor of success in physical therapy is the amount of therapy undertaken, and guidelines for patients recommend high intensity repetitive motions. Rehabilitative therapy has focused on practicing “normal” movements to encourage return of relevant function and inhibit compensatory habits that may prevent further recovery. More recently, there has been an emphasis on strengthening, practice of functional tasks, and forcing use of the weak limb to complete everyday activities using constraint-induced movement therapy.4

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Experiencing a burn injury and enduring the painful treatment is often traumatizing to children and adolescents.5 The accident, hospitalization, and remaining scars evoked questions, remarks, and attention of other people. Children reported to have received a lot of positive comments, praises, and expressions of understanding. Sometimes, children valued other people’s interest and curiosity, but occasionally this was unwanted. Some children disliked the look of their scars and the idea of exposing scars could lead to fear of others’ negative reactions.6 As our world will always evolve, the development of technologies are going further ahead. In physical medicine and rehabilitation field, a lot of changes has been made since the use advanced technology. The most used technology is virtual reality (VR) and Wii. Virtual reality (VR) technologies require multimedia devices and computer simmulation to allow users to interact with a simulated enveironment, creating a life-like experience. Over the past two decades, VR has been tested and examined as a technology to assist patients’ recovery and rehablitation, both physical and cognitive. It is proven useful to for rehabilitation assesment and rehabilitation exercise. In training and exercise, several outcomes have been reported. Improved clinical conditions in patients with loss memory function, memory deficits, Alzheimer’s disease and many other mental illnesses. This proves that VR is proven useful in rehabilitation focusing on mental illnesses.7 On the other hand, Wii is proven to be more useful in rehabilitation involving physical trauma. Wii is a type of active video game with console produced by Nintendo in 2006. It introduced motion controlled gaming where players are required to move according to the game to achieve their goal. In rehabilitation, Wii has been used across a variety of clinical specialties such as neurology, geriatric rehabilitation, respiratory, pediatrics, orthopedics, burn, etc. Since they have better outcomes, further research are being developed for better modifications.8 Thus, the objective of this white paper is to propose a solution for pediatric burn injury patients’ rehabilitation. We will use Wii videogame to help them overcome their fear and encourage them to do rehabilitation routine. We hope we could enhance their rehabilitation outcome and prevent chronic complication such as scar contracture.

Method We surfed the internet to look for literatures regarding our theme. We used several search engines such as Googlescholar and looked more from Pubmed and Sciencedirect. We used the keyword video game, rehabilitation and burn injury. We found more than 50 literatures and sort them according to the significance to our paper. Findings

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Children have low adherence to burn injury rehabilitation. They tend to think their injury as more severe when they realized that admission to a hospital was required. Some children disliked the idea of other people looking at their burn scars because they think it could lead to negative reactions. Which is why they decide to cover their burn scar.6 Children low adherence to rehabilitation may be caused due to trauma symptoms that resulted due to their fear of pain on experiencing a burn injury. These trauma symptoms can cause cognitive difficulties, physical difficulties, behavioral difficulties, and emotional difficulties that will have a negative impact to everyone around them on their daily lives.5 Pediatric patients must be monitored during rehabilitation therapy to prevent malformation on joints and limbs that can be cause due to pressure garment that is applied incorrectly.9 Rehabilitations that focus on active functional body movements is needed to improve motor control, functional recovery, and strength. It is very important that pediatric burn units realize the need for a child psychiatrist and a psychotherapist in their rehabilitation team. Good psychotherapy along with burnsrelated treatment will go a long way to enhance the quality of life of these patients. Appropriate feedback on rehabilitation is also needed to enchance both motor learning and relearning process for postburn pediatric patients so they can return to normal daily lives with society. 10 Post-burn injury with low rehabilitation outcome may cause contractures, muscle atrophy, and abnormalities on range of motion. Contracture is the most frequently cause of impairment in a postburn individuals with examples such as foot burn reconstruction which may cause toe contracture. Toe burn scar contractures can be quite debilitating, interfering with a patient's daily functional activities, increasing risk of inadvertent injuries due to anatomical deformities, and subjecting the patient to ulcers with subsequent infections.11 There is also possibility that postburn injury might cause neck burn reconstruction. Post-burn scar contractures of the neck produce extension restrictions varying from mild to very severe flexion contractures. This poses intubation difficulties and is the major anesthetic concern. The problem is not only in the severe limitation of extension but also in the associated facial burns producing microstomia, limiting access to the larynx and trachea. Additionally, the contracting forces of the healing burn wound tend to bring about deformities in the normal laryngo-tracheal anatomy and thereby further cause difficulty in intubation.12 By using exercise-based rehabilitation, studies show that the prevalence of scar contracture at discharge is high, around 40% to 55%, thus showing a need for optimal continued rehabilitation and reconstructive care.13 Literature also indicates that the time to heal directly correlates to the propensity

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to form hypertrophic scars (HSs), with those healing in 14 to 21 days having a 30% incidence of HSs and those more than 21 days with a 78% incidence.14 With conventional methods such as patients doing normal exercises while being accompanied by Intensive Care Unit team, is proved to be insufficient to maintain children’s range of movements. This can be caused by the lack of fun of rehabilitation which will make children not doing the rehabilitation correctly. This problem might lead to reduced range of motion on post-rehabilitation. Which is why it is required to come up with new solution so children will enjoy their time on rehabilitation. Therefore, a solution is needed to solve pediatric patients fearness on rehabilitation by using a more fun rehabilitation method. A solution is also needed to prevent the emersion of contractures and to make sure their range of motions stays in good condition so that pediatric the rehabilitation outcome is better and their quality of life can return to normal even after the rehabilitation. Proposed Policy/Solution To overcome the explained problems, we propose a solution where pediatric burn injury patients could use interactive video games in their rehabilitation process. Video games that we propose will use Wii game mechanism. It is a type of Active Video Game (AVG) which involves the use of remote. This remote should be held by patients or attached to their limbs and will be linked to the game which is presented in a television screen. This game is designed with motion sensor technology. Therefore, players should move according to the game instruction and their movements will be assessed. This requires players to do physical movements in order to achieve their goal on the game. We will use Wii in patients’ physical rehabilitation routine. Maintaining Range of Motions (ROM) and doing physical activities are crucial in burn rehablitation to prevent scar contracture and limb deformities.10 Therefore, the game’s theme will require patients to do movements that are adjusted to rehabilitation routine. Example of it are walking, stretching their limbs and at the same time doing mild exercise. We will also make the game interactive to children so they will be encouraged to complete the routine. By using active video games such as Wii, we could encourage patients to maintain their ROM as the part of rehabilitation while they play. This will make them treat rehabilitation as something they could enjoy. Rehabilitation will be held on the regular rehabilitation center. Children will be observed by the rehabilitation team and could also be accompanied by their parents.

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This solution is feasible to be applied since video games have been used in a lot of health purposes. Video games industries and health industries have collaborated a lot in the past years and their outcome are proven to be good. Some video games have been developed for educating society for knowledge and self-management of diabetes, supporting psychotherapy medication and training medical skills.

Wii has even been used for burn rehabilitation in patients. However, to our

knowledge, there is still no application of this method in Indonesia yet. We also emphasize its usage on pediatric burn injury patients with the relevance of their low of adherence in rehabilitation. Video games have also been proven effective to distract patients from pain treatment and the fear of it. As explained by American Pain Society, playing video games could decrease brain response to pain stimuli since their attention are being pointed towards another focus and could even reduce 50% of the pain. Moreover, video games are categorized as an audiovisual active distraction from pain and is proven to be more effective than passive distraction such as music.16 Children are familiar enough with video games mechanism and they are quick to learn. There will be no major problems operating the game. Even if there are further trouble to operate it, the rehabilitation team could help them. This rehabilitation will be done 3 times a week for 12 consecutive weeks with 15 to 30 minutes duration per session. 17 Among other technology option that has been discussed in a lot of journals such as Virtual Reality, we picked Wii since it is less costly and more feasible to be developed in Indonesia. Wii has been recognized as very beneficial for specifically burn rehabilitation with its advantage other advantages such as easier to use and safe for more populations. On the other hand, Virtual Reality systems are not clinically suited for burn therapy. Wii is also focused since its movements are goaloriented.18 We would like to apply this solution until children could fully do their usual activites after rehabilitation. Our goal of this proposal is to reduce children’s treatment pain and fear of rehabilitation while maximizing their range of motion exercise. Outcome that we hope we could get is better adherence to rehabilitation. Conclusion From the explanation above, due to children’s low adherence to burn injury rehabilitation, we could use Wii video game to overcome it. Therefore, unwanted complications such as scar contracture, limb malformations and reduced ROM will be prevented. Recommendation

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Since this solution has not been applied before in Indonesia, futher experiments and studies on countries that have applied this must be done by the government. Development of the video game could first be tested in hospitals with sufficient rehabilitation equipment and further be developed in lower grade of hospitals. Acknowledgements and Conflict of Interest We would like to acknowledge the people who had written the literatures that we used while making this paper. We would like to thank AMSA-Indonesia for giving the members opportunities to participate in such academic events. References 1.

World Health Organization. The Global Burden Of Disease 2004 Update [Internet]. 2008 [cited

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Kemenkes RI. Riset Kesehatan Dasar. Jakarta: Balitbang Kemenkes RI; 2013.

Goel A, Shrivastava P. Post-burn scars and scar contractures. Indian J Plast Surg Off Publ Assoc

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Richard RL, Hedman TL, Quick CD, Barillo DJ, Cancio LC, Renz EM, et al. A clarion to recommit and reaffirm burn rehabilitation. J Burn Care Res. 2008;29(3):425–32.

Toon MH, Maybauer DM, Arceneaux LL, Fraser JF, Meyer W, Runge A, et al. Children with burn injuries-assessment of trauma, neglect, violence and abuse. J Inj Violence Res. 2011;3(2):99–111.

Egberts MR, Geenen R, de Jong AEE, Hofland HWC, Van Loey NEE. The aftermath of burn injury from the child’s perspective: A qualitative study. J Health Psychol. 2020;25(13– 14):2464–74.

S C. Virtual Reality Applications in Rehabilitation. Springer [Internet]. 2016; Available from: https://link.springer.com/chapter/10.1007%2F978-3-319-39510-4_1

Tsekleves E, Warland A, Kilbride C, Paraskevopoulos I, Skordoulis D. The use of the nintendo wii in motor rehabilitation for virtual reality interventions: A literature review. Intell Syst Ref Libr. 2014;68:321–44.

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Gu S, Ohgi S. Pediatric burn rehabilitation: Philosophy and strategies. Burn Trauma. 2013;1(2):73.

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Chiou GJ, Puri V, Davis DJ. Foot burn reconstruction [Internet]. Global Reconstructive Surgery. Elsevier Inc.; 2018. 285–297 p. Available from: https://doi.org/10.1016/B978-0-32352377-6.00037-9

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Khundkar SH. Neck burn reconstruction [Internet]. Global Reconstructive Surgery. Elsevier Inc.; 2018. 255–262 p. Available from: https://doi.org/10.1016/B978-0-323-52377-6.00032-X

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Oosterwijk AM, Mouton LJ, Schouten H, Disseldorp LM, van der Schans CP, Nieuwenhuis MK. Prevalence of scar contractures after burn: A systematic review. Burns [Internet]. 2017;43(1):41–9. Available from: http://dx.doi.org/10.1016/j.burns.2016.08.002

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Sharp PA, Pan B, Yakuboff KP, Rothchild D. Development of a best evidence statement for the use of pressure therapy for management of hypertrophic scarring. J Burn Care Res. 2016;37(4):255–64.

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Primack BA, Carroll M V., McNamara M, Klem M Lou, King B, Rich M, et al. Role of video games in improving health-related outcomes: A systematic review. Am J Prev Med [Internet]. 2012;42(6):630–8. Available from: http://dx.doi.org/10.1016/j.amepre.2012.02.023

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Ariyanti AD, Ode L, Rahman A. Penggunaan Teknologi Virtual Reality Dalam Penurunan Rasa Nyeri Pada Anak. 2020;10(1).

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Atiyeh B, Janom HH. Physical rehabilitation of pediatric burns. Ann Burns Fire Disasters. 2014;27(1):37–43.

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Yohannan SK, Tufaro PA, Hunter H, Orleman L, Palmatier S, Sang C, et al. The utilization of Nintendo® WiiTM during burn rehabilitation: A pilot study. J Burn Care Res. 2012;33(1):36– 45.

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FIRST AID MANAGEMENT WITH G-ALERT FOR ONLINE TAXIBIKE DRIVERS AS FIRST RESPONDERS TO ROAD TRAFFIC INJURIES Angela Lady Kezia, Mavelyn Levene, Indah Paskahila Rindawa Mus, Chatrine Angelica Dwi Christy AMSA-Universitas Kristen Indonesia Abstract. The number of online taxibike is growing bigger every day. This can be seen from the spreading taxibike drivers on the road, which has become a daily necessity when traveling across the city. With their jobs which are always on the road, some would have seen the incidence of traffic accidents firsthand. It is expected to the taxibike drivers to practicing first aid management for prehospital care. Using literature review with Google Scholar, SciHub, PubMed, Elsevier, and Research Gate, we used the following keywords “taxibike, accidents, first aid, effectiveness of online taxibike accident first aid training in Indonesia, online taxibike accident first aid training in Indonesia” in conjunction with a range of time from 2017 until 2021, written in English and Bahasa Indonesia. We found there is an implementation of training held with the topic of Handling Basic Life Assistance First Aid with 4 stages and a significant improvement can be seen through the increasing abilities and knowledge of the participant's post-test score. We come up with an idea of adding a new first aid management feature named G-Alert. It acts as an emergency signal in the driver’s application to the nearest hospital and driver colleague, and also as a virtual guidance on how to manage the injury on the accident site before the medical help arrives. Besides having first aid training for road traffic injuries practically, G-Alert shows a possibility for taxibike drivers to lessen the risks of death from road traffic injuries. Their technology can help excellence their skills and knowledge into real action on the accident site. Key Findings: taxi bike, road traffic injury, first aid

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FIRST AID MANAGEMENT WITH G-ALERT FOR ONLINE TAXIBIKE DRIVERS AS FIRST RESPONDERS TO ROAD TRAFFIC INJURIES

Authors: Angela Lady Kezia Mavelyn Levene Indah Paskahila Rindawa Mus Chatrine Angelica Dwi Christy

AMSA-Universitas Kristen Indonesia

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INTRODUCTION The motorcycle is a type of vehicle that is mostly used by society (Fig. 1). Starting with the presence of the company PT Go-Jek Indonesia in 2011 which was founded by Nadiem, taxi bikes-which are two-wheeled motorbikes-are becoming very effective transportation. This application allows users to be able to order taxi bikes online, which was then followed by the GrabTaxi company with the GrabBike service. According to GARDA (Gabungan Aksi Roda Dua), currently, there are more than 4 million taxi bike drivers spread across Indonesia. Based on electronic documents obtained by CNBC Indonesia, currently, Gojek has handled more than 3 million orders every day. This order is handled by more than 2 million drivers. In 2017, The Indonesian Consumers Foundation (YLKI) surveyed the existence of non-route public transportation or online-based transportation (Fig. 2). In response, increased use of transportation can also increase the risk of traffic accidents. Based on data reported by the Minister of Transportation, 79% of online taxi bike drivers experienced traffic accidents or a total of 58,715 cases in 2017.

FIG. 2 ONLINE TRANSPORTATION FREQUENCY OF USE (YLKI, 2017)

FIG. 1 VEHICLES PROPORTION 2019 Motorcycle

Car

Truck

2-3x/week

Bus

1-2x/day

1x/week

>3x/week

10%

5% 2% 11% 17%

82%

39%

34%

From all these data, we can see that injuries are an important public health concern, and remain a growing problem in some countries. Although the ultimate goal must be to prevent injuries from happening in the first place, much can be done to minimize the disability and ill-health arising from the events that do occur. Improving the organization, planning, and access to trauma care systems, including pre-hospital and hospital-based care, can help reduce the effects of injuries. The goal of the prehospital emergency care system should be to match the needs of the patients to the available resources so that optimal, prompt and cost-effective care can be offered. Evidence from many countries shows that dramatic successes in preventing injuries can be achieved through concerted

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efforts that involve, but are not limited to, the health sector. First aid is done as a first intervention done to a victim of trauma to protect his life and limb and to reduce suffering. Often the person most likely to be around at the time of a road crash is likely to be a layperson. However, even laypersons can provide valuable help by calling for expert help, getting the patient to a safer place and positioning the patient, and splinting him for reducing pain. They can also help reduce bleeding by simple elevation or compression bandage of the wound. They could be trained, and several programs help train laypeople in providing bystander care. Training drivers first aid – a group of people most likely to be on the road to help in the time of a road crash has been used by many. In correlation to this, an observational study was done in Banyumas in 2018. It was found 9 out of 10 drivers have seen direct accidents, but do not dare to help traffic accident victims. It is because most of the online taxi bike drivers do not know first aid techniques in accidents. Another survey was conducted and it was found that 86% of online taxi bike drivers had encountered cases of road accidents, 33% had assisted by calling for help from local people and 66% did nothing because they did not know what to do. In 2019, it was known that online taxi bike companies such as GrabBike and Gojek have finally done first aid training to traffic injuries for their drivers. Despite that, the training was only attended by a small proportion of drivers and was carried out in a short time. According to this problem, we aim to help to lessen the burden of trauma caused by road traffic accidents through online taxi bike drivers as the first responders. Based on the fact that the use of online taxi bikes, which has become a daily necessity, is offset by the number of online taxi bike drivers that are increasingly spreading on the streets every day. This shows the possibility that online taxi bikes are prone to accidents both by experiencing it themselves and by other accidents that may occur on the streets. Besides having first aid training to road traffic injuries, through their technology, which is the online application for orders, we come up with the idea of adding an emergency tool or feature, use for this kind of occasion in helping their skills and knowledge on first aid into real action on site. This feature acts as virtual guidance for the trained drivers in giving first aid, but also as an emergency call for help in general.

METHOD In this literature review, data obtained using scientific database including Google Scholar, SciHub, PubMed, Elsevier, and Research Gate using certain keyword such as “effectiveness of online taxibike accident first aid training in Indonesia”, “online taxibike accident first aid training in Indonesia”, “taxibike” AND “accident”, “taxibike” AND “first aid”, etc. From this search, 20 articles are found, sorted by year range of 2017-2021, full text articles, and written in English or Bahasa.

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Furthermore, it is sorted out by relevance of the study to our aim of understanding. Finally, Wahyuningtyas et al study is chosen for this literature review, supporting our idea for this white paper proposed solution. The methods used in this study which to be implemented include lectures, discussions, demonstrations, simulation of wound management in various cases of wounds, as well as monitoring and evaluation in wound management that has been practiced. This activity will involve 15 representatives of the GrabBike online taxibike drivers association in Magelang.

FINDINGS Table 1. Implementation of Training Stages of Training

Dates

Results

First Training

January 20th 2018

The first training was held at the Muhammadiyah University of Magelang for two hours only. In this first stage, some participants were unable to attend the training. This session began with a discussion of the problems faced by the participants in handling accidents, such as assisting when dealing with mild to severe injuries. After that, the material related to the basics of first aid and the basics of wound care as first aid was given. Then, the participants were asked to work on pre-test questions which consisted of 3 aspects, namely basic concepts, principles and stages, and application. The mean pre-test score of the participants was 52.5.

Second Training

January 27th, 2018

The second training was also held in the same place and time as the first stage of training. There were an additional 20 participants who attended the training from the Grab Bike community in the Wonosobo area. The second stage of training was carried out with the lecture and demonstration method with the topic of Handling Basic Life Assistance first aid. After that, participants were divided into groups and each group demonstrated the handling of victims who needed Basic

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Life Assistance. Feedback is given to perfect the simulation that the participants are showing. Third Stage

February 17th, 2018

Some participants were unable to attend the training. This session began with a presentation on two topics, namely shock and bleeding management and splint dressing techniques. After that, a demonstration was showed by the speakers, namely Ns Eka Sakti W, M.Kep and Nurul Hidayah, MS. Then the participants were divided into several groups again to demonstrate the techniques that have been shown. Feedback is always given to perfect the simulation that was demonstrated by the participants.

Fourth Stage

February 24 , 2018

This stage was held for four hours. No participant was absent. This session begins with the application of all materials on wound care or first aid treatment, bandage techniques, and splints. As usual, participants were divided into groups and demonstrate the materials given. Feedback is always given in perfecting the simulation. In the final stage, participants are also given a post-test to evaluate learning outcomes.

From the implementation of four stages of training (Table 1), there was an increase in the average result in each aspect. After given training, the Basic Knowledge aspect increase 62% with an average pre-test score is 52.5 and a post-test score is 85. While the increase in the Principles and Stages aspects is 50%, from 60 to 90 for the average of each test. The implementation aspect shows an initial average value of 50 and increases to 80 or there is an increase of 60%. Therefore, the training can be said to be successful because it can increase the abilities and knowledge of the participants. There are supporting factors and obstacles in the implementation of activities. Support from organizations or associations by sending online taxi bike drivers as participants are one of the supporting factors for the implementation of this activity. Grab Bike management also plays a role by granting permits to the team. However, there were obstacles that the team encountered, where some participants could not attend because they were still working.

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PROPOSED SOLUTION We come up with a solution through additional features that can be accessed via the installed online taxi bike application. This feature is called G-Alert. It should be noted that G-Alert is only available in the application system specifically for online taxi bike drivers, meaning it can’t be accessed by the passenger. To make it easier to use, this feature must be on the main page of the application. For a more detailed description of how this feature works will be described as below: 1. Registration This is the first stage to activate G-Alert. This stage requires verification data on the legal authority that the driver has passed recent first aid training. This process can be done by inputting the required pieces of information and submitting a picture of the certificate as proof. If they are guaranteed as trained first aid drivers, they can use the provided virtual guidance to assist them in doing their needed first aid. However, if they didn’t pass the verification process, the only thing they can access is the provided emergency signal. 2. Emergency signal This feature can be accessed by both trained and untrained drivers. The goal is to send a signal of aid to the nearest hospital and driver colleague automatically so that a helping hand can come faster than waiting for someone calling for help. This also may help to reduce panic. To get a better understanding, here are the working steps: A) First, press the G-Alert emergency button. To anticipate mischievous action, a pop-up will appear asking“Are you sure this is an emergency?”, then the driver can choose “Yes” or “No”. This is expected to make drivers think again about mischievous things. With an additional note as well, if it is found out that the signal is just a false alarm, the company has the right to impose sanctions on the related driver. B) After the emergency button is pressed, location and notification for help will be sent automatically to the nearest hospital and driver colleague. While waiting for help to arrive, the driver will be diverted to fill in the identity of the victim. •

If the victim is the driver himself, his initial personal data registered on the application will be automatically delivered. This means he doesn’t need to fill in the identities again.

•

If the victim is the passenger, his initial personal data registered, connected to the driver’s application will be automatically delivered. This means the driver doesn’t need to fill in the identities again.

•

If the victim is another person, his data will be input manually.

After filling up the identity of the victim, the driver will be asked to choose the type of injury that occurred. This type of information will also be sent to notify the

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hospital and trained driver colleague (not untrained drivers)for the situation to be faced. C) How G-Alert emergency signal works on the other end •

Hospital It should be noted that this system requires cooperation between each hospital and the online taxi bike company which is connected through the same application used by online taxi bike drivers. ➢ Signal will be sent to the nearest location by radius (for example 100m, 250m, 500m, 1km, 1.5km, etc.). This means that if there are several hospitals in the same radius, an emergency signal will be sent to both hospitals. ➢ There is a time limit based on the golden hour of first aid injury management according to the type of injury chosen by the driver at the first input. If the first nearest hospital doesn’t respond yet in the given time, the notification will be sent to the next radius further, while the notification for the first nearest hospital is still there. This will goes on until one hospital responds to send help. ➢ When one hospital finally responds and takes action, all notifications in other hospitals will be gone (which means it has been taken care of). ➢ Identity of the victim, type of injury input, and information on victim’s progressing state with actions done by performing driver will also be received by the responding hospital in order for administrative purpose and management preparations.

•

Trained drivers It should be noted that only drivers who are not receiving orders can receive these notifications. ➢ Same as hospital end, the signal will be sent to the nearest trained drivers by radius (for example 100m, 250m, 500m, 1km, 1.5km, etc.). ➢ Identity of the victim and type of injury input will be received for a better early understanding of the situation before taking an action. ➢ When helping on the accident site is enough, all notifications will be gone (which means it has been taken care of).

•

Untrained drivers It should be noted that only drivers who are not receiving orders can receive these notifications.

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➢ Same as hospital end, the signal will be sent to the nearest drivers by radius (for example 100m, 250m, 500m, 1km, 1.5km, etc.). ➢ Untrained drivers are expected to help the reporting driver by bringing the requested item needed for first aid management to the accident site. ➢ When helping on the accident site is enough, all notifications will be gone (which means it has been taken care of). 3. Virtual guidance This feature is the critical point of G-Alert’s purpose. The goal is to help improve the performance of first aid trained drivers to road traffic injuries. In case of forgetting some details on performing first aid, this may help to reduce the panic that causing wrong moves. To get a better understanding, here are the working steps: A) This feature will be automatically activated for trained drivers after the process of choosing the type of injury that occurred. B) Once activated, there will be steps to follow based on the chosen type of injury and questions asked to guide for the next step. •

Video virtual guidance This type of virtual guidance is the first one to show up while waiting for the live virtual guidance. ➢ It is equipped with demonstration video with voice and text, to make it easier for trained drivers to do first aid performance. ➢ Each step that requires information of the victim’s progressing state, there will be questions asked before moving on to the next step. The performing driver can answer these questions by text or even voice detect, to make it more efficient. All of this informations will be automatically stored and reported to the responding hospital later. ➢ Some of the instructions may require an item to help administer first aid, but the performing driver might not have the item needed. This can be solved by requesting the item through notification for an untrained driver colleague that is coming to help. ➢ It also provides alternative solutions so that the options are not limited and can improve the victim’s quality of life.

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Live virtual guidance This type of virtual guidance is the primary help for trained drivers as first responders to road traffic injuries. This might be the easiest way for trained drivers to do first aid performance.

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➢ It is equipped with a video call with the operator from the responding hospital (can be doctor, nurse, resident, or other medical personnel responsible) ➢ This feature will only activate automatically if there is an operator available. This means whenever an operator is ready, the ongoing video virtual guidance will be switched to video call automatically.

CONCLUSION Among the causes of injury, traffic accidents alone are the main cause, fundamentally in lowmiddle income countries. It is predicted to become the 7th leading cause of death by 2030. This shows the possibility that online taxi bikes are prone to accidents both by experiencing it themselves and by other accidents that may occur on the streets. According to this problem, the burden of trauma caused by road traffic accidents can be lessened through online taxi bike drivers as the first responders, based on the fact that the use of online taxi bikes, which has become a daily necessity, is offset by the number of online taxi bike drivers that are increasingly spreading on the streets every day. Besides having first aid training for road traffic injuries, through their technology, which is the online application for orders, this kind of solution which is the G-Alert can be used for helping their skills and knowledge on first aid into real action on accident site.

RECOMMENDATION This solution can be realized if there is a collaboration between online taxi bike companies and each existing hospital, together with software expertise, to make this special first aid management feature added to the existing installed application used by now. Also, this solution needs every driverpartner involved to take part in pre-hospital trauma care to decreasing fatality caused by unattended road traffic injuries, using this special first aid management feature. In hope, there will be no excuse to not have the ability for helping traffic accident victims.

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